Abstract W P191: Neurology Consultation During Assessment of Acute Stroke Patients With Mild or Rapidly Improving Symptoms
Background: Emergency Department (ED) physicians frequently cite mild and rapidly improving symptoms (RIS) as rationale for not treating acute ischemic stroke (AIS) patients with IV tPA. Approximately 33% of AIS not treated with IV tPA with RIS have poor short-term outcomes, evidenced by inability to ambulate on discharge, and not being discharged home. Determining treatment in an evolving infarct with waxing/waning symptoms is challenging. The decision not to proceed with IV tPA treatment may have lasting consequences and should be done in collaboration with neurology.
Methods: A retrospective cohort study of 794 records was reviewed with patients presenting to the ED at a 5 campus hospital system from January to June 2013. Inclusion criteria: MD documentation of stroke symptoms within 3 hours of arrival to the ED and RIS as criteria for withholding IV tPA. Exclusion criteria: patients who received IV tPA, evidence of hemorrhage on imaging, time of onset unclear or greater than 3 hours, and patients transferred to outside facilities where discharge data was not available.
Results: After applying criteria, 54 records were included in this review. Of the patients not treated with IV tPA for RIS, 8 patients (25%) were discharged to a skilled nursing facility (SNF) or an assisted living facility. A total of 7 patients (22%) presented on admission with a Modified Rankin Scale (mRS) of 2 or greater, while a total of 11 patients (35%) were discharged with a mRS of 2 or greater. As a health care system, neurology was consulted during the AIS assessment in 45 patients (83% of the time). Significant variations were found with geographic location and availability of in-house neurology for consultation. Campuses with telemedicine neurology or fellows covering stroke codes cited the rationale of RIS in approximately 14-18% of cases during the period studied. In contrast, the sites with neurology at the bedside for all stroke codes only cited RIS in 5-8% of cases during the study period.
Conclusions: Opportunities for education exists with ED staff in the treatment of RIS. This study also highlights the potential importance for neurology at the bedside for treatment of AIS with IV tPA and warrants additional research.
Author Disclosures: L. Olson-Mack: None. K. Clarkson-Afshar: None. R. Richetts: None. C. Bajkiewicz: None. L. Berger: None.
- © 2014 by American Heart Association, Inc.