Therapeutic yield and outcomes of a community teaching hospital code stroke protocol.
OBJECTIVE
To describe the experience of a community teaching hospital emergency department (ED) Code Stroke Protocol (CSP) for identifying acute ischemic stroke (AIS) patients and treating them with tissue plasminogen activator (tPA) and to compare outcome measures with those achieved in the National Institute of Neurological Disorders and Stroke (NINDS) trial.


METHODS
This study was a retrospective review from a hospital CSP registry.


RESULTS
Over a 56-month period, CSP activation occurred 255 times, with 24% (n = 60) of patients treated with intravenous (IV) tPA. The most common reasons for thrombolytic therapy exclusion were mild or rapidly improving symptoms in 37% (n = 64), intracerebral hemorrhage (ICH) in 23% (n = 39), and unconfirmed symptom onset time for 14% (n = 24) of patients. Within 36 hours of IV tPA treatment, 10% (NINDS = 6%) of patients (n = 6) sustained a symptomatic ICH (SICH). Three months after IV tPA treatment, 60% of patients had achieved an excellent neurologic outcome, based on a Barthel Index of > or =95 (NINDS = 52%), while mortality measured 12% (NINDS = 17%). Among IV tPA-treated patients, those developing SICH were significantly older and had a significantly higher mean initial glucose value. Treatment protocol violations occurred in 32% of IV tPA-treated patients but were not significantly associated with SICH (Fisher's exact test).


CONCLUSIONS
Over the study period, the CSP yielded approximately one IV tPA-treated patient for every four screened and, despite prevalent protocol violations, attained three-month functional outcomes equal to those achieved in the NINDS trial. For community teaching hospitals, ED-directed CSPs are a feasible and effective means to screen AIS patients for treatment with thrombolysis.
Asimos
Andrew W
AW
Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232, USA. aasimos@carolinas.org
Norton
H James
HJ
Price
Marlow F
MF
Cheek
Wilkie M
WM
D017677:Age Distribution; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D002985:Clinical Protocols; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D020521:Stroke / Q000097:blood / Q000175:diagnosis* / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome
D001786:Blood Glucose; D010959:Tissue Plasminogen Activator