t-PA should be given in the ED, study says
A new study holds up the ED as the future of stroke care. In the study, neurologists evaluated and treated 20 stroke patients, and ED physicians treated and evaluated 23 stroke patients after a phone consultation with a neurologist and review of brain scans by a radiologist.1 The door-to-needle times were similar (97 minutes for neurologists and 108 minutes for ED physicians).
"There was a need to evaluate whether emergency physicians could administer tissue plasminogen activator [t-PA, the only FDA-approved clot-busting medication] safely and effectively," says Paul Akins, MD, PhD, co-director of the Regional Stroke Intervention Program for Mercy Healthcare in Sacramento, CA. "Our results showed that it could be done." The ED is where the fate of a vast number of stroke patients is largely determined, says Akins. "Those early minutes of arrival are critical in determining whether a patient will regain his or her life, or be left severely disabled," he says.
Be realistic about neurologists
Expecting neurologists to drop everything and come running to the ED for every stroke patient is unrealistic, says Akins. The study showed that patients had identical outcomes whether they were treated by ED physicians or neurologists, says Akins.
"That’s very important when you consider that some ED physicians have been leery of taking on this treatment," he says. Using TPA for stroke is relatively new in the ED and carries the possibility of life-threatening complications such as hemorrhage, Akins notes.
The study found that protocol violations for the way in which t-PA is administered were much more frequent in the ED physician group than the neurology group, says Christi DeLemos, RN, stroke research coordinator at Mercy General Hospital in Sacramento, CA, and a co-author of the study. "That’s primarily because the drug was new and is not administered in same way as for myocardial infarction."
Once the high rate of error became apparent, an education program for the ED physicians was implemented. The hospital’s stroke team provided inservicing at staff meetings, and cards for dosages and inclusion/exclusion criteria were given to physicians, says Howard. "The physicians were also encouraged to page the stroke team to discuss every case."
"The rate of error went down dramatically," says DeLemos. "Our rate of error is none at the ED level now. This shows that giving t-PA in the ED is safe and effective."
Providers must be knowledgeable in the use of t-PA and the nuances of case selection, cautions Akins. "Close, compulsive adherence to published guidelines is critical to avoid bleeding complications and to select patients that will benefit," he says.
Reference
1. Akins PT, DeLemos C, Wentworth D, et al. Clinical outcomes are similar when stroke neurologists and emergency room physicians prescribe intravenous tissue plasminogen activator for acute ischemic stroke. Abstract presented at the American Stroke Association's 25th International Stroke Conference. New Orleans; February 2000.
For more information about the study, contact:
• Paul Akins, MD, PhD, Regional Stroke Intervention Program, Mercy Healthcare, Department of Neurology, 2825 Jay St., Suite 435, Sacramento, CA 95816. Telephone: (916) 441-7796. Fax: (916) 441-3038. E-mail: [email protected].
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