Rates Of tPA Use Research Articles

Safety and Efficacy of Ethanol for Catheter Salvage and Central Line-Associated Bloodstream Infection Prophylaxis in Polyurethane Catheters in the PICU.

Ethanol lock therapy (ELT) is a potential method of central catheter salvage following central line-associated bloodstream infection (CLABSI) although there is potential risk of catheter damage in polyurethane catheters. Further, there is limited efficacy data across the spectrum of common pediatric catheters, and published ELT protocols describe dwell times that are not feasible for critically ill children. We sought to evaluate the safety and efficacy of ELT in polyurethane catheters using brief (30 min to 2 hr) dwell times in our PICU. Investigational pilot study using historical control data. PICU in quaternary care, free-standing children's hospital. ELT in polyurethane central venous catheters for catheter salvage. ELT with brief dwell times was used in 25 patients, 22 of whom were bacteremic. Ultimately 11 patients, comprising 14 catheters, were diagnosed with a primary CLABSI. The catheter salvage rate in primary CLABSI patients receiving ELT was 92% (13/14) and significantly higher than the salvage rate in patients receiving antibiotics alone (non-ELT) (62%, 39/64; mean difference 0.32, 95% CI [0.14-0.50], p = 0.03). The rate of catheter fracture in all patients receiving ELT was 8% (2/25) while the rate of fracture in the non-ELT group was 13% (8/64; mean difference -0.05, 95% CI [-0.18 to 0.09], p = 0.72). The rate of tissue plasminogen activator (tPA) use in the ELT group was 8% (2/25), whereas the rate of tPA use in the non-ELT group was significantly higher at 42% (26/64; mean difference -0.34, 95% CI [-0.49 to -0.17], p = 0.002). The use of ELT for catheter salvage and prophylaxis in the PICU is safe in a variety of polyurethane catheters. Dwell times ranging from 30 minutes to 2 hours were effective in sterilizing the catheters while allowing other therapies to continue. This approach may decrease the need for frequent line changes in a medically fragile pediatric population.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention.

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

A systematic review and meta-analysis of interventions to increase stroke thrombolysis

BackgroundAlthough the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness.MethodsWe searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics.ResultsThe search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45–2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44–2.09) for EMS, 1.58 (95% CI, 0.72–3.47) for telemedicine, and 1.89 (95% CI, 0.77–4.65) for public education, the latter not restricted to ischemic stroke patients.ConclusionsInterventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.

Abstract TMP70: Hospital Factors Associated With Interhospital Stroke Transfer Destination in the Northeast United States

Background: The role of hospital factors in the decision to transfer acute ischemic stroke (AIS) patients is not clear. Objective: To determine whether hospital quality is associated with the transfer of stroke patients between 2 hospitals. Methods: Medicare claims data were used to identify AIS patients transferred between hospitals in the Northeast US from 2007-2011. We categorized hospitals as transferring hospitals (TH), retaining hospitals (RH), and accepting hospitals (AH) based on the largest proportion of AIS patient encounters that were transferred, retained, or accepted. All AHs participated in Get With The Guideline (GWTG)-Stroke, enabling the use of registry data to determine hospital performance by tPA use, composite quality measure score and door-to-needle (DTN) time for tPA. We identified connected TH-AH dyads as those with &gt; 5 patients transferred annually and used logistic regression to identify hospital characteristics associated with the establishment of a given TH-AH connection. We fitted separate models for each measure of performance (rate of tPA use, GWTG composite quality measure and median DTN time); we also adjusted for driving distance between hospitals, AH stroke volume, and the number of hospitals in the AH’s referral region. Results: Of 394 Northeast hospitals, there were 136 THs, 241 RHs, and 17 AHs. The odds of an establishing an AH-TH connected dyad were influenced by many factors and increased when quality measure performance increased at the AH or decreased at the TH (Table). Conclusion: Among Northeast U.S. hospitals, we found that interfacility transfer destinations of choice were sensitive to differences in AH quality, with higher AH performance associated with increased likelihood of being a transfer destination. Further research is needed to better understand AIS transfer patterns in order to optimize the transfer system for maximal patient benefit in the future.

