Phillip Scott, M.D. (left), studied the ability of community hospitals to administer tPA safely.
Stroke of Genius
New guidelines and statewide study spotlight local stroke response
issue 18 | spring/summer 2013
When a patient begins experiencing symptoms of stroke, the nearest major stroke center could be miles away, and the patient may not recognize or act on the symptoms right away. That combination of delay and distance can keep patients from receiving optimal care, including timely tPA treatment for ischemic stroke.
But a new national guideline for emergency stroke care, and results from a statewide study of stroke treatment in 24 Michigan community hospitals, point to new possibilities that could benefit patients nationwide.
U-M emergency physician Phillip Scott, M.D., who co-authored the guidelines and directed the statewide study, says physicians of all specialties should be aware of the new recommendations and findings.
"Educating our patients about their personal risk for stroke, and about the need for rapid action if they experience stroke-like symptoms, could affect their long-term outcomes," he says.
“If [a community] hospital partners with a primary or comprehensive stroke center, early treatment decisions can be made.”
Phillip Scott, M.D.
NEW NATIONAL GUIDELINES
The new American Stroke Association guidelines, published in Stroke, extend the time window for tPA treatment to 4.5 hours, from the previous 3 hours. This longer period means that more patients may be eligible for tPA, which has been shown to improve long-term motor and cognition effects from stroke.
But the guidelines also put new pressure on hospitals to reduce the "door to needle" time for stroke patients to 60 minutes— including triage, brain imaging and preparation for tPA administration.
If a hospital isn't equipped to provide tPA treatment, ischemic stroke patients should be rapidly transferred to the closest available certified primary stroke center or comprehensive stroke center, which might involve air medical transport, the guidelines say.
"However, for patients brought to hospitals that don't offer specialized stroke expertise, telemedicine and simple telephone support can provide real-time access to expertise," says Scott. "If such a hospital partners with a primary or comprehensive stroke center, early treatment decisions can be made."
The role of community hospitals and physicians is made clear by recently published results from the study that Scott directed, called INSTINCT. It evaluated the ability of 24 community hospitals to deliver tPA, with training and 24/7 support available from U-M. The study was funded by the National Institute of Neurological Diseases and Stroke.
By the end of the study, the community hospitals that had the U-M experts as the "sixth man" on their teams did better at delivering tPA to eligible patients, without increased risk of hemorrhage, than those that didn't. The findings of the randomized controlled trial were published in Lancet-Neurology.
“Telemedicine and simple telephone support can provide real-time access to expertise.”
Phillip Scott, M.D.
Data from 22 of the hospitals show that tPA use more than doubled in the 11 hospitals randomized to receive assistance, versus a smaller increase in the other 11. Some hospitals even surpassed national targets for tPA use that large stroke centers don't always reach — a true game-changing performance.
Across the U.S., less than 5 percent of stroke patients receive tPA — when more than 11 percent could — largely because of the time factor. The INSTINCT results demonstrate that tPA can be used safely in the community hospital setting, and that more work needs to be done to expand public access to the only treatment approved by the FDA to reverse the effects of stroke.
As for other ischemic stroke treatments, such as stent retrievers used to remove large clots, the new guidelines call for further studies to determine if they improve patient outcomes before being seen as substitutes for intravenous tPA during the time window when tPA can be given.