Abstract
Background: There is uncertainty among many emergency medicine physicians about the decision to give intravenous tissue-type plasminogen activator (tPA) in suspected acute ischemic stroke patients, which limits its use. A checklist approach has been suggested as a solution. Objective: To compare agreement on tPA treatment in suspected acute ischemic stroke patients between vascular neurology and emergency medicine physicians using a checklist. Methods: Every suspected acute stroke patient brought to our comprehensive stroke center emergency room within 4.5 hours from symptom onset was prospectively evaluated simultaneously and independently by vascular neurology fellows (VNF) and emergency medicine residents (EMR). The latter used a tPA screening checklist, which included guideline exclusion criteria to help with their treatment decision. Agreement between the EMR and the VNF and a senior VN faculty was determined using Cohen’s kappa (κ) statistics. Results: Over 5 months, 60 patients were enrolled, age 63±16, 50% female, NIHSS median 6 (IQR: 1,14), premorbid mRS > 2 30%. Eventual etiology was: 10% large vessel atherosclerosis, 18% cardioembolism, 12% small vessel, 12% cryptogenic, and 48% mimic. 25 (42%) were deemed tPA eligible by the EMR, 18 (30%) by the VNF, and 22 (37%) by the VN faculty. Agreement was substantial between EMR and VNF (κ=0.68, 95% CI 0.49 to 0.87) and between EMR and VN faculty (κ=0.69, 95% CI 0.50 to 0.87]). Age, NIHSS, premorbid mRS, gender and race had no effect on agreement. There were no complications in any tPA treated patients. Stroke mimics were the main cause of disagreement between EMR and VNF (κ=0.24, 95% CI -0.15 to 0.63) and between EMR and VN faculty (κ=0.35, 95% CI -0.08 to 0.78). Conclusions: Our data suggest that with the aid of a checklist, emergency medicine physicians can reliably treat acute stroke patients with tPA. Areas for improvement include recognition of stroke mimics. Further studies are warranted to evaluate checklist enhanced tPA treatment in order to allay emergency medicine physician uncertainty and expand the use of tPA.
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