Impact of Participation in a Telestroke Network on Clinical Outcomes.

A telestroke program, known as the Remote Evaluation for Acute Ischemic Stroke program, has been implemented in Georgia since 2003. This study examined whether a hospital's participation in a telestroke network was associated with improvement in clinical outcomes and quality indicators. An observational study was conducted using data from the Georgia Coverdell Acute Stroke Registry between September 2005 and September 2016 for patients aged ≥18 years with ischemic stroke. We use a difference-in-differences approach to compare the following clinical outcomes and quality indicators among those admitted at hospitals within and outside of the Remote Evaluation for Acute Ischemic Stroke network: tPA (tissue-type plasminogen activator) use, complications related to tPA use, door-to-needle time, ambulation at discharge, discharge status, and destination. Logistic regression models and a propensity score weighting approach were performed to adjust for patients' age, sex, race, insurance coverage, arrival mode, ambulatory status before the current stroke, stroke severity, medical history, admission time, and hospital bed size. A total of 25 494 patients with ischemic stroke admitted at 15 nonteaching hospitals located outside of the Atlanta metropolitan area were included in the analysis. After propensity score weighting, hospitals participated in a telestroke network was not associated with a significant increase in the rate of tPA use, while it was significantly associated with a modest decline in the rate of complications related to tPA (-5.9%; 95% CI, -9.2% to -2.6%). Telestroke participation showed no significant difference in other clinical outcomes and quality measures except for a marginally significant decrease in in-hospital mortality (-1.1%; 95% CI, -2.2% to -0.1%). Although a slight decrease in tPA complication was observed among hospitals participating in the telestroke network, overall the impact of telestroke participation on a hospital's stroke care quality was not statistically significant based on our observational study.

Racial disparities in refusal of stroke thrombolysis in Chicago.

To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago. Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression. Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99). Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Use and Outcomes of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients ≥90 Years of Age.

Intravenous tissue-type plasminogen activator (tPA) is a proven treatment for acute ischemic stroke, but there has been limited evaluation among patients aged ≥90 years. We analyzed data from the Get With The Guidelines-Stroke national quality improvement registry from January 2009 to April 2013. Frequency, determinants, and outcomes of tPA use were compared among patients aged ≥90 and 3 younger age groups (18-64, 65-79, and 80-89 years). Among 35 708 patients from 1178 sites who arrived within 2 hours of time last known well and received tPA, 2585 (7.2%) were ≥90 years. Compared with younger patients, the rate of tPA use among patients without a documented contraindication was lower among patients aged ≥90 years (67.4% versus 84.1% in 18-89-year olds; P<0.0001). Discharge outcomes among individuals aged ≥90 years included discharge to home or acute rehabilitation in 31.4%, independent ambulation at discharge in 13.4%, symptomatic hemorrhage in 6.1%, and in-hospital mortality or hospice discharge in 36.4%. On multivariable analysis, good functional outcomes generally occurred less often and mortality more often among patients aged ≥90 years. The risk of symptomatic hemorrhage was increased compared with patients <65 years but was not significantly different than the risk in 66- to 89-year olds. The use of intravenous tPA among those aged ≥90 years is lower than in younger patients. When fibrinolytic therapy is used, the risk of symptomatic hemorrhage is not higher than in 66- to 89-year olds; however, mortality is higher and functional outcomes are lower.

Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke

Interhospital transfer after use of intravenous tissue-type plasminogen activator (tPA) in acute stroke (drip and ship) is increasingly frequent. Small studies have suggested that drip and ship tPA is safe and increases rates of tPA use; however, little is known about real-world practice patterns. We sought to evaluate temporal trends in drip and ship tPA use and to compare the patient and hospital characteristics with that of conventional (front door) thrombolysis. We analyzed data from 44 667 patients with ischemic stroke treated with intravenous tPA ≤3 hours of symptom onset in the Get With The Guidelines-Stroke program from April 2003 to October 2010 in 1440 hospitals. The main outcomes were the frequency of drip and ship tPA use over time, the characteristics of patients treated, and in-hospital outcomes, treatments, and complications. Among 44 667 patients treated with tPA, the drip and ship method was a common method (n=10 475; 23.5%), the use of which increased in parallel with the traditional tPA method over time. Patients treated by the drip and ship method differed significantly from front-door patients, with lower National Institutes of Health Stroke Scale scores when recorded (n=35 467). Crude in-hospital mortality (10.9%) and symptomatic intracranial hemorrhage (5.7%) in patients treated by the drip and ship method were slightly higher compared with those in front-door patients, and these differences persisted after risk adjustment. Drip and ship tPA is common, used in 1 in 4 patients treated with tPA in the United States. Modest differences in mortality and symptomatic intracranial hemorrhage may be because of patient selection bias, post-tPA care differences, or unmeasured confounding. The drip and ship paradigm may facilitate widespread tPA use in patients with acute stroke.

Abstract W P307: Utilization of Tissue-Type Plasminogen Activator for Ischemic Stroke in California -Evidence From Ischemic Stroke Outcomes Validation Study

Background and Purpose: A recent ischemic stroke data validation study using California (CA) patient discharge data (PDD) was conducted as part of a public reporting program for the Office of Statewide Health Planning and Development (OSHPD). This validation study demonstrated that use of tissue-type plasminogen activator (tPA) is well-coded in the PDD. Supported by this evidence, we sought to measure tPA usage for ischemic stroke in CA acute care hospitals and to determine whether some hospital or patient characteristics are associated with greater or lower tPA utilization. Methods: Using the OSHPD PDD, we selected adult patients with a primary diagnosis of ischemic stroke admitted to CA acute care hospitals between January 2010 and November 2011. Using bivariate analysis, we explored the association between rates of tPA use and patient age, gender, race, and expected payer, as well as hospital teaching status, location, and size. Results: Among the 74,586 patients hospitalized with acute ischemic stroke in CA, 4,488 patients (6.02%) received tPA. The observed rate of tPA usage among hospitals ranged from 0% to 22.13%.There were no significant gender differences. Younger patients had a higher rate of tPA usage than older patient groups (7.4% vs. 5.8% and 6.1%, P=0.0029). White patients had a higher rate of tPA utilization than Black and Hispanic patients (6.8% vs. 4.2% and 4.4%, P&lt; 0.0001). Those with Medicare (5.9%) and Medi-Cal (5.1%) had a lower rate of tPA utilization than those with private insurance (7.5%), but higher than self-pay patients (4.4%) (P&lt; 0.0001). There was a significantly higher rate of tPA usage in teaching hospitals than non-teaching hospitals (8.6% vs. 5.7%, P&lt; 0.0001) and tPA utilization was significantly greater at urban versus rural hospitals (6.3% vs. 3.3%,P&lt;0.0001). Higher rates of tPA utilization were associated with increased hospital bed size (P&lt; 0.0001). Conclusions: Rates of tPA utilization in CA acute care hospitals varied significantly by hospital teaching status, location, licensed bed size and patient demographic characteristics.

Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines-Stroke Hospitals

Substantial efforts over the past decade have increased rates of intravenous tissue plasminogen activator (tPA) use in the United States. We sought to determine changes in patient characteristics and rates of tPA use over time among hospitalized acute ischemic stroke (AIS) patients. We analyzed all AIS patients (n=1 093 895) and those arriving ≤ 2 hours and treated with tPA ≤ 3 hours after onset (n=50 798) from 2003 to 2011 in the American Heart Association's Get with the Guideline-Stroke (GWTG-Stroke). Categorical data were analyzed by Pearson χ(2) and continuous data by Wilcoxon test. Intravenous tPA use ≤ 3 hours after onset increased from 4.0% to 7.0% in all AIS admissions and 42.6% to 77.0% in AIS patients arriving ≤ 2 hours and fully eligible for tPA (P<0.001). In univariate analysis, tPA use increased over time, especially in those aged >85 years, nonwhite, and with milder strokes (National Institutes of Health Stroke Scale 0-4). Door-to-image time (median 24 versus 20 minutes) and door-to-tPA time (median 81 versus 72 minutes) also improved, with ≈65% of tPA-treated patients getting brain imaging ≤ 25 minutes after arrival. Multivariable analysis showed that with each additional calendar year, the odds that an eligible patient would receive tPA increased by 1.37-fold, adjusting for other covariates. The frequency of IV tPA use among all AIS patients, regardless of contraindications, nearly doubled from 2003 to 2011. Treatment with tPA has expanded to include more patients with mild deficits, nonwhite race/ethnicity, and oldest old age.

Temporal Trends in Patient Characteristics and Treatment With Intravenous Thrombolysis Among Acute Ischemic Stroke Patients at Get With the Guidelines–Stroke Hospitals

Background— Substantial efforts over the past decade have increased rates of intravenous tissue plasminogen activator (tPA) use in the United States. We sought to determine changes in patient characteristics and rates of tPA use over time among hospitalized acute ischemic stroke (AIS) patients. Methods and Results— We analyzed all AIS patients (n=1 093 895) and those arriving ≤2 hours and treated with tPA ≤3 hours after onset (n=50 798) from 2003 to 2011 in the American Heart Association’s Get with the Guideline–Stroke (GWTG–Stroke). Categorical data were analyzed by Pearson χ 2 and continuous data by Wilcoxon test. Intravenous tPA use ≤3 hours after onset increased from 4.0% to 7.0% in all AIS admissions and 42.6% to 77.0% in AIS patients arriving ≤2 hours and fully eligible for tPA ( P &lt;0.001). In univariate analysis, tPA use increased over time, especially in those aged &gt;85 years, nonwhite, and with milder strokes (National Institutes of Health Stroke Scale 0–4). Door-to-image time (median 24 versus 20 minutes) and door-to-tPA time (median 81 versus 72 minutes) also improved, with ≈65% of tPA-treated patients getting brain imaging ≤25 minutes after arrival. Multivariable analysis showed that with each additional calendar year, the odds that an eligible patient would receive tPA increased by 1.37-fold, adjusting for other covariates. Conclusions— The frequency of IV tPA use among all AIS patients, regardless of contraindications, nearly doubled from 2003 to 2011. Treatment with tPA has expanded to include more patients with mild deficits, nonwhite race/ethnicity, and oldest old age.

Abstract 103: Temporal Trends in Patient Characteristics and Use of IV tPA in Acute Ischemic Stroke Patients Treated at GWTG-Stroke Hospitals

Intro: Substantial efforts over the past decade have been made to increase rates of IV tPA use in the US. We sought to determine changes in patient characteristics and rates of tPA use over time among hospitalized stroke patients. Methods: We analyzed all acute ischemic stroke (AIS) patients (n=1,093,895) and those arriving ≤ −2 hr and treated with IV tPA ≤ 3 hr of onset (n=50,798) from 2003-2011 in the GWTG-Stroke registry. Categorical data were analyzed by Pearson Chi-square and continuous data by Wilcoxon test, with multivariable GEE models (with and without NIHSS) for analysis of calendar time effect. Results: IV tPA use increased from 4.0% to 7.0% in all AIS admissions, and 42.6% to 77.0% in AIS patients arriving ≤ 2hr and tPA treated ≤ 3 hr (p &lt;0.001) (Figure). In univariate analysis, IV tPA use increased over time in those aged &gt;85 yr, non-white, and with milder strokes (NIHSS 0-4) (Table). Door-to-image time (median 24 vs. 20 min) and door-to -tPA time (median 81 vs. 72 min) also improved, with ~65% of tPA treated patients getting CT &lt;25 min of arrival (Table). Multivariable GEE analysis of the effect of calendar year on rates of tPA use (n= 45656) found an adjusted OR of 1.37 (95%CI 1.35 - 1.40; p &lt; 0.0001) per year. Including NIHSS in the model (n=39814) did not change the results substantially (OR=1.32, CI 1.29 - 1.35; p&lt;0.0001) per yr. Conclusion: The frequency of IV tPA use among all AIS patients, regardless of contraindications, and among eligible patients without contraindications arriving within two hours nearly doubled from 2003-2011. Treatment with tPA has expanded over the past decade to include more stroke patients with milder deficits, non-white race-ethnicity, and in the oldest old.

