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Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams.

ABSTRACT: The objective was to evaluate safety of intravenous (IV) tissue plasminogen activator (tPA) delivered without dedicated thrombolytic stroke teams.This was a retrospective, observational study of patients treated between 1996 and 2005 at four southeastern Michigan hospital emergency departments (EDs) with a prospectively defined comparison to the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke study cohort. Main outcome measures were mortality, intracerebral hemorrhage (ICH), systemic hemorrhage, neurologic recovery, and guideline violations.A total of 273 consecutive stroke patients were treated by 95 emergency physicians (EPs) using guidelines and local neurology resources. One-year mortality was 27.8%. Unadjusted Cox model relative risk (RR) of mortality compared to the NINDS tPA treatment and placebo groups was 1.20 (95% confidence interval [CI] = 0.87 to 1.64) and 1.04 (95% CI = 0.76 to 1.41), respectively. The rate of significant ICH by computed tomography (CT) criteria was 6.6% (odds ratio [OR] = 1.03, 95% CI = 0.56 to 1.90 compared to the NINDS tPA treatment group). The proportions of symptomatic ICH by two other prespecified sets of clinical criteria were 4.8 and 7.0%. The rate of any ICH within 36 hours of treatment was 9.9% (RR = 0.94, 95% CI = 0.58 to 1.51 compared to the NINDS tPA group). The occurrence of major systemic hemorrhage (requiring transfusion) was 1.1%. Functional recovery by the modified Rankin Scale score (mRS = 0 to 2) at discharge occurred in 38% of patients with a premorbid disability mRS < 2. Guideline deviations occurred in the ED in 26% of patients and in 25% of patients following admission.In these EDs there was no evidence of increased risk with respect to mortality, ICH, systemic hemorrhage, or worsened functional outcome when tPA was administered without dedicated thrombolytic stroke teams. Additional effort is needed to improve guideline compliance.

SUBMITTER: Scott PA

PROVIDER: S-EPMC3058313 | biostudies-literature | 2010 Oct

REPOSITORIES: biostudies-literature

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Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams.

Scott Phillip A PA Frederiksen Shirley M SM Kalbfleisch John D JD Xu Zhenzhen Z Meurer William J WJ Caveney Angela F AF Sandretto Annette A Holden Ann B AB Haan Mary N MN Hoeffner Ellen G EG Ansari Sameer A SA Lambert David P DP Jaggi Michael M Barsan William G WG Silbergleit Robert R

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 20101001 10

<h4>Objectives</h4>The objective was to evaluate safety of intravenous (IV) tissue plasminogen activator (tPA) delivered without dedicated thrombolytic stroke teams.<h4>Methods</h4>This was a retrospective, observational study of patients treated between 1996 and 2005 at four southeastern Michigan hospital emergency departments (EDs) with a prospectively defined comparison to the National Institute of Neurological Disorders and Stroke (NINDS) tPA stroke study cohort. Main outcome measures were m ...[more]

PMID: 21040107

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Project description:ObjectivesWake-up stroke is an important clinical problem that may account for a quarter of all ischemic strokes. This study aimed to establish the safety and efficacy of intravenous thrombolytic treatment of wake-up strokes by comparing it to the standard thrombolysis treatment in strokes with clear onsets and wake-up strokes that did not receive reperfusion therapy.MethodsThis retrospective study enrolled 95 patients with ischemic strokes who underwent thrombolytic treatment with alteplase, including nine patients with wake-up strokes. The safety profile (mortality and intracranial bleeding) and efficacy (clinical and functional outcomes on admission, discharge, and 90 days after stroke onset) were evaluated.ResultsWhen assessed using the modified Rankin scale (mRs), the patients with wake-up strokes had significantly more favorable functional outcomes on discharge when compared to those who received standard thrombolysis (p = .0289). No significant differences were noted when the favorable outcome rate (mRs score = 0-2) at three months post-thrombolysis (Odds ratio [OR] = 2.07; 95% confidence interval [CI] = 0.41-10.6; p = .3807) and safety outcomes (death during hospitalization: OR = 0.49; 95% CI = 0.03-9.11; p = .6295 and intracranial bleeding 24 hr after treatment: OR = 0.43; 95% CI = 0.02-7.58; p = .5707) were compared between the two groups. The Cochran-Mantel-Haenchel shift analysis showed a significantly more favorable distribution of the mRs scores at three months after the stroke onset in the patients with wake-up strokes who were treated with alteplase compared to those who did not receive thrombolysis (OR = 1.42; 95% CI = 1.01-1.82; p = .0426).ConclusionsOur study demonstrated that in patients who awaken with stroke symptoms, intravenous thrombolytic treatment is a safe procedure that may lead to favorable outcomes. Further studies should be performed to increase the size of the group of patients with wake-up strokes who can be treated with reperfusion therapy.

