Abstract
Background: IMPROVE Stroke Care is a regional implementation science study in the Southeastern US aimed at reducing acute stroke treatment times and improving outcomes through wide scale application of best practices. Optimal blood pressure in acute ischemic stroke (AIS) and acute intracerebral hemorrhage (ICH) remains controversial. Current guidelines lack specific targets for non-tPA treated AIS or ICH. We sought to evaluate current BP management processes for acute stroke within the 65 hospitals in the IMPROVE consortium. Methods: A 27-question survey was conducted using Qualtrics software. Topics covered existing protocols, guideline adherence, target BP in various settings, medication availability and use cases, and EMS practices. Simple proportions were calculated. Results: Overall survey completion rate was 71% (Hub 8/9 (89%) and Spoke 38/56 (68%)). The majority of participating sites (89%) have BP management protocols in place, as do their transport agencies (89%). Order sets are utilized for this in 87% of Emergency Departments and 83% of Intensive Care Units. Significant variation in practice was seen regarding goal BP in AIS patients who were not tPA candidates, with ‘provider discretion’, ‘unsure’ or ‘NA’ accounting for 63% of responses. Similarly, target BP prior to and following thrombectomy varied greatly. In tPA eligible AIS patients 76% (32/42) reported goal BP in line with the AHA guideline recommendation of <185/110mmHg; 21% (9/42) reported a goal <180/100mmHg. BP goals for ICH also vary widely, with systolic goals <150mmHg (46%) and <140mmHg (24%) the most common choices, with no difference in anticoagulated patients. The first-line drugs used in ED and EMS are labetalol (ED 83%/ EMS 35%), hydralazine (10%/26%), and nicardipine (8%/26%). In the ED, medications are obtained from a ‘cart or closet’ 62%, walked from pharmacy 27%, ‘tubed’ 17%, or ‘other’ 27%. Importantly, no participating sites indicated BP control as a common reason for stroke treatment delay. Conclusion: The survey demonstrates that many Southeastern US hospitals have BP management protocols in place that follow guidelines where available, and have tools to prevent treatment delays, yet no consensus exists on goal BP in thrombectomy, non-tPA treated AIS and ICH patients.
Published Version
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