Abstract 20: Acute Stroke Care and Thrombolysis at Critical Access Hospitals in Illinois

Background: Critical access hospitals (CAH) are the first point of stroke care in many rural regions of the United States (US). The Illinois Critical Access Hospital Network (ICAHN), a network of 51 CAH in Illinois, began a quality improvement program to address acute stroke care in 2009. We evaluated the performance on several metrics in acute stroke care at CAH between 2009 and 2011. Methods: Currently, 28 of 51 CAHs in Illinois currently participate in the American Heart Association’s Get With The Guidelines - Stroke (GWTG-S) registry for quality improvement. The GWTG-S registry captured elements including demographics, diagnosis, times of arrival, imaging completion, and intravenous tissue plasminogen activator (IV tPA) administration, and final discharge disposition. We analyzed the change in percent of stroke patients receiving tPA, door-to-needle (DTN) time, and proportion of total stroke patients admitted versus transferred to another facility over the 3 years. Fisher’s exact and Mann-Whitney tests were used as appropriate. Results: In the baseline assessment (2009), there were 111 strokes from 8 sites which grew to 12 sites and 305 strokes in year 1 (2010) and 14 sites and 328 strokes in year 3 (2011). The rate of tPA use for ischemic stroke was 2.2% in 2009, 4.0% in 2010, and 6.2% in 2011 (P=0.20). EMS arrival (41.1%), EMS pre-notification (82.6%), door-to-CT times (median 35 minutes; 34.6% &lt; 25 minutes), and DTN times (average 93 minutes; 13.3% DTN time &lt; 60 minutes) were not different over time. The rate of transfer from CAH to another hospital (51.3%) was constant. Every patient that received tPA except 1 (96.9%) was transferred (drip-ship) for post-tPA care. Conclusions: Improving acute stroke care at CAHs is feasible and represents a significant opportunity to increase tPA utilization in rural areas. As stroke systems develop, it is vital that CAHs be included in quality improvement efforts. The ICAHN stroke collaborative provided the opportunity to coordinate resources, share best practices, participate in targeted educational programming, and utilize data for performance improvement through the funded GWTG-S registry.

Abstract 193: IV TPA Administration to Eligible Patients at Certified Primary Stroke Centers

Introduction: The use of IV TPA at Primary Stroke Centers (PSCs) is a key performance metric that can greatly impact patient outcomes after acute ischemic stroke. Concerns remain about whether PSCs administer IV TPA to most eligible patients. Methods: We used data from PSCs certified by The Joint Commission (TJC) from 2008 to 2011. Patients who presented within 2 hours of ischemic stroke onset were included if they met a list of eligibility criteria for IV TPA consistent with current guidelines.Results were further analyzed based on several hospital characteristics, including teaching status, urban vs rural setting, and number of certification cycles. Results: Data were available from 34,909 patients at 842 hospitals. The overall rate of TPA use in eligible patients was 81% (28269 of 34909 patients). From 2008 to 2011 the rate of TPA use increased from 79.4% to 83.5% (P &lt; 0.0001). The rate of TPA use at teaching hospitals (n=455) was always greater than at non-teaching hospitals (n=367) overall (82% vs 79%, P &lt; 0.001) and each year (80.4% vs 77.6%, 2008; 82.6% vs 80.2%, 2009; 82.3% vs 77.9%, 2010; 84.7% vs 81.4%, 2011; P &lt; 0.005 for all comparisons). The rate of TPA use always increased with the number of certification cycles that a hospital had completed (absolute increase one cycle vs 4 cycles, 20% in 2008; 12.1% 2009; 12.9% 2010; 5.6% 2011; P &lt; 0.004 for all comparisons). The use of TPA was higher at the 783 urban hospitals compared with the 39 rural hospitals (81.3% vs 72.5%, P &lt; 0.001). Conclusions: The rate of IV TPA use in eligible patients has increased from 2008 through 2011, and is higher the longer a hospital has been a PSC, and at teaching and urban facilities. Overall PSCs have a high rate of IV TPA administration.

