New evidence report helps improve acute stroke care

October 24, 2005

Stroke, which results from decreased blood flow to a portion of the brain, remains a leading cause of disability and mortality in America. According to the American Stroke Association, many patients do not recognize acute stroke symptoms and most institutions lack the necessary structure to promptly and efficiently manage stroke patients.

In an effort to improve the quality of stroke care provided by hospitals, the Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based Practice Center (EPC), has released a new evidence report on stroke evaluation and treatment. The evidence report cites that less than 2% of acute stroke patients nationally receive tissue plasminogen activator (tPA), a thrombolytic agent that must be administered within three hours of symptom onset.

These low rates have been partly attributed to delayed patient presentation to the hospital and clinicians' concern over bleeding risks. "Prompt initiation of appropriate treatment requires rapid recognition of stroke symptoms and presentation to a facility with essential resources," said Neil Schamban, M.D., vice chairman and medical director, Department of Emergency Medicine at Newark Beth Israel Medical Center, Newark, N.J.

According to Schamban, these emerging data are promising; however, the potential use of tPA in the later time window requires further evaluation in clinical trials before incorporation into current practice. Additional studies may help clinicians determine characteristics of the group most likely to benefit, or conversely be harmed, from tPA administration beyond three hours.

While the national guidelines on stroke management also acknowledge the possible benefit of tPA administration beyond the current three-hour window, the document states that additional evidence is warranted before the maximal time window can be increased to 4.5 hours in the guidelines (published in Stroke in 2005).

The AHRQ evidence report indicates that crucial measurements for improving stroke care have been implemented in several hospitals nationwide. The process of optimizing stroke care involves a pre-hospital phase and an emergency department (ED) phase. Strategies for enhancing the pre-hospital phase care involve early recognition of symptoms, a decision to seek care, and transportation to a facility capable of providing stroke care. "You can begin this phase with educating your community on the warning signs of stroke," said Schamban.

"A multidisciplinary approach is the key to delivering optimal stroke care in the hospitals," noted Schamban. He advocates the utilization of a "brain attack" team to rapidly execute stroke care and administer thrombolytic therapy to selected patients. He emphasized that pharmacists should integrate with other stroke team members to develop treatment protocols and ensure that thrombolytic therapy is initiated in a timely and safe manner for selected patients. "In a situation where clinicians need to act rapidly and efficiently, using ED protocols can help prevent treatment delays, reduce medication errors, and improve patient outcomes," he said.

For more information about AHRQ's evidence report on stroke care, visit http://www.ahrq.gov/.

The Author is a writer and hospital pharmacist based in New Jersey.