Abstract W P339: Time Is Brain: A Tale of Unintended Consequences
Background: There is a narrow therapeutic range for thrombolysis in stroke. “Time is Brain” emphasizes the concept that nervous tissue is rapidly lost as stroke progresses. Research suggests 1.9 million neurons are lost each minute of untreated stroke. Urgency to treat led to the practice of estimating weight on arrival. Unfortunately, expediency of weight estimation can result in over or under dosing. After a devastating adverse outcome related to misdose of tPA based on estimated weight, SBUH implemented a protocol that ensures actual weight measurement before administration of thrombolytics without delaying time to treatment.
Process: Our state accredited stroke program is recognized with the AHA Gold Plus Award. Door to needle time for tPA was below 60 minutes. Estimated weight dosing was standard as supported in the NINDS t-PA stroke study as not having negative impact on outcome. At SBUH in 2013 a patient had estimated weight entered of 90 kg. A CT Scan was performed within 9 minutes and tPA dose of 81 mg given within 57 minutes. Stroke symptoms resolved. This was an apparent successful implementation of protocol. Five hours later patient had mental status changes and emergent CT Scan revealed catastrophic intracranial hemorrhage. The patient died 13 hours later. It was believed that this patient was among the 6.9% that experience this known complication of tPA. A review of the chart revealed that the measured weight entered on the stroke unit did not match the estimated weight; the calculated dose was 40% more than should have been. The error was disclosed to the family and a deep dive and RCAs were completed. The error was reported to TJC and the state DOH.
Outcomes: EPR changes including soft stops, changes in the weight fields, and process changes including a tPA time out and equipment use to ensure measured weights were implemented. The new processes did not compromise door to needle time. Average Door to needle time pre implementation was 66.88 minutes. Post implementation time is 63.1.
Conclusions: The expediency of weight estimation can result in over or under dosing of tPA. At SBUH, we implemented a process that ensures actual weights before administration of thrombolytics but does not delay time to treatment. This is a safer and more effective process for stroke care.
Author Disclosures: C. Santora: None. D. Cammarata: None. E. Conlon: None. E. Dowdy: None. K. Ferrara: None. M. Guido: None. A. Kabacinski: None. J. Mount: None. A. Rowe: None.
- © 2015 by American Heart Association, Inc.