Nancy Newcommon

Effectiveness of t-PA in acute ischemic stroke: Outcome relates to appropriateness

Objective: To examine whether the demonstrated efficacy of tissue-type plasminogen activator (t-PA) for acute ischemic stroke can be effective in a community setting. Methods: Sixty-eight consecutive patients with acute ischemic stroke treated with IV t-PA within 3 hours of symptom onset by attending general neurologists in a busy teaching hospital. Outcome measures at 3 months were the National Institute of Health Stroke Scale (NIHSS), functional outcome (independence [modified Rankin score 0–2], dependence [modified Rankin score 3–5], and death), and symptomatic hemorrhage. Appropriately treated patients were defined by adherence to the National Institute of Neurological Disorders and Stroke (NINDS) guidelines. Effectiveness is expressed as the absolute risk reduction in which the baseline risk is assumed to be similar to that of the NINDS control group. Results: Of 68 consecutively treated patients (with a mean baseline NIHSS score of 15 ± 6), 26 (38%) made a full recovery and 39 (57%) made an independent recovery. The 11 patients who violated protocol had a lower probability of independence (p < 0.02) and full neurologic recovery (p < 0.02) and a higher probability of symptomatic hemorrhage (p < 0.05) and death (p < 0.01) compared with those of 57 patients treated according to NINDS guidelines. Conclusions: The use of t-PA for stroke in this community is effective with a number needed to treat of six. The risk of symptomatic hemorrhage is similar to that noted in randomized trials. Treating patients who violate protocol results in excess risk with no observable benefit.

Reliability of point-of-care testing of INR in acute stroke.

BACKGROUND In the emergency department, portable point-of-care testing (POCT) coagulation devices may facilitate stroke patient care by providing rapid International Normalized Ratio (INR) measurement. The objective of this study was to evaluate the reliability, validity, and impact on clinical decision-making of a POCT device for INR testing in the setting of acute ischemic stroke (AIS). METHODS A total of 150 patients (50 healthy volunteers, 51 anticoagulated patients, 49 AIS patients) were assessed in a tertiary care facility. The INRs were measured using the Roche Coaguchek S and the standard laboratory technique. RESULTS The interclass correlation coefficient and 95% confidence interval between overall POCT device and standard laboratory value INRs was high (0.932 (0.69 - 0.78). In the AIS group alone, the correlation coefficient and 95% CI was also high 0.937 (0.59 - 0.74) and diagnostic accuracy of the POCT device was 94%. CONCLUSIONS When used by a trained health professional in the emergency department to assess INR in acute ischemic stroke patients, the CoaguChek S is reliable and provides rapid results. However, as concordance with laboratory INR values decreases with higher INR values, it is recommended that with CoaguChek S INRs in the > 1.5 range, a standard laboratory measurement be used to confirm the results.

Good is not Good Enough: The Benchmark Stroke Door-to-Needle Time Should be 30 Minutes.

Noreen Kamal, Oscar Benavente, Karl Boyle, Brian Buck, Ken Butcher, Leanne K. Casaubon,RobertCote,AndrewMDemchuk,YanDeschaintre,DarDowlatshahi,GordonJGubitz,GaryHunter,Tom Jeerakathil, Albert Jin, Eddy Lang, Sylvain Lanthier, Patrice Lindsay, Nancy Newcommon,Jennifer Mandzia, Colleen M. Norris, Wes Oczkowski, Celine Odier, Stephen Phillips,Alexandre Y Poppe, Gustavo Saposnik, Daniel Selchen, Ashfaq Shuaib, Frank Silver, Eric E Smith,Grant Stotts, Michael Suddes, Richard H. Swartz, Philip Teal, Tim Watson, Michael D. Hill

Advancing nursing practice : The role of the nurse practitioner in an acute stroke program

Both patient and staff satisfaction with the SNP role has been high as it relates to quality of care delivery and accessibility of care and service. In particular, patients express satisfaction with the continuity of care experienced throughout the stroke care continuum, from acute in-hospital care to postdischarge follow-up. Improvements have been realized in systems and processes of care with the implementation of the SNP role. These include reductions in door-to-needle times in the administration of tPA (from 90 minutes to 60 minutes), rapid assessment and diagnostic interventions through coordination of are activities (e.g., door-to-CT scan times reduced from 60 minutes to 30 minutes), and faster consultation responses within the organization. Instituting the nurse practitioner role early in the development of the Calgary Stroke Program enhanced patient care while advancing the nursing discipline. The SNP has created a role that extends beyond that of physician helper to an autonomous nursing practice that has been beneficial to both patients with stroke and the regional healthcare delivery system. With the ability to practice autonomously, the nurse practitioner can aid in the expedient delivery of complex, comprehensive stroke care, as has been the case in the Calgary Stroke Program.

Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner

Background— The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion. Methods and Results— The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%–55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%–42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%–20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%–20%), and stroke severity (National Institutes of Health Stroke Scale score 6–8: 19% decrease in DTN time, 95% CI 6%–31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%–37%). Conclusions— Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.

Diurnal Variance in Stroke Onset

To the Editor: We were interested to read the article by Stergiou et al and response by Dr Burszstyn.1–3 The diurnal variation in stroke onset is of both practical and physiological interest. The hypothesis that siesta may be associated with stroke suggests real changes in physiology. In Calgary, Canada, siesta is not practiced. We collected time of stroke onset, defined by the last-seen-well principle, for all strokes (n=538) admitted to Foothills Medical Center in Calgary over the calendar year 2000. Stroke onset times …