title: Where Does the Time Go? The Effect of Protocols for Stroke Last Known Well Documentation on Intravenous Recombinant Tissue Plasminogen Activator Delivery in the Northeast.
abstract: BACKGROUND
  Despite significant efforts to improve thrombolytic use in the United States, only a small number of patients with ischemic stroke are currently treated. Although there are a number of contraindications to tissue plasminogen activator use, many patients are excluded because of the narrow therapeutic time window, which is determined by the "last known well" (LKW) time. However, it is unclear how the LKW is obtained and documented in the acute hospital setting.
  
  
  METHODS
  We surveyed hospitals throughout the Northeast region to determine if they had established protocols for documenting LKW times. Treatment rates as reported to Get with The Guidelines Stroke were then compared in hospitals with and without established protocols for documenting LKW times.
  
  
  RESULTS
  The majority of hospitals (73%) lacked established protocols for LKW documentation. Those without established protocols more often missed this variable when reporting to Get With The Guidelines-Stroke. Treatment rates were low overall (7%), although rates in patients who presented within 2 hours of symptom onset were high in hospitals whether they had an established protocol (86%) or not (87%). However, the lack of documentation of LKW is common and could influence the treatment rates if patients are erroneously excluded from treatment.
  
  
  CONCLUSIONS
  Improved documentation of LKW times should be attempted. The addition of this variable to existing protocols could more accurately track the number of patients ineligible for treatment based on delayed presentation.
authors.affiliation: Questions or comments about this article may be directed to Rita Zanichkowsky at rita.zanichkowsky@heart.org. She is a Director QII, American Heart Association, Scarborough, ME. Jennifer A. Nascimento, BS RN, is a Stroke Program Coordinator, St. Vincent's Medical Center, Bridgeport, CT. Marie McCune, BS RN SCRN, is a Stroke Nurse Coordinator, Mount Auburn Hospital, Cambridge, MA. Cindy Spencer, RN BS, is a Clinical Nurse Educator and a Stroke Program Coordinator, Wentworth-Douglass Hospital, Dover, NH. Florence Chukwuneke, RN BS CNRN, is a Comprehensive Stroke Center Coordinator, JFK Medical Center/NJ Neuroscience Institute, Edison, NJ. Tiana Wyrick, RN BS, is a Health Care Coordinator, New York State Department of Health, New York, NY. Louise D. McCullough, MD PhD, FAHA Professor, Departments of Neurology and Neuroscience, The University of Connecticut Health Center, The Stroke Center at Hartford Hospital, Farmington, CT.
authors.forename: Rita
authors.initials: R
authors.lastname: Zanichkowsky
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Nascimento
authors.forename: Marie
authors.initials: M
authors.lastname: McCune
authors.forename: Cynthia
authors.initials: C
authors.lastname: Spencer
authors.forename: Florence
authors.initials: F
authors.lastname: Chukwuneke
authors.forename: Tiana
authors.initials: T
authors.lastname: Wyrick
authors.forename: Louise D
authors.initials: LD
authors.lastname: McCullough
mesh_terms: D004282:Documentation; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D019983:Guideline Adherence; D006761:Hospitals; D006801:Humans; D009733:Nursing Diagnosis; D017410:Practice Guidelines as Topic; D020521:Stroke / Q000188:drug therapy*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator