Abstract TP112: Clinical Consequences of Tenecteplase Substitution for Alteplase at a Large Hub-Spoke Care Model

Abstract

Introduction: Tenecteplase (TNK) is becoming the preferred thrombolytic for acute brain ischemia. We report a system-wide transition using intentional change management of a hub-spoke delivery model annually providing about 300 intravenous thrombolytic administrations to 3000 stroke alerts from alteplase to TNK. Methods: By 2021, evidence supported transition to TNK from alteplase to treat acute ischemic stroke at 0.25mg/kg (maximum 25mg). We began by gathering opinions from key stakeholders regarding TNK’s clinical merit to gauge support. We subsequently educated constituents including nursing, pharmacy, technical and clinical staff. A six-month lead-in, six-month introductory, and one-year transition period began in April 2021 using an intentional change method. Median door-to-needle (DTN), door-to-puncture (DTP), thrombolytic utilization and symptomatic hemorrhage rates were recorded at five primary (P) and a comprehensive stroke center (C). Results: During lead-in to TNK, DTN were 60(P), 26(C) minutes with 10%(P), 19%(C) utilization. DTP was 73 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of alteplase-treated patients. During TNK’s 6-month introductory period DTN were 60(P), 20(C) minutes with 10%(P), 19%(C) utilization. DTP was 71 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of TNK patients. During the subsequent one-year transition period, DTN was 53(P) and 23(C) minutes with 8%(P),16%(C) utilization. DTP was 78 minutes. Symptomatic hemorrhage occurred in 1.5%(P) and 3.0%(C). Conclusions: Hub-spoke delivery systems can safely transition to TNK using intentional process change reducing DTN and hemorrhagic complications with stable utilization. Substitution may not reduce DTP if thrombolytic administration is not the rate-limiting step. Intentional process change provides smooth transition when stakeholder education precedes, and pathway adherence follows implementation.