Quality Improvement and Tissue-Type Plasminogen Activator for Acute Ischemic Stroke

Abstract

Background and Purpose— A systematic audit of intravenous tissue-type plasminogen activator (tPA) use and stroke outcomes in Cleveland, Ohio, during 1997–1998 demonstrated higher rates of symptomatic intracranial hemorrhage (ICH) than reported in the National Institute of Neurological Disorders and Stroke (NINDS) trial. We now report updated results of intravenous tPA use in the Cleveland Clinic Health System (CCHS). Methods— A stroke quality improvement program was initiated in the 9-hospital CCHS in 1999. A retrospective chart review for all stroke patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 434 and 436 admitted to the 9 hospitals from June 1999 to June 2000 was used to determine outcomes of patients treated with intravenous tPA. Results— Intravenous tPA was given to 18.8% of patients arriving within 3 hours of symptom onset. Protocol deviations occurred in 19.1% of patients given intravenous tPA. The symptomatic ICH rate was 6.4%. Conclusions— Since 1997, intravenous tPA use has increased, while the rates of symptomatic ICH and protocol deviations have decreased in the CCHS. The CCHS symptomatic ICH rate is now similar to that reported in the NINDS trial. These improvements occurred after initiation of a stroke quality improvement program.

Factors Associated With In-Hospital Mortality After Administration of Thrombolysis in Acute Ischemic Stroke Patients

“…3,4 Nevertheless, only a minority of patients who present with acute ischemic stroke are treated with tPA. [5][6][7][8][9][10][11] One factor that may contribute to this low rate is clinician concern about the safety of the treatment. 12 Because the prospective trials evaluating this therapy were conducted at academic and community hospitals with institutional commitment to stroke care, relatively little data are available regarding the safety of thrombolysis as it is used in a broad range of hospitals in the community.…”

Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care

“…34,35 Reassuringly, studies have shown that with training and implementation of stroke teams, complication rates return to expected and acceptable levels. 36 National guidelines from the American College of Emergency Physicians recommend that hospitals alert local emergency medical systems regarding their stroke treatment readiness so that optimal routing of patients with suspected stroke to appropriate facilities may be implemented.…”

Thrombolysis for acute ischemic stroke: does it work?—the con position

“…2 Symptomatic ICH occurs in about 2% of controls but 7% of treated patients (up to 22% in less strictly controlled community studies). 17,21,22 The case for thrombolysis is a "house of cards" resting on two weak RCTs. Let's be honest; the overwhelming majority of hard evidence shows no benefit, yet the risk of harm is clear.…”