Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians

• Published in: Annals of emergency medicine 2019-02, Vol.73 (2), p.105-112
• Main Authors: Heikkilä, Iiro, Kuusisto, Hanna, Holmberg, Markus, Palomäki, Ari
• Format: Article
• Language: English
• Subjects: Aged; Brain Ischemia - diagnosis; Brain Ischemia - physiopathology; Brain Ischemia - therapy; Clinical Competence - standards; Clinical Protocols; Emergency Medical Services; Female; Fibrinolytic Agents - therapeutic use; Humans; Male; Middle Aged; Retrospective Studies; Stroke - diagnosis; Stroke - physiopathology; Stroke - therapy; Thrombolytic Therapy; Time-to-Treatment - statistics & numerical data; Tissue Plasminogen Activator - therapeutic use; Treatment Outcome
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2018.07.019

Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician–based protocol when no stroke neurologist is available. This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization. A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval –8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization. Implementation of a stroke protocol with emergency physician–directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.