Abstract 2703: In-hospital Versus Out-of-hospital Stroke Treated With Iv Tpa And 3 Month Outcomes.

Background: Most hospitals set up Code Stroke alert teams in the Emergency Departments. Expanding sufficient Code Stroke coverage to in-hospital areas requires additional resources, often through Neuro-hospitalist teams. Most data on outcomes after stroke are based on out-of-hospital stroke. We evaluated the outcomes of patients with stroke that occurs in the hospital versus out-of-hospital. Methods: We included all adult patients with Code Stroke alerts, diagnosis of acute ischemic stroke, who had 90-days post Code Stroke modified Rankin Scale from the UCSD SPOTRIAS database (2004 to 2011) and excluded patients transferred from acute care facilities. The patients were grouped into 1: out-of-hospital Code Stroke alerts (EMS or ED) and 2: in-hospital (all inpatient units) and analyzed by baseline demographics, time to treatment decision, frequency of IV tPA use, 90-day modified Rankin Scale (mRS) and adjusted for multiple co-variables. Symptomatic intracranial hemorrhage (SICH) was defined as ≥4 point increase in NIHSS and ICH that was deemed the cause of the clinical change. Results: We identified 590 Code Stroke alerts; 563 in group 1 and 27 in group 2. Baseline demographics were balanced, except group 2 patients younger (64.26±16 vs 70.2±15.5 years of age, p=0.0497) and were more likely to be Hispanic (29.6 vs 14.2%, p=0.047). IV tPA was given in 13/27 (48.2%) patients in Group 2 and 266/563 (47.3%) in Group 1 (NS). Anticoagulation was the reason for exclusion in 4/14 (28.6%) of patients in Group 2 vs 18/266 (6.5%) (p=0.017). The frequency of other diagnoses and reasons for exclusion were similar between groups. The time from stroke onset to tPA treatment in group 2 was 135.1±57.9 vs 151.4±121.2 min (NS). A 90-day mRS of 0 or 1 was achieved in 9/27 (33.3%) patients in Group 2 and 221/563 (39.3%) patients in Group 1 (NS); in tPA treated patients: Group 2 3/13 (23.1%), Group 1 83/266 (31.2%) (NS). SICH occurred in the tPA treated patients: Group 2 1/13 (7.7%); Group 1 9/266 (3.4%) (NS). Conclusion: We identified a relatively small group of ischemic stroke patients with in-hospital onset. In those patients, however, rates of tPA use and outcomes were similar to out-of-hospital stroke.

