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Coordination of care among EMS, stroke teams, and stroke centers is key to optimizing outcomes

In April 2007, the American Heart Association/American Stroke Association (AHA/ASA) published its updated Guidelines for the early management of adults with ischemic stroke.

The following are key recommendations regarding acute ischemic stroke care1:

  • Stroke centers are a part of a stroke system of care — a much larger network that encompasses stroke prevention, education of healthcare practitioners and the public, acute care, rehabilitation, and quality improvement in the delivery of healthcare.1
  • Activation of the 911 system by patients or others
    • – Leads to faster treatment of stroke
    • – As many as 65% of patients with signs or symptoms of acute stroke receive their initial care from EMS
  • EMS personnel should transport patients to the closest facility that has the resources to treat stroke
    • – Ambulance may bypass the nearest hospital if the EMS personnel know that there is a stroke-capable center within a reasonable distance
    • – Creation of educational programs to increase public awareness of stroke
      • – According to the guidelines, EMS activation appears to be a function primarily of someone other than the patient; 62% to 95% of 911 calls are made by a family member, coworker, paid caregiver, or other bystander

Protocols

ProtocolsEstablished protocols help to standardize stroke treatment, which supports efficient processes and effective metric tracking and may improve the quality of patient care.2

Here are some recommendations on how you may maintain successful protocols in your center:

  • Care paths, standing orders, protocols, flow charts, and/or stroke scales may be compiled in a stroke packet and used upon presentation in the ER
    • – Ideally initiated in the ED and carried through in the ICU
  • Allow quick, accurate assessment, administration of t-PA to eligible patients, tracking patient's neurologic status, and documentation of treatment outcomes
  • Identify performance measures and methods for improving procedures and systems through rigorous self-assessment

Impact of standardized orders on optimal treatment in individual hospitals

Adapted from CASPR Investigators. Neurology. 2005;65:360.

Mean scores for individual hospitals at 1 and 2 years. A solid line represents hospitals with significant improvement of overall treatment score. A dotted line represents hospitals whose change in score was not significant (based on the Wilcoxon rank sum test). The only hospital with no increase in score did not implement the standardized stroke orders.


Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Important Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.
2.
Rymer MM, Summers D, Khatri P, eds. The Stroke Center Handbook: Organizing Care for Better Outcomes. New York, NY: informa healthcare; 2006. Questionnaire courtesy of MM Rymer.
3.
California Acute Stroke Pilot Registry (CASPR) Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology. 2005;65:360-365.