What if it's not safe to give tPA in your hospital?
What if it's not safe to give tPA in your hospital?
Poor monitoring, transfer delays can result in lawsuits
Before giving a stroke patient tissue plasminogen activator (tPA), you must consider not only whether the patent is a candidate, but also whether the setting is appropriate, says Edward Jauch, MD, MS, assistant professor in the department of emergency medicine at University of Cincinnati and a member of the Greater Cincinnati/Northern Kentucky Stroke Team.
"It's not just pushing a drug and walking away from the patient. You need to manage the patient afterward to do it safely and effectively," he says. "Because what can happen is, the patient gets the drug, but they are still at risk for complications long after they are admitted to the hospital."
Therefore, if the hospital has not made a commitment to provide the necessary resources to treat stroke effectively and safely or the ED physician is not confident in the capacity of the hospital to appropriately care for the stroke patient, he or she might be doing the right thing by not exposing the patient to the risk of thrombolytics.
"It's unfortunate that there are hospitals like that, but that's the harsh reality," says Jauch. "If you treat in the absence of a safe medical environment, you expose them perhaps to undue risk and harm. If you can't control that, then it's probably best not to treat even if you are depriving the patient of potential improvement from thrombolytics."
Close monitoring is key
After treatment, the patient's blood pressure needs to be well-controlled, with checks every 30 minutes and sometimes more often for the first six hours. If the blood pressure starts to become elevated after receiving the drug, the patient is at higher risk for hemorrhage.
"A lot of the improvement in morbidity and mortality that stroke patients can achieve is due to attention to these details," says Jauch.
However, asking a nurse in a very busy ED to assess the patient every 30 minutes, and then to know how to act upon that, is probably unrealistic and not in the patient's best interest. "In the ED, our front door is always open. We need to make sure that the back door of the ED is just as open, so patients can be admitted to the appropriate setting as soon as possible," says Jauch.
However, if your hospital has an existing protocol and you don't adhere to it, such as by failing to call the stroke team, then you are deviating from your own local standard of care and you are exposed to liability. "If your hospital provided the resources to do this appropriately, with neurology backup and the like, and the patient was an appropriate candidate for lytics, then it will be difficult to justify why thrombolytics were not considered or administered," says Jauch.
If your hospital lacks adequate resources to treat stroke patients, then an existing transfer program must be in place to get the patient to another hospital to receive tPA in a timely fashion. If the patient arrives at the destination hospital after a significant delay in transfer and is now well beyond the therapeutic window, you are exposed to risk of a lawsuit based on the delay.
Even if your hospital doesn't treat stroke, 40% of patients still arrive on their own without calling 911.1 "So even if every ambulance takes patients to the appropriate hospital, many stroke patients may end up in your ED even if you are not capable of handling it," says Jauch, noting that gunshot victims are often dropped off at hospitals that are not trauma centers.
In this case, the hospital doesn't say 'We don't do that here, so you'll just be admitted to the floor,' says Jauchthey should consider transferring that patient to another ED, including by helicopter if necessary, to receive the level of care they require with the therapeutic window.
"That same mentality is needed for stroke," he says. "If you are sitting on a patient for six hours before you transfer them and the hospital is ten minutes away, it will be hard to justify that to the family if there is a bad outcome."
Reference
1. Kleindorfer DO, Lindsell CJ, Broderick JP, et al. Community socioeconomic status and prehospital times in acute stroke and transient ischemic attack: do poorer patients have longer delays from 911 call to the emergency department? Stroke 2006; 37:1508-1513.
Before giving a stroke patient tissue plasminogen activator (tPA), you must consider not only whether the patent is a candidate, but also whether the setting is appropriate, says Edward Jauch, MD, MS, assistant professor in the department of emergency medicine at University of Cincinnati and a member of the Greater Cincinnati/Northern Kentucky Stroke Team.Subscribe Now for Access
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