Abstract 2539: Evaluation of Emergency Department Acute Ischemic Stroke Patients With and Without Blockage on Computed Tomography Angiography

Background: CT angiography (CTA) provides early assessment of cerebral vasculature in ED patients presenting with Acute Ischemic Stroke (AIS). Prior studies using 4 row detector CT scanners have suggested that results may be used to determine who receives thrombolytics (tPA). We sought to evaluate the rate of normal CTA and the use of tPA in AIS patients with and without blockages using modern CT technology. Methods: We conducted a retrospective cohort study of all code stroke patients presenting to our ED over a 3 year period ending in February 2011. Inclusion criteria included an ED and neurology diagnosis of AIS with a CTA performed at presentation. All patients had a NIHSS score recorded at presentation and underwent imaging using a 64 row detector scanner (Phillips) with 50cc of non-ionic contrast. Demographic, imaging, and clinical data were collected. Modified Rankin Scores (mRS) were assigned at presentation and hospital discharge. Good clinical outcome was defined as a mRS of 0-2. Data are reported as frequencies and medians with interquartile ranges (IQR) as appropriate. Rates of tPA use were evaluated using χ 2 testing. Changes in mRS were evaluated with the paired t-test. Results: A total of 209 subjects met inclusion for analysis of which 104 (50%) were male and 116 (55%) had no blockage on CTA. The median NIHSS score and mortality rates were 14 (IQR 8-19), 14 (15%) with CTA blockage, and 4 (IQR 2-7), 3 (3%) for those without. The use of tPA occurred in 46(50%) with 29 patients receiving intra-arterial therapy, and 14 (12%) patients with and without blockage respectively. Post tPA bleeding occurred in 12 (13%) patients with blockage on CTA and in 0 patients without blockage. Use of tPA was significantly more frequent in patients with a blockage on CTA, P &lt;0.001. As a group, patients without a blockage had a significant decrease in mRS at discharge, however the overall difference was greater in the tPA group, difference = 0.4 (0.2-0.7) P&lt;0.0002 and 1.9 (1.2-2.6) P&lt;0.0001 respectively. Only AIS patients with a blockage and given tPA had a significant reduction of mRS, difference = 0.6 (0.2-1.0) P&lt;0.005 compared with no tPA, difference = -0.1 (-0.4-0.3) P&lt;0.7. Conclusion: More than half of our AIS patients presenting through our ED have no blockage on CTA. Patients with AIS and no blockage on CTA have less severe strokes and are less likely to receive tPA. Both AIS patients with and without a blockage on CTA appear to derive benefit from tPA.

Abstract 3309: Enrolling the Oldest Old is Achievable in Acute Stroke Clinical Trials

Background: Acute stroke clinical trials have frequently excluded the very elderly, leading to a lack of data regarding therapy effect in this rapidly growing population. We sought to describe the frequency and characteristics of the oldest old (patients aged 80-95) enrolled in an ongoing multicenter prehospital treatment trial, the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study. Methods: FAST-MAG is a phase 3, NIH-funded, randomized, double-blind study of field-administered magnesium sulfate vs. placebo in stroke patients enrolled within 2 hours of symptom onset. All patients who were not disabled prestroke up to age 95 are eligible for enrollment. Results: Among the first 1207 subjects enrolled in FAST-MAG, 353 (29%) were &gt;= 80 and 42 (4%) were &gt;= 90 years old. Compared with younger trial subjects, individuals &gt;=80 years old had higher mean age (85 v 63, p&lt;0.0001), were more often women (53% vs. 38%, P&lt;0.0001), less often Hispanic ethnicity (13% v 27%, p&lt;0.0001), more often racially white (87% v 76%, p&lt;0.0001), and were less likely to have intracerebral hemorrhage (15% v 28%, p&lt;0.0001). However, the very elderly had similar stroke deficit severity (NIHSS 11 v 11, p=0.65) and were evaluated by paramedics (mean 37 v 37 min) and arrived in the ED (73 v 71 min, p=0.65) at similar time points. In the field, the very elderly had similar SBP (160 v 158, p=0.59) but lower DBP (78 v 86, p&lt;0.0001). Medical history variables distinguishing the very elderly from younger patients were higher frequency of HTN (87% vs. 77%, P&lt;0.0001), atrial fibrillation (40% vs. 17%, p&lt;0.0001), coronary artery disease (27% vs 18%, p&lt;0.0001), and lower tobacco use (4% vs 23%, p&lt;0.0001). Rates of TPA use among cerebral ischemia patients did not differ between the very elderly and younger patients (31% v 28%, p=0.507). The subgroup of extremely old patients, aged 90-95, were similar to patients aged 80-89, except there were no smokers, and even higher proportions were women (69%), non-Hispanic (91%) and white (93%). Conclusions: The very elderly can account for nearly 3 in 10 patients enrolled in a hyperacute stroke treatment trial. The oldest old have distinct clinical characteristics, indicating that their inclusion is in clinical trials is important for study results to be widely generalizable to clinical practice.

