Protocol adherence and safety of intravenous thrombolysis after telephone consultation with a stroke center.
Intravenous tissue plasminogen activator (tPA) for acute ischemic stroke must be provided in an appropriate setting. The best way to provide thrombolysis in small community hospitals remains uncertain. Medical records were reviewed of tPA treatments at a stroke center between January 2002 and October 2005. The stroke center provides phone consultation for acute stroke to smaller hospitals in the region. Subjects were classified into 3 groups: tPA started at referring hospitals before transfer (treat and transfer group), tPA started at the stroke center after transfer (transfer and treat group), and the control group of patients who presented directly to the stroke center and received tPA (stroke center group). We recorded the patient and treatment characteristics, protocol deviations, symptomatic intracranial hemorrhage (ICH), and in-hospital deaths. There were 133 patients in the treat and transfer group, 35 patients in the transfer and treat group, and 86 patients in the stroke center group. Time from onset to treatment was similar in the treat and transfer and the stroke center groups, but the door-to-needle time was shorter by 12 minutes in the latter (P=.02). Fifty-five protocol deviations occurred in 38% patients in the treat and transfer group, compared with 6% in the stroke center group (P<.001). The most common deviations were related to time window violations and incorrect tPA dosing. Symptomatic ICH occurred in 8.2%, with no significant difference between the groups. Neither community hospital treatment nor protocol deviation was a predictor of symptomatic ICH or in-hospital mortality. Our findings indicate the need for improved protocol adherence for stroke thrombolysis in patients presenting to small community hospitals.
University of Pittsburgh Medical Center Stroke Institute, Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. uchinok@ccf.org
Ken
K
Uchino
Lori
L
Massaro
Tudor G
TG
Jovin
Maxim D
MD
Hammer
Lawrence R
LR
Wechsler
D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D002985:Clinical Protocols; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D019983:Guideline Adherence; D006297:Health Services Accessibility; D006742:Hospital Bed Capacity; D017052:Hospital Mortality; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006801:Humans; D007262:Infusions, Intravenous; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D016015:Logistic Models; D008875:Middle Aged; D016017:Odds Ratio; D010360:Patient Transfer; D010414:Pennsylvania; D017410:Practice Guidelines as Topic; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy* / Q000401:mortality; D017216:Telemedicine / Q000706:statistics & numerical data; D013689:Telephone; D015912:Thrombolytic Therapy / Q000009:adverse effects; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator