Scott J. Mendelson

Racial disparities in refusal of stroke thrombolysis in Chicago

Objective To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago. Methods Using the Get With The Guidelines–Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression. Results Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3–4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2–8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14–3.90), age (adjusted OR 1.04, 95% CI 1.02–1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90–0.99). Conclusions Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race–ethnic disparities in tPA treatment for AIS.

A resident boot camp for reducing door-to-needle times at academic medical centers

Background: We sought to determine if a structured educational program for neurology residents can lower door-to-needle (DTN) times at an academic institution. Methods: A neurology resident educational stroke boot camp was developed and implemented in April 2013. Using a prospective database of 170 consecutive acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA) in our emergency department (ED), we evaluated the effect of the intervention on DTN times. We compared DTN times and other process measures preintervention and postintervention. p Values < 0.05 were considered significant. Results: The proportion of AIS patients treated with tPA within 60 minutes of arrival to our ED tripled from 18.1% preintervention to 61.2% postintervention (p < 0.001) with concomitant reduction in DTN time (median 79 minutes vs 58 minutes, p < 0.001). The resident-delegated task (stroke code to tPA) was reduced (75 minutes vs 44 minutes, p < 0.001), while there was no difference in ED-delegated tasks (door to stroke code [7 minutes vs 6 minutes, p = 0.631], door to CT [18 minutes in both groups, p = 0.547]). There was an increase in stroke mimics treated (6.9% vs 18.4%, p = 0.031), which did not lead to an increase in adverse outcomes. Conclusions: DTN times were reduced after the implementation of a stroke boot camp and were driven primarily by efficient resident stroke code management. Educational programs should be developed for health care providers involved in acute stroke patient care to improve rapid access to IV tPA at academic institutions.

Pace of Progress in Stroke Thrombolysis: Are Hospitals Running To Stand Still?

Stroke is a time-sensitive medical emergency and a leading cause of disability in the United States. Therapies to halt and even reverse ischemic injury to the brain, such as intravenous tissue-type plasminogen activator (tPA), are available, but the systems to deliver them rapidly have not been optimized to ensure timely treatment of as many eligible patients as possible. Although ≈40 000 to 50 000 acute ischemic stroke patients per year receive tPA,1,2 benefits from the drug are not simply related to receiving it or not but rather are closely linked to time from onset to treatment.3,4 Delays to treatment lead to more disability because every additional 5 minutes is tantamount to the permanent loss of nearly 10 million brain cells.5 National guidelines and quality measures have, therefore, emphasized speed of stroke thrombolysis, focusing on the time between patient arrival to the hospital and tPA administration, also known as door-to-needle (DTN) time.6,7 Alarmingly, recommendations that hospitals evaluate acute ischemic stroke patients and administer tPA within 60 minutes of a patient’s arrival to the emergency department have existed since the original National Institutes of Neurological Disorders and Stroke tPA trial.8 Despite this, as the first decade of the new millennium closed, US hospitals were not meeting this goal in a majority of patients. See Articles by Xian et al and Kamal et al In response to lagging performance nationwide, the first phase of the American Stroke Association Target: Stroke campaign began in January 2010 and provided Get With The Guidelines-Stroke participating hospitals best practice strategies and supporting resources to …

National Practice Patterns of Obtaining Informed Consent for Stroke Thrombolysis

Background and Purpose— No standard approach to obtaining informed consent for stroke thrombolysis with tPA (tissue-type plasminogen activator) currently exists. We aimed to assess current nationwide practice patterns of obtaining informed consent for tPA. Methods— An online survey was developed and distributed by e-mail to clinicians involved in acute stroke care. Multivariable logistic regression analyses were performed to determine independent factors contributing to always obtaining informed consent for tPA. Results— Among 268 respondents, 36.7% reported always obtaining informed consent and 51.8% reported the informed consent process caused treatment delays. Being an emergency medicine physician (odds ratio, 5.8; 95% confidence interval, 2.9–11.5) and practicing at a nonacademic medical center (odds ratio, 2.1; 95% confidence interval, 1.0–4.3) were independently associated with always requiring informed consent. The most commonly cited cause of delay was waiting for a patient’s family to reach consensus about treatment. Conclusions— Most clinicians always or often require informed consent for stroke thrombolysis. Future research should focus on standardizing content and delivery of tPA information to reduce delays.

Lipid levels: A novel biomarker of impending intracerebral hemorrhage?

Despite many established behavioral and medical risk factors, such as smoking, hypertension, and atrial fibrillation, predicting which patients will develop a stroke and when it will occur remains vexing for clinicians and researchers alike. No matter how intuitive their existence, establishing more proximate triggers of stroke has proven quite difficult with some notable exceptions. One example of a known exogenous, environmental trigger is stimulant drugs that can cause cerebral vasospasm or acute hypertension leading to ischemic stroke or intracerebral hemorrhage (ICH).1 Another body of evidence supports the link between preceding infectious disease triggers and incident cerebrovascular events.2