Emergency & Acute Care: Delivery of thrombolytic (blood clot) therapy
CT scans are essential for diagnosing acute stroke. A CT scan is recommended for all stroke patients, and is essential if the patient is being considered for thrombolytic therapy. The geography of the province becomes a major factor potentially limiting access to a CT scanner in northern B.C. and parts of the interior. This results in wait times for diagnostic testing, which is a major factor influencing the successful treatment of stroke.
Both Health Canada and the American FDA have approved the use of Tissue Plasminogen Activator (rt-PA) in thrombolysis for acute ischemic stroke. Clinical trials have clearly demonstrated improved patient outcomes with administration of rt-PA within 3 hours of symptom onset. Patients treated with rt-PA were at least 30 per cent more likely to have minimal or no disability at three months compared to study control groups. The financial benefits to the health care system were identified in a study by Fagan (1998). In a study of 1000 eligible patients, the use of rt-PA resulted in hospitalization costs of $1.7 million. However, rehabilitation costs were $1.4 million less, nursing home costs $4.8 million less and an estimated 564 quality adjusted years saved.
Current guidelines specify that thrombolytic therapy must be given within three hours of the onset of a stroke, but this needs to be preceded by a CT scan, and interpretation by a stroke specialist, to rule out a hemorrhagic stroke. Given these time constraints, the prehospital and emergency phases are critical. A reluctance on the part of ER doctors to be involved in the administration of rt-PA hampers the use of this life-saving drug. Greater medical education to encourage its use, as well as an increased reliance on internists and intensivists to administer it (and a decreased dependence on ER physicians), would help hospitals assume the responsibility for a high standard of stroke care for patients in their regions. A Texas study showed that a planned multilevel intervention can improve community stroke treatments in smaller communities. The intervention used radio and television public service announcements, newspaper articles, brochures, billboards, posters and volunteer training sessions to increase awareness of rt-PA. They also developed treatment guidelines for physicians and emergency medical services staff, implemented continuing medical education classes, and highlighted the success of acute stroke treatment in physician newsletters. At the beginning of the 3-year campaign, just 14 per cent of eligible patients received rt-PA, while 69 per cent received it after intervention.
Increased rt-PA use was associated with four elements of an organized stroke centre, as recommended by the American Brain Attack Coalition. These predictive factors were: written care protocols, integrated emergency medical services, organized emergency departments, and continuing medical/public education in stroke.
Recommendations to improve the delivery of thrombolytic care for stroke in B.C.:
- Increase the number of CT scanners in B.C. to increase access to more of the rural population, which would assist in making CT scanning within the time limits for thrombolytic therapy a possibility.
- Promote, adapt and adopt STEP guidelines, which include education around screening and use of rt-PA for appropriate patients, throughout the province to ensure a provincial standard in acute stroke care is being consistently met.
- Increase the use of electronic prompting system protocols (i.e., the Stroke Guidance System) for acute stroke care that flows from the emergency through to acute care.
- Develop and deliver a physician education package for training in this area, and target it at internists, intensivists, ERPs, and GPs.
The following prototype projects are underway in B.C. as part of the BC Stroke Strategy: