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ED consultant delivered stroke thrombolysis
- Kelvin D Wright, Geeta Aggarwal, Johann Jeevaratnam, Keith Mundy, Claire Davies (10 July 2008)
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Kelvin D Wright, Consultant ED/ICU Frimley Park Hospital, Geeta Aggarwal, Johann Jeevaratnam, Keith Mundy, Claire Davies
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kelvin.wright{at}fph-tr.nhs.uk Kelvin D Wright, et al.
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Dear Editor McCarron (1) and colleagues raise important issues for ischaemic stroke care in the United Kingdom. SITS-MOST (2) demonstrated the ‘number needed to treat’ for thrombolysis in acute ischaemic stroke is 7 and that thrombolysis within 3 hours from onset of symptoms is safe in ischaemic stroke. NINDS (3) shows that for every 1000 patients treated 140 more will return to independent life. It is vital that patients have access to this gold standard therapy. Much has been said about stroke teams which are designed to meet the stroke patient at the door and ensure rapid treatment. Our impression from local network meetings is that often this does not happen (unpublished data). Below, we share our model, which is being adopted by neighbouring trusts, due to its success. a. Pre-alert by the ambulance service of possible stroke b. Patient is assessed by an ED SHO and ED Consultant/Middle grade. c. Senior ED doctor organises CT scan (rate limiting step) d. CT reported by consultant radiologist (24 hour service) e. If ischaemic stroke confirmed, thrombolysis carried out by ED Consultant f. Patient admitted to stroke observation unit. Our rota ensures ED consultant presence from 0800 till 2200. Outside these hours, therapy is administered by middle grades under supervision. The ability to view CT scans and resuscitation room monitors from home via remote link increases the safety factor. In 6 months, we have thrombolysed 14 patients, with no adverse incidents, no bleeds and no neurological worsening. 3 patients have achieved significant return of neurology and have regained independence. Our ‘record’ door to needle time is 27 minutes. All patients are protocol compliant with SITS-MOST We aim to formally publish these results at a later date. In the current climate we felt sharing our model may inspire others to adopt this successful approach. Kelvin Wright Consultant Emergency Medicine & Critical Care Geeta Aggarwal ST1 Emergency Medicine Johann Jeevaratnam ST1 Medicine Keith Mundy Consultant Stroke Physician Clare Davies Physiotherapist, Stroke project lead. Correspondence to Kelvin Wright Emergency department Frimley Park Hospital Portsmouth Road Frimley Surrey Competing interests: none References. 1. McCarron MO, Armstrong M, McCarron P. Potential for improvement of acute stroke management in a district general hospital. EMJ. 2008, Vol. 25, 5, pp. 270-273. 2. Wahlgren NG, Ahmed N, Davalos A et al. Thrombolysis with alteplase for acute ischaemic stroke in Safe Implementation of Thrombolysis in Stroke Monitoring Studt (SITS-MOST). Lancet. 369, 2007, 275-82. 3. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischaemic stroke. N Eng J Med. 333, 1995, pp. 1581-7. |
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