Project description:BackgroundMost ischaemic strokes are caused by blockage of a cerebral artery by a thrombus. Intravenous administration of recombinant tissue plasminogen activator given within 4.5 hours is now standard treatment for this condition. Percutaneous vascular interventions use an intra-arterial, mechanical approach for thrombus disruption or removal (thrombectomy). Recent randomised trials indicate that percutaneous vascular interventions are superior to usual care (usual care usually included intravenous thrombolysis). However, intravenous thrombolysis was usually given in both arms of the trial and there was a lack of direct comparison of percutaneous vascular interventions with intravenous thrombolysis.ObjectivesTo assess the effectiveness and safety of percutaneous vascular interventions compared with intravenous thrombolytic treatment for acute ischaemic stroke.Search methodsWe searched the Cochrane Stroke Group Trials Register (last search: August 2018). In addition, in September 2017, we searched the following electronic databases: CENTRAL, MEDLINE, Embase, and Science Citation Index; and Stroke Trials Registry, and US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov.Selection criteriaRandomised controlled trials (RCTs) that directly compared a percutaneous vascular intervention with intravenous thrombolytic treatment in people with acute ischaemic stroke.Data collection and analysisTwo review authors applied the inclusion criteria, extracted data, and assessed risk of bias. We obtained both published and unpublished data. We assessed the quality of the evidence using the GRADE approach.Main resultsWe included four trials with 450 participants. Data on functional outcome and death at end of follow-up were available for 443 participants from three trials. Compared with intravenous thrombolytic therapy, percutaneous vascular intervention did not improve the proportion of participants with good functional outcome (modified Rankin Scale score 0 to 2, risk ratio (RR) 1.01, 95% confidence interval (CI) 0.82 to 1.25, P = 0.92). The quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). At the end of follow-up, there was a non-significant increase in the proportion of participants who died in the percutaneous vascular intervention group (RR 1.34, 95% CI 0.84 to 2.14, P = 0.21). The quality of evidence was low (wide confidence interval). There was no difference in the proportion of participants with symptomatic intracranial haemorrhages between the intervention and control groups (RR 0.99, 95% CI 0.50 to 1.95, P = 0.97). The quality of evidence was low (wide confidence interval). Data on vascular status (recanalisation rate) were only available for seven participants from one trial; we considered this inadequate for statistical analyses.Authors' conclusionsThe present review directly compared intravenous thrombolytic treatment with percutaneous vascular interventions for ischaemic stroke. We found no evidence from RCTs that percutaneous vascular interventions are superior to intravenous thrombolytic treatment with respect to functional outcome. Quality of evidence was low (outcome assessment was blinded, but not the treating physician or participants). New trials with adequate sample sizes are warranted because of the rapid development of new techniques and devices for such interventions.

Project description:BackgroundEnhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.Materials and methodsFour EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.ResultsOverall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.DiscussionUsing CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.ConclusionThis study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Project description:INTRODUCTION:The receipt of remote clinical care for children via telecommunications (pediatric telemedicine) appears to improve access to and quality of care in U.S. emergency departments (EDs), but the actual prevalence and characteristics of pediatric telemedicine receipt remain unclear. We determined the prevalence and current applications of pediatric telemedicine in U.S. EDs, focusing on EDs that received telemedicine from clinicians at other facilities. METHODS:We surveyed all 5,375 U.S. EDs to characterize emergency care in 2016. We then randomly surveyed 130 (39%) of the 337 EDs who reported receiving pediatric telemedicine. The second survey was administered by phone to ED directors primarily. It confirmed that the ED received pediatric telemedicine services in 2017 and asked about ED staffing and the nature, purpose, and concerns with pediatric telemedicine implementation. RESULTS:The first survey (4,507/5,375, 84% response) showed that 337 (8%) EDs reported receiving pediatric telemedicine. Among the randomly sampled EDs completing the second survey (107/130, 82% response), 96 (90%) confirmed 2016 use and 89 (83%) confirmed 2017 use. Reasons for discontinuation included technical and scheduling concerns. Almost all who confirmed their pediatric telemedicine use in 2017 also reported 24/7 availability (98%). The most widely reported use was for patient placement and transfer coordination (80%). Many EDs (39%) reported no challenges with implementing pediatric telemedicine and described its utility. However, the most frequently reported challenges were process concerns (30%), such as concerns about slowing or interrupting providers' work flow and technological concerns (14%). CONCLUSION:Few EDs receive telemedicine for the delivery of pediatric emergency care nationally. Among EDs that do use telemedicine for pediatric care, many report process concerns. Addressing these barriers through focused education or interventions may support EDs in further developing and optimizing this technological adjunct to pediatric emergency care.

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Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams.

Publications

Safety of intravenous thrombolytic use in four emergency departments without acute stroke teams.

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