Can you break the 10-minute barrier for tPA delivery to stroke patients?
Top stroke hospitals get the patient in the door and the drug to the patient
Recent results of a study performed by the HCIA-Sachs Institute (formerly Health Care Investment Analysts) reveal that U.S. hospitals can save as much as $117 million annually just by managing Medicare stroke patients in a manner similar to leading stroke hospitals. The HCIA-Sachs study, 100 Top Hospitals: Stroke Benchmarks for Success, identified the hospitals setting benchmarks in stroke treatment. Results of the study show that there are significant opportunities for hospital pharmacists to improve treatment of stroke patients while at the same time reducing costs.
This particular top-100 hospitals study reviewed the number, severity, lengths of stay, costs, and outcomes of stroke patients. St. Luke’s Hospital in Kansas City, MO, is among those listed.
St. Luke’s is involved in a study sponsored by the National Institutes of Health. "We’re enrolling patients in this study for the interventional management of stroke," says Debbie Summers, RN, MSN, stroke clinical program coordinator at St. Luke’s Hospital. "The primary investigators are a team at the University of Cincinnati.
"Timing is everything," Summers tells Drug Utilization Review. "If a patient reaches us within a three-hour window of the onset of the stroke, he’s a candidate for IV tPA. That’s one option. There are studies looking at intra-arterial tPA for the cerebral arteries, but again, the timing must be right. The patient must get to the hospital, then be evaluated to determine what type of stroke is occurring, then treatment begun — all within a rather narrow window of time."
Information from the American Heart Association (AHA) confirms Summers’ sense of urgency in getting patients treated. The AHA advises readers at its web site to take immediate action when a stroke occurs. It lists the following as actions people should take when they suspect either they or someone around them is suffering from a stroke:1
- Don’t ignore signs of stroke — not all of the warning signs occur with each stroke, so don’t ignore individual signs, even if they go away.
- Check the time — make note of the time the first warning sign started; physicians will need this piece of information later.
- Don’t delay — if one or more stroke symptoms are present, call for help immediately; patients should be instructed to call 911 immediately.
- If you’re with someone who is displaying stroke symptoms, call 911 immediately, despite their requests not to; patient denial is common; don’t take no for an answer; insist on prompt action.
Part of getting a stroke patient to the hospital quickly is being able to recognize the signs and symptoms of stroke. Several symptoms manifest during and leading up to a stroke. These signs and symptoms include:1
- sudden numbness or weakness of the face, arm, or leg, especially on one side of the body;
- sudden confusion, trouble speaking or understanding;
- sudden trouble seeing in one or both eyes;
- sudden trouble walking, dizziness, loss of balance or coordination;
- sudden, severe headache with no known cause.
A transient ischemic attack (TIA) should not be taken lightly, according to the AHA. Any of the above-listed signs and symptoms may be temporary and last only a few minutes. This is how a TIA can manifest. TIAs don’t occur before most strokes, but they are definitely predictive of future strokes. In fact, among patients who have had one or more TIAs, more than 30% will later suffer a stroke.1 Because they are so predictive of later stroke, TIAs should not be ignored and medical help should be sought immediately.
Where pharmacists fit in
"Pharmacists are an important part of the stroke team," Summers says. "Treatment of a stroke patient is acute. It’s urgent. tPA is not stocked in the emergency department, so pharmacists are needed for emergent preparation of the drug.
"We’re doing a quality review of our time frame. The national time frame for patients with neurological diseases and stroke is to get them from the moment they enter the emergency department to treatment within one hour’s time. That includes the time needed for CT scans, labs — including PT/INR — to be drawn, assuming the stroke is not hemorrhagic. The pharmacist is part of the team. The minute the patient rolls in, the pharmacist is called and put on alert that we have a possible tPA patient. After we’re sure by CT scan that the stroke is appropriate for tPA use, we call pharmacist with the go-ahead and the patient’s weight. It’s then up to the pharmacist to get the drug to the emergency department. Our goal is to have drug to the patient within 10 minutes. The faster the patient is treated, the better the patient outcomes."
Pharmacists can play an important role in helping the patient’s family understand what’s happening while they wait in the emergency department for a prognosis, according to Summers.
