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Neurology 2000;55:1801-1805
© 2000 American Academy of Neurology
Articles

Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke?

P.T. Akins, MD, PhD;, C. Delemos, RN;, D. Wentworth, RN;, J. Byer, MD;, S.J. Schorer, MD; and and R.P. Atkinson, MD

From Mercy Healthcare Sacramento, CA.

Address correspondence and reprint requests to Dr. Paul T. Akins, Mercy Healthcare Sacramento, 2825 J St., Suite 435, Sacramento, CA 95816; e-mail: akins @cwnet.com

OBJECTIVE: To review the clinical outcomes of stroke patients treated with IV tissue plasminogen activator (tPA; alteplase) in a community setting and to compare outcomes when treatment was initiated by a neurologist or an emergency department (ED) physician in telephone consultation with a neurologist and radiologist.

METHODS: Clinical information was prospectively collected for 43 stroke patients treated with IV tPA (alteplase) within a five-hospital network of affiliated community hospitals. Blinded 3-month outcomes were obtained with telephone interview or patient visit.

RESULTS: Excellent functional recovery measured by a Modified Rankin score of 0 to 1 (42%), symptomatic intracerebral hemorrhages (7%), and mortality (16.3%) were similar to those reported by National Institute of Neurological Disorders and Stroke (39%, 7.7%, 17.3%). After initial screening by an ED physician, 20 patients were directly examined by a stroke neurologist who then prescribed tPA. Twenty-three patients received tPA prescribed by an ED physician after telephone consultation with a neurologist and review of the head CT by a radiologist. Functional outcome, symptomatic intracerebral bleeding rate, and mortality rate were similar between these groups. Door-to-needle time was similar. Protocol deviations were much higher when ED physicians prescribed the tPA compared to when neurologists did (30% versus 5%). These protocol deviations were reduced with staff education.

CONCLUSIONS: The clinical results of the National Institute of Neurological Disorders and Stroke tPA Stroke Trial were replicated in this small series of patients treated in a community setting. Outcomes were similar whether the prescribing physician was a neurologist or an ED physician.




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