NEW ORLEANS -- The future of stroke care is in the emergency room, according to researchers who say that emergency room physicians are just as capable as their neurologist counterparts of administering clot-busting treatments to stroke patients.
Study results were presented here today at the American Stroke Association's 25th International Stroke Conference. The American Stroke Association is a division of the American Heart Association.
"The emergency room is where the fate of a vast number of stroke patients is largely determined," says the study's lead author Paul T. Akins, M.D., Ph.D., co-director of the Regional Stroke Intervention Program for Mercy Healthcare, Sacramento, Calif. "Those early minutes of arrival are critical in determining whether a patient will regain his or her life or be left severely disabled."
Saving time is a primary concern of medical professionals who treat stroke. The only federally approved clot-busting medication, tissue plasminogen activator (TPA), must be given within three hours of a stroke to be effective. In the study, neurologists evaluated and treated 20 stroke patients, and emergency medicine physicians evaluated and treated 23 stroke patients following phone consultation with a neurologist and review of brain scans by a radiologist.
The researchers found that door-to-needle time -- the time elapsed between the stroke patient arriving at the hospital and receiving TPA -- was similar in neurologists (97 minutes) and emergency room physicians (108 minutes). The amount of time it took between taking the scan of the patient's brain and administering TPA was shorter for neurologists (48 minutes) than it was for emergency room physicians (68 minutes).
"We have the benefit of history with the use of TPA for heart attack patients," says Akins. "When that was first being done, it was only the cardiologists who were able to administer clot-busting medication. Now it's standard practice for ER doctors to give it. That same model could be applied to stroke.
"There was a need to evaluate whether emergency doctors could administer TPA safely and effectively. Our results showed that it could be done." Akins says the results of the study were comparable to those reported in the original National Institutes of Neurological Disorders and Stroke (NINDS) trial examining the safety and effectiveness of TPA.
"In the original trial, the model for treatment was different than that in the real world," says Akins. "It required neurologists to drop everything and come running into the ER when a stroke patient came in. Practically speaking, that's difficult to achieve in everyday clinical practice."
During the acute portion of the patients' hospital stay, 46 percent of those in the study were discharged directly home and 36 percent either went to acute inpatient rehabilitation or skilled nursing facilities. Another 10 percent were transferred to other hospitals for insurance reasons and 8 percent died. "The bottom line is how well the patients recovered and our results show that whether people are treated by ER physicians or neurologists, they had identical outcomes," says Akins. "That's very important when you consider that some emergency room physicians have been leery of taking on this treatment."
The researchers add that violations of protocol -- the process by which the drug is administered -- were more frequent in the emergency physician group than in the neurologist group. Akins says those problems were solved after an education program was implemented.
Another heartening result from the study, according to Akins, was that older patients also seemed to fare well when receiving clot-busting therapy for their strokes.
"The average age of our patients was almost five years older than those in the original trial of TPA," says Akins. "The older patients in our study did extremely well."
Co-authors are Christi Delemos, R.N.; Deidre Wentworth, R.N.; John Byer, M.D.; and Richard P. Atkinson, M.D.