Trends in thrombolytic use for ischemic stroke in the United States.

Although recombinant tissue plasminogen activator (tPA) improves outcomes from ischemic stroke, prior studies have found low rates of administration. Recent guidelines and regulatory agencies have advocated for increased tPA administration in appropriate patients, but it is unclear how many patients actually receive tPA. To determine whether national rates of tPA use for ischemic stroke have increased over time. We identified all patients with a primary diagnosis of ischemic stroke from years 2001 to 2006 in the National Hospital Discharge Survey (NHDS), a nationally representative sample of inpatient hospitalizations, and searched for procedure codes for intravenous thrombolytic administration. Clinical and demographic factors were obtained from the survey and multivariable logistic regression used to identify independent predictors associated with thrombolytic use. Among the 22,842 patients hospitalized with ischemic stroke, tPA administration rates increased from 0.87% in 2001 to 2.40% in 2006 (P < 0.001 for trend). Older patients were less likely to receive tPA (adjusted odds ratio [OR] and 95% confidence interval [CI]; 0.4 [0.3-0.6] for patients ≥80 years vs. <60 years), as were African American patients (0.4 [0.3-0.7]). Larger hospitals were more likely to administer tPA (3.3 [2.0-5.6] in hospitals with at least 300 beds compared to those with 6-99 beds). Although tPA administration for ischemic stroke has increased nationally in recent years, the overall rate of use remains very low. Larger hospitals were more likely to administer tPA. Further efforts to improve appropriate administration of tPA should be encouraged, particularly as the acceptable time-window for using tPA widens.

Advance Hospital Notification by EMS in Acute Stroke Is Associated with Shorter Door-to-Computed Tomography Time andIncreased Likelihood of Administration of Tissue-Plasminogen Activator

Background. Rapid brain imaging is a critical step in facilitating the use of intravenous (IV) tissue-plasminogen activator (tPA) or catheter-based thrombolysis. We hypothesized that advance notification by emergency medical services (EMS) would shorten emergency department (ED) arrival-to-computed tomography (CT) time andincrease the use of IV andintra-arterial thrombolysis, even at a tertiary care stroke center with high baseline rates of tPA use. Methods. We analyzed data on all acute stroke patients transported from March 2004 to June 2005 by EMS from the scene to our facility arriving ≤6 hours from symptom onset. We reviewed digital voice recordings of all EMS communications to our hospital andin-hospital time intervals andoutcomes from our stroke database. Results. Among the 118 patients who met criteria, there were no significant differences between those with notification (n = 44) andthose without (n = 74) in terms of age, gender, history of prior stroke, median National Institutes of Health Stroke Scale (NIHSS) score in the ED, proportion with mild stroke (NIHSS score ≤4), or mean onset-to-ED arrival time. Door-to-CT time was 17% shorter (40 vs. 47 minutes, p = 0.01) in the advance-notification group, andthrombolysis occurred twice as often (41% vs. 21%, p = 0.04). Conclusion. Advance notification of patient arrival by EMS shortened time to CT andwas associated with a modest increase in the use of thrombolysis at our hospital. This occurred even with protocols in place to shorten the time to CT for all acute stroke patients. Further research is needed to understand how to increase rates of advance notification by EMS in potential tPA candidates.

Acute Stroke Management in the Elderly

Background and Purpose: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. Methods: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. Results: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the ≧80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the ≧80 cohort).The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the ≧80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. Conclusions: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.