Thrombolytic guidelines may stop controversy

Are physicians in your ED skeptical about the use of thrombolytics for stroke patients? If so, this may soon change, as a result of new recommendations from the Northbrook, IL-based American College of Chest Physicians (ACCP).

The evidence-based guidelines review existing and new medications for stroke patients, including thrombolytics. "A grading system is used, based on available evidence and strength of that evidence," says Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain & Spine Center at Brackenridge Hospital in Austin, TX. "Several of the stronger recommendations directly affect the ED."1

The guidelines might put an end to a longstanding controversy over use of thrombolytics for stroke patients in the ED, says Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, stroke center coordinator at The Stroke Center at Hartford (CT) Hospital. "The initial studies were criticized because they were heavily sponsored by the industry that makes the drug," she says. "Now, an independent analysis of the data still supports those findings. The initial study results have been confirmed to show that thrombolytics do lessen disability and death from stroke."

Many ED physicians did not believe thrombolytics were warranted for these patients, but the guidelines give solid evidence that this should now be standard of care, emphasizes Beland. "I just don’t see the argument that someone could use to withhold treatment from eligible patients," she says. "Even if the guidelines still don’t convince some physicians, it will convince the public that they should start requesting this."

You can dramatically improve care of stroke patients by using these recommendations from the new guidelines:

  • Patients who are eligible for thrombolytics should be given aspirin.

"It should become part of the ED nurse’s routine that once an acute ischemic stroke patient is found ineligible for thrombolytics, they should administer aspirin orally or rectally if necessary, prior to the patient’s transfer out of the ED," says Beland.

  • Use of thrombolytics is recommended within a three-hour window for acute ischemic stroke.

However, the guidelines state that thrombolytics should not be used in the presence of early computerized tomography (CT) changes, explains Brandt. "The use of thrombolytics should be considered in all eligible patients if they present within the three-hour window, unless they have early CT changes."

The ACCP found enough documented evidence to make this a Grade 1A recommendation, adds Brandt. "They looked at six randomized, controlled trials. This evidence is very well documented — better than with a lot of other interventions that we use consistently."

The guidelines also recommend against the use of thrombolytics for acute ischemic stroke in the three- to six-hour window, she adds.

  • Patients with an angiographically demonstrated major cerebral artery occlusion and not other signs of major early infarction should be considered for intra-arterial thrombolytics.

"If your hospital has intra-arterial capability, you should be aware of that option, especially since it opens the time-to-treatment window to six hours or possibly longer for basilar artery thrombolism," says Brandt.

  • Appropriate resources should be utilized to improve stroke care.

The Stroke Center at Hartford Hospital uses a hotline to help manage stroke patients in EDs throughout Connecticut and in surrounding states, including Vermont, New York, and Massachusetts, says Beland. "We provide this service to as many people and institutions as we can, and we market it heavily," she says. This marketing is done through direct mail, educational presentations, and conference exhibits, says Beland.

When the hotline is called, the following steps occur:

— The bed coordinator checks to see if there is space for the patient. Meanwhile, the on-call neurologist is notified and contacts the referring physician to discuss the patient’s symptom onset and potential treatments for which they might be eligible.

— If the patient is eligible for thrombolytic therapy, the neurologist will counsel the ED physician to start administering it while transport is being arranged.

Other times, there is no reason to transfer the patient because the time frames are too long or the center can’t provide anything the ED is not already doing, says Beland. "We don’t want ED physicians to do anything they’re uncomfortable with. But if they are unable to provide the care, they need to be able to find a link that can."

Reference

1. Hirsh J, Guyatt G, Albers GW, et al. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Chest 2004; 126:172S-173S.

Sources/Resource

For more information on the new thrombolytic guidelines, contact:

  • Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, Stroke Center Coordinator, The Stroke Center at Hartford Hospital, 80 Seymour St., Hartford, CT 06102-5037. Telephone: (860) 545-1976. Fax: (860) 545-5062. E-mail: dbeland@harthosp.org.
  • Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain & Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Telephone: (512) 324-7782. Fax: (512) 324-7051. E-mail: lbrandt@seton.org.

Single copies of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines can be obtained for $18 plus $8 shipping. To order, contact:

  • American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062-2348. Telephone: (800) 343-2227 or (847) 498-1400. E-mail: accp@chestnet.org. Web: www.chestnet.org.