Critical Path Network: Do you keep stroke patients waiting too long?

She may be an ideal candidate for thrombolytic therapy: A woman tells triage nurses that she first noticed symptoms exactly two hours ago. But by the time the patient is appropriately assessed, the window of time for eligibility to be treated with thrombolytics has passed.

Has that occurred in your emergency department (ED) recently? Currently, only 2% to 5% of all eligible patients receive the thrombolytic drug t-PA (tissue plasminogen activator), which was approved in 1996 for treatment of ischemic stroke within three hours of symptom onset.1

Although there is widespread support for the use of thrombolytics in stroke, not everyone is convinced by the existing evidence, explains Heidi Jahnke, RN, MSN, clinical research nurse at Barrow Neurological Institute of St. Joseph’s Hospital and Medical Center in Phoenix. "Some argue that this treatment should not be used until far better evidence of its benefits outweighs its harm," she says.2

Now a new study shows that acute ischemic stroke patients treated within 90 minutes with t-PA have the best chance of recovery. Results showed that t-PA may be of some benefit to patients up to four hours after symptom onset, but those treated in a five- or six-hour window had almost no benefits.1

New drugs may exceed the current three-hour window, with several current clinical trials using thrombolytic agents in acute ischemic stroke for up to 24 hours, Jahnke predicts. "We’ll have to await the data analysis to see if the benefits outweigh the risks, but it would be great to have another agent to use beyond three hours." (To review clinical trials for stroke, go to www.clinicaltrials.gov. Type in "stroke" in the "Search Clinical Trials" box.)

If a new thrombolytic was available for use within a four- to five-hour window of symptom onset, it would significantly increase the number of patients who could be treated at the ED, says Jahnke. "For instance, all of our 27 stroke patients in March 2004 were seen within six hours of their symptom onset," she says. "These patients potentially would have been considered for treatment if a new drug was available."

To increase the numbers of stroke patients eligible for treatment, do the following:

Educate nurses about stroke signs and symptoms. "In our ED, we undertook a huge education program on signs and symptoms for what resembles a stroke, including headache, facial numbness, and one-sided weakness," says Tom Garrity, RN, an ED nurse at St. Joseph’s.

All ED nurses were inserviced by the stroke neurologist and clinical educator on presentation of stroke. "These signs and symptoms are also printed on the back page of our acute stroke pathway," he says. As nurses became aware of the full range of symptoms patients could present with, the stroke team then focused on the importance of quickly identifying patients who needed immediate assessment: those who presented within a three-hour window with ongoing symptoms, Garrity says.

Public information campaigns about the warning signs of stroke, coupled with education of paramedics, has increased the number of patients coming to the ED within the three-hour time window, Jahnke reports.

When in doubt, page the stroke team. "When patients present with vague neurological symptoms, we ask nurses to go ahead and start the pathway and page the stroke team. The neurologist and ED physicians will further evaluate the patient," Garrity says.

Get the computed tomography (CT) scan and blood work done immediately. Standing orders are used for patients placed on the stroke pathway, with the average door to CT scan running about 22 minutes, he adds. "Decision-making time of our neurologists on whether to give t-PA has been a source of delay in our institution, but we are trying to improve on this. ED nurses take t-PA with us now to CT, so that the physician can order the t-PA while the patient is still in the CT area."

Identify patients eligible for t-PA. Patients with stroke symptoms now are designated as "Stroke 1" with symptom onset of fewer than six hours, and "Stroke 2," which are patients outside of that window, Jahnke says. She estimates that the ED sees 20-25 Stroke 1 patients per month and 15-20 Stroke 2 patients. "We treat all Stroke 1-eligible patients with t-PA, unless they decline, which are very few. We treat approximately three to nine stroke patients with thrombolytics per month, or approximately 25% to 35% of the Stroke 1s."

Use pre-printed orders. The ED uses pre-printed orders and protocols, along with a universal pager for radiology technicians and neurology physicians, Garrity explains. The following are expected time frames:

— The neurology resident in the ED assesses the patient within 10 minutes.
— Labs and CT are done within an hour of the patient’s arrival.

Share success stories with staff. "This helps reinforce to our ED staff how important this early recognition is to our patients," Garrity says.

References

1. The ATLANTIS, ECASS, and NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004; 363:768-774.

2. Hoffman JR. Tissue plasminogen activator (tPA) for acute ischemic stroke: Why so much has been made of so little. Med J Aust 2003; 179:333-334.