Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians - 21/01/19

Doi : 10.1016/j.annemergmed.2018.07.019

Iiro Heikkilä, MD ^a,^⁎ , Hanna Kuusisto, MD, PhD ^b, Markus Holmberg, MD ^a, Ari Palomäki, MD, PhD ^a,^c
^a Department of Emergency Medicine, Kanta-Häme Central Hospital, Hämeenlinna, Finland
^b Department of Neurology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
^c Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland

^∗Corresponding Author.

Abstract

Study objective

Thrombolysis with tissue plasminogen activator should occur promptly after ischemic stroke onset. Various strategies have attempted to improve door-to-needle time. Our objective is to evaluate a strategy that uses an emergency physician–based protocol when no stroke neurologist is available.

Methods

This was a retrospective before-after intervention analysis in an urban hospital. Reorganization of the acute ischemic stroke treatment process was carried out in 2013. We evaluated time delay, symptomatic intracerebral hemorrhage, and clinical recovery of patients before and after the reorganization. We used multivariable linear regression to estimate the change in door-to-needle time before and after the reorganization.

Results

A total of 107 patients with comparable data were treated with tissue plasminogen activator in 2009 to 2012 (group 1) and 46 patients were treated during 12 months in 2013 to 2014 (group 2). Median door-to-needle time was 54 minutes before the reorganization and 20 minutes after it (statistical estimate of difference 32 minutes; 95% confidence interval 26 to 38 minutes). After adjusting for several potential cofounders in multivariable regression analysis, the only factor contributing to a significant reduction in delay was group (after reorganization versus before). Median onset-to-treatment times were 135 and 119 minutes, respectively (statistical estimate of difference 23 minutes; 95% confidence interval 6 to 39 minutes). The rates of symptomatic intracerebral hemorrhage were 4.7% (5/107) and 2.2% (1/46), respectively (difference 2.5%; 95% confidence interval –8.7% to 9.2%). Approximately 70% of treated patients were functionally independent (modified Rankin Scale score 0 to 2) when treated after the reorganization.

Conclusion

Implementation of a stroke protocol with emergency physician–directed acute care decreased both door-to-needle time and onset-to-treatment time without increasing the rate of symptomatic intracerebral hemorrhage.

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Plan

Introduction

Background

Materials and Methods

Methods of Measurement

Results

Limitations

Discussion

	Please see page 106 for the Editor’s Capsule Summary of this article.
	Supervising editor: William J. Meurer, MD, MS
	Author contributions: IH, HK, and AP designed the study. IH organized the data collection. HK, MH, and AP participated substantially in interpretation of the data. IH and AP carried out statistical analyses. All authors drafted the article, critically revised it, and approved it. AP takes responsibility for the paper as a whole.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The study was funded by the Finnish Cultural Foundation, Häme Regional Fund (a grant to Iiro Heikkilä, MD), and the Ministry of Health and Social Welfare in Finland through the Medical Research Fund of Kanta-Häme Central Hospital.
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