Review stroke basics with family
There are four main types of stroke. Two are caused by blood clots or other particles, and two are caused by hemorrhage. Cerebral thrombosis and cerebral embolism are the most common types of stroke, accounting for about 70% to 80% of all strokes. Cerebral and subarachnoid hemorrhages are caused by ruptured blood vessels. A subarachnoid hemorrhage occurs when a blood vessel on the brain’s surface ruptures and bleeds into the space between the brain and the skull (but not into the brain itself). A cerebral hemorrhage occurs when a defective artery in the brain bursts, flooding the surrounding tissue with blood. Hemorrhagic strokes have a much higher fatality rate than ischemic strokes.1
Stroke is a cardiovascular disease that affects the blood vessels supplying blood to the brain. A stroke occurs when a blood vessel bringing oxygen and nutrients to the brain bursts or is blocked. Because of this rupture or blockage, part of the brain doesn’t get the blood flow it needs. Deprived of oxygen, nerve cells in the affected area of the brain can’t function and die within minutes. As a result, the part of the body controlled by these cells can’t function either. When those cells die, the effect is permanent since they aren’t replaced.1
As a cardiovascular disease, stroke treatment and prevention can mean treating the heart. Damaged heart valves may require surgery or treatment with anticoagulants to reduce the chance of clot formation around them. Patients with atrial fibrillation are also at risk for clot formation and are thus treated with anticoagulants.
Push for anti-hypertensive compliance
Stroke prevention includes monitoring and controlling blood pressure. "Pharmacists play a role in secondary prevention of stroke," says Summers. "They help monitor patient blood pressure, for example. High blood pressure causes 80% of strokes. Pharmacists can educate patients about the importance of taking their blood pressure and other medications. Pharmacists know the importance of continuing to take blood pressure medicine, even when you feel good, and they can help pass that understanding along to patients."
Knowledge of various drug classes is important in knowing which drugs patients should take. "There is much data provided in the results of the HOPE trial," says Cathy Carroll, RPh, PhD, of the University of Missouri-Kansas City. "The American Heart Association published guidelines for high-risk cardiovascular patients to receive ramipril for the prevention of stroke. The HOPE trial demonstrated a 32% reduction in the incidence of stroke in high-risk cardiovascular patients receiving ramipril. Pharmacists can help patients by being aware of the patient’s drug regimen upon discharge and making sure at-risk patients are on ACE inhibitors. Other data are showing us that patients who should be on an ACE inhibitor often are not."
Patient counseling is very important when warfarin is prescribed. "Nurses sometimes counsel these patients, but we’ve seen better results and better patient compliance when pharmacists provide the counseling," says Summers. "Every one of our patients who gets warfarin gets patient education." Pharmacists can also develop and run anticoagulation clinics and smoking cessation programs, two services extremely useful to stroke and cardiac patients.
The days are gone when all pharmacists did was lick, stick, count, and pour. Today’s pharmacists are relied upon for more cognitive services, including educating patients about the importance of taking their medications as directed. "Pharmacists also educate patients about their disease states and different signs and symptoms to watch for that require further medical attention," says Carroll. "Stroke is one condition for which a pharmacist’s counseling — and the patient’s compliance with that counseling — is of the utmost importance."
How fast can you move?
Every pharmacy needs a protocol regarding its delivery time of tPA. Is it pushing toward the three-hour goal? Summers suggests a quality improvement study to determine the time taken at each institution from the moment the patient enters the door to the time the patient receives treatment. Additionally, she suggests a time study to determine how long it takes from the time the pharmacy is notified of the definite need for tPA to delivery of the drug to the patient. "St. Luke’s is not yet at the 10-minute mark, but we’re close," Summers says.
(Editor’s note: To see which hospitals in your area made the top 100 hospitals for the treatment of stroke, visit www.100tophospitals.com.)
Reference
1. American Heart Association. Web site: www.americanheart.org/Heart_and_Stroke_A_Z_Guide/strokews.html.
Sources
• Debbie Summers, RN, MSN, Stroke Clinical Program Coordinator, St. Luke's Hospital, 4401 Wornall Road, Kansas City, MO 64111; (816) 932-2000.
• Cathy Carroll, RPh, PhD, University of Missouri-Kansas City, Assistant Professor, School of Pharmacy, 5005 Rockhill Road, Kansas City, MO 64110; (816) 235-1000.
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