Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acute stroke care

Abstract

BackgroundStroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.ObjectivesTo test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and designA cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks.DiscussionTIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12613000939796

The Epidemiology of Stroke in a Developing Country (Pakistan)

“…One follow-up study helped in the identification of two groups of risk factors: Preventable and non preventable risk factors. The latter is associated with high stroke risk [50], whereas the former is associated with relatively lower risk of stroke. Preventable risk factors are open to intervention for lower stroke risk; these include diabetes mellitus, cardiovascular causes such as high blood pressure, raised cholesterol, smoking, valvar heart diseases, obesity/hyperlipidaemia, sedentary habits, diet high in fats and carbohydrates, neuropsychiatric disorders, and postoperative conditions.…”

Review of acute ischaemic stroke in Pakistan: progress in management and future perspectives

“…The fact that brain tissue is viable to be salvaged within a given period of time is the key concept in understanding why the time frame for delivering thrombolysis or intervention is so crucial in acute ischaemic stroke as shown in figure 4. [28][29][30][31][32][33][34][35][36][37][38][39][40] …”

Changes in Activated Thrombin-Activatable Fibrinolysis Inhibitor Levels Following Thrombolytic Therapy in Ischemic Stroke Patients Correlate with Clinical Outcome

“…However, partial recanalization and early reocclusion have been recognized as causes of poor outcomes in stroke patients treated with intravenous rt-PA [5][6][7][8] . The effective recanalization rate with rt-PA is close to 45% [6][7][8] .…”