Abstract P29: Improving Door to Needle Alteplase Times: Pharmacist Involvement During Code Stroke

Abstract

Introduction: According to the American Stroke Association’s “Guidelines for Acute Ischemic Stroke (2018),” it is a Class IIb recommendation that hospitals set a goal of achieving Door to Needle (DTN) times within 45 minutes in > 50% of ischemic stroke patients who are treated with IV alteplase (tPA). Furthermore, a new Class I recommendation states that “multidisciplinary teams with access to neurological expertise [be utilized] to safely increase IV thrombolytic treatment.” Review of the literature shows that there is still limited research in this area, and the potential exists to discover more about the utility of the pharmacist role in the acute stroke patient. Methods: A retrospective, single-center study of patients who received alteplase for acute ischemic stroke in the Emergency Department, based on the initial “Code Stroke” activation, between January 1, 2019 and July 1, 2020 was conducted. The purpose was to investigate the difference in DTN treatment times when a pharmacist is involved compared with times when a pharmacist is not available. The primary outcome was the median DTN administration time, with secondary outcome of achievement of DTN time < 45 minutes. Results: The patients who had a pharmacist involved in their care (n=30) showed a median DTN time of 42.5 minutes, compared to 58 minutes in the group without pharmacy involvement (n=22). Patients in the pharmacy group achieved a DTN time of < 45 minutes in 57% of cases, versus 32% of cases in the non-pharmacy group. Conclusion: Our current practice in the ED regarding availability of a pharmacist varies, given variable patient volume and limitation of resources in our community-based, Primary Stroke Center. Our data suggests that expanding the number of hours covered by a dedicated pharmacist might help improve DTN times. Though our standard practice is still to provide scheduled, regular training on alteplase to ED nursing staff, the unique expertise and additional benefits provided by a pharmacist may serve to complement and enhance the treatment effectiveness of the entire team.

The Role of Pharmacists in Providing Pharmaceutical Care in Primary and Secondary Prevention of Stroke: A Systematic Review and Meta-Analysis

“…Of the cluster randomized studies, one [ 26 ] was a sub-analysis of the completed study [ 25 ]. Three studies were of experimental before-and-after design [ 28 , 29 , 30 ], five were cross-sectional [ 31 , 32 , 33 , 34 , 35 ] and fourteen were cohort studies [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. To capture the breadth of pharmacist interventions, two audit reports [ 50 , 51 ] and five conference abstracts [ 23 , 33 , 40 , 41 , 47 ] were also included for data extraction although quality assessment was not possible using standard tools.…”

“…Individual study characteristics are shown in Table 5 , Table 6 and Table 7 . Seven studies reported pharmacist interventions for primary stroke prevention [ 28 , 29 , 30 , 32 , 33 , 36 , 50 ] and twenty-four focussed on secondary stroke prevention [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 31 , 34 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 45 , 46 , 47 , 48 , 49 , 51 ].…”

“…Most studies (24 of 31) investigated the impact of pharmacist interventions for the secondary prevention of stroke. These interventions were at different stages of the patient treatment pathway and ranged from the immediate emergency treatment of stroke (i.e., at initial emergency department presentation) [ 35 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 46 , 47 , 48 ] and intermediate hospital-based post-acute phase care [ 22 , 27 , 34 , 51 ] through to long-term follow-up post-stroke in outpatient clinics [ 23 , 31 , 39 , 45 , 49 ], tertiary referral centres [ 21 ] or community care [ 24 , 25 , 26 ].…”

“…Pharmacist interventions in the emergency and acute care of patients diagnosed with stroke were described in eleven studies [ 35 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 46 , 47 , 48 ]. These were categorised as secondary prevention because appropriate acute treatment has the potential to reduce and prevent stroke recurrence.…”

“…Nine studies [ 35 , 37 , 38 , 41 , 42 , 43 , 44 , 46 , 47 ] reported the impact of pharmacist involvement in emergency stroke response teams responsible for the preparation and administration of emergency thrombolysis (e.g., intravenous recombinant tissue plasminogen activator (rtPA); alteplase). Emergency thrombolytics are high-cost drugs and involve complex patient assessment criteria and intense patient monitoring.…”