Hostname: page-component-586b7cd67f-dsjbd Total loading time: 0 Render date: 2024-11-27T13:52:33.630Z Has data issue: false hasContentIssue false
  • English
  • Français

Improvement in Thrombolytic Therapy Administration in Acute Stroke with Feedback

Published online by Cambridge University Press:  02 December 2014

Esseddeeg Ghrooda ,
Susan Alcock  and
Alan C. Jackson
Esseddeeg Ghrooda
Affiliation:
Department of Internal Medicine (Neurology), Winnipeg, Manitoba, Canada
Susan Alcock
Affiliation:
University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
Alan C. Jackson*
Affiliation:
Department of Internal Medicine (Neurology), Winnipeg, Manitoba, Canada
*
Health Sciences Centre, GF-543, 820 Sherbrook Street, Winnipeg, Manitoba, R3A 1R9, Canada. Email: [email protected]
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

The benefits of intravenous recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke is time dependent. Guidelines recommend a door-to-needle (DTN) time of less than 60 minutes.

Methods:

A retrospective audit of 730 stroke charts from 2008 - 2011 was conducted at Health Sciences Centre. 158 patients treated with IV rt-PA were identified. The time intervals between Emergency Department (ED) arrival, administration of rt-PA and uninfused brain computed axial tomographic scan (CT) were recorded. From this, CT to needle times were calculated. During November 2010 to January 2011 feedback was given to neurologists, ED physicians, ED nurses, and CT technologists. This raised awareness and emphasized the importance of this time driven protocol.

Results:

The median DTN times for 2008, 2009, and 2010 were 69, 71 and 76 minutes respectively. The median CT-to-needle time for this time period was 47 minutes. In 2011 (n =58) the median DTN time was 49 minutes and the median CT-to-needle was 18 minutes, which were marked improvements (p<0.00005 and p<0.005, respectively). In 2008-2010 only 31% of treated patients (n=100) received rt-PA within 60 minutes, whereas in 2011 this increased to 64%.

Conclusions:

Dramatic improvements in DTN times and in the percentage of patients receiving rt-PA treatment within 60 minutes were observed in 2011 after feedback was provided regarding the suboptimal performance. Prior to receiving feedback, DTN times were similar to national median DTN times. All centres administering rt-PA for acute ischemic stroke should monitor their clinical performance and give feedback on a regular basis.

Résumé

RÉSUMÉ Contexte:

Les bénéfices de l'administration intraveineuse de l'activateur tissulaire recombinant du plasminogène (rt-PA) dans l'accident vasculaire cérébral (AVC) ischémique aigu est fonction du temps écoulé depuis le début des symptômes. Les lignes directrices recommandent un délai de l'arrivée du patient à l'administration du traitement thrombolytique de moins de 60 minutes.

Méthode:

Nous avons effectué une révision de 730 dossiers de patients admis au Health Sciences Centre pour AVC de 2008 à 2011. Nous avons identifié 158 patients traités par rt-PA intraveineux. Le temps écoulé entre l'arrivée au service des urgences (SU), l'administration de rt-PA et la tomodensitométrie cérébrale sans contraste ont été colligés afm de calculer le temps écoulé entre la tomodensitométrie et la thrombolyse. Nous en avons informé les neurologues, les urgentologues, les infirmières du service des urgences et les techniciens entre novembre 2010 et janvier 2011, ce qui a contribué à les sensibiliser et a souligné l'importance de ce délai.

Résultats:

Le temps médian écoulé de l'arrivée du patient à la thrombolyse était de 69 minutes en 2008, 71 minutes en 2009 et 76 minutes en 2010. Le temps médian écoulé de la tomodensitométrie à la thrombolyse était de 47 minutes. En 2011, chez 58 patients, le temps médian écoulé de l'arrivée du patient à la thrombolyse était de 49 minutes et de 18 minutes de la tomodensitométrie à la thrombolyse, ce qui constitue une amélioration notoire (p < 0,00005 et p < 0,005 respectivement). En 2008-2010, seulement 31% des patients traités (n = 100) ont reçu le rt-PA en dedans de 60 minutes, alors qu'en 2011 64% de ces patients l'ont reçu en dedans de 60 minutes.

Conclusions:

Une amélioration importante du délai entre l'arrivée du patient et la thrombolyse et du taux de patients qui reçoivent le rt-PA en dedans de 60 minutes a été observé en 2011, après le retour d'information aux soignants concernant le traitement sous-optimal de ces patients. Avant ce retour d'information, les délais de l'arrivée à la thrombolyse étaient similaires aux délais médians nationaux. Tous les centres où le rt-PA est administré chez des patients atteints d'un AVC ischémique aigu devraient évaluer leur performance clinique avec retour d'information régulièrement au personnel concerné.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 39 , Issue 6 , November 2012 , pp. 789 - 792
Copyright
Copyright © The Canadian Journal of Neurological 2012

References

1. Lindsay, MP, Gubitz, G, Bayley, M, Hill, MD. Canadian Best Practice Recommendations for Stroke Care (Update 2010). On behalf of the Canadian Stroke Strategy Best Practices and Standards Writing Group. 2010. Ottawa, Ontario, Canada: Canadian Stroke Network. Available from: http://www.canadianstrokestrategy.ca/eng/home.html Google Scholar
2. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.CrossRefGoogle Scholar
3. Hacke, W, Kaste, M, Bluhmki, E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008; 359(13):1317–29.CrossRefGoogle ScholarPubMed
4. Bluhmki, E, Chamorro, A, Davalos, A, et al. Stroke treatment with alteplase given 3.0-4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial. Lancet Neurol. 2009;8(12):1095–102.CrossRefGoogle Scholar
5. Wardlaw, JM, Murray, V, Berge, E, Del Zoppo, GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2009;CD000213.CrossRefGoogle ScholarPubMed
6. Fonarow, GC, Smith, EE, Saver, JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(19):750–8.Google Scholar
7. Saver, JL. Time is brain-quantified. Stroke. 2006;37(1):263–6.CrossRefGoogle ScholarPubMed
8. Chatterjee, P, Cucchiara, BL, Lazarciuc, N, Shofer, FS, Pines, JM. Emergency department crowding and time to care in patients with acute stroke. Stroke. 2011;42(4):1074–80.CrossRefGoogle ScholarPubMed
9. Assanasen, S, Edmond, M, Bearman, G. Impact of 2 different levels of performance feedback on compliance with infection control process measures in 2 intensive care units. Am J Infect Control. 2008;36(6):407–13.CrossRefGoogle ScholarPubMed
10. Frenzel, JC, Kee, SS, Ensor, JE, Riedel, BJ, Ruiz, JR. Ongoing provision of individual clinician performance data improves practice behavior. Anesth Analg. 2010;111(2):515–9.CrossRefGoogle ScholarPubMed
11. Berhe, M, Edmond, MB, Bearman, G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. Am J Infect Control. 2006;34(8):537–9.CrossRefGoogle ScholarPubMed
12. Duncan, K, Pozehl, B. Effects of performance feedback on patient pain outcomes. Clin Nurs Res. 2000;9(4)379–97.CrossRefGoogle ScholarPubMed
13. Whiteman, R, Gould, L, Oczkowski, W, LeBlanc, K, Leonard, P. Using a quality improvement process to create measurable improvement in care delivery for acute stroke. Healthcare Quarterly. 2011;14(3):75–9.CrossRefGoogle ScholarPubMed
14. Canadian Stroke Network. The quality of stroke care in Canada 2011; 2011. Available from: http://www.canadianstrokenetwork.ca Google Scholar