Increasing the Use of Thrombolytic Therapy by 50% in a Community Hospital, Safely and Successfully.
Background and Purpose: A recent report in JAMA, concerning thrombolytic therapy for AIS in the Cleveland area, suggested the use of tPA for AIS be limited to academic stroke centers, rather than community hospital settings. That study reported that less than 2–6% of AIS patients receive thrombolytic therapy and the incidence ICH following thrombolytic therapy was as high as 15%. This report provides data from a community hospital near Cleveland with success in increasing thrombolytic therapy administration in one year from 2% to 4%. Thrombolytic therapy was successful and safe, with a 0% ICH rate. Methods: Data were collected retrospectively for a 2 year period (1998–1999) for AIS patients presenting to a community hospital ED with AIS. Results: In 1998, there were 383 patients admitted with stroke; of those, 334 were AIS. 54 (11%) of the patients arrived within 3 hours of symptom onset. Of these, 5 (9%) met inclusion criteria for thrombolytics. The overall tPA acministration rate was 2%. After an educational program consisting of community education, paramedic education and the development of a paramedic protocol for AIS, the 1999 data were 351 patients admitted with stroke; 326 being AIS. Patients presenting within 3 hours increased to 17% and 12 (22%) met inclusion criteria for tPA. Overall, tPA administration in 1999 increased to 4%. During the 2 years of analysis, there were no incidences of ICH following tPA administration. Door to needle times for 1998 and 1999 average 64 minutes and 90 minutes, respectively. Conclusions: Our data confirm that thrombolytic therapy in a community hospital setting can safely and effectively be administered with effective protocols and clinical pathways. The success of a program is dependent upon the dedication of the hospital and the stroke program personnel. Education of the community and the EMS personnel are pivotal in bringing tPA candidates into the hospital for evaluation. Education of ED physicians, neurologists, residents, and nurses, with the establishment of strict standards of care can assure safe and successful results. It is, therefore, possible to deliver tPA safely in a community hospital.