Are Primary Stroke Centers Living Up to Potential?

Thirteen years have passed since intravenous tissue plasminogen activator (tPA) was approved for treating patients with acute ischemic stroke, but some experts think hospitals-even those designated as primary stroke centers (PSCs)-have been slow to implement the strategy.

Mark J. Alberts, MD, a neurologist at Northwestern Memorial Hospital in Chicago, and other stroke experts gave an overview of current tPA use using quantitative data gathered by various sources.¹ The rate of tPA administration was defined as the number of ischemic stroke patients who arrive within 120 minutes of symptom onset and in whom tPA was initiated within 180 minutes of stroke onset.

In analyzing tPA and stroke outcomes, Dr Alberts found that certified PSCs had higher rates of tPA administration to eligible stroke patients and that the longer a hospital was certified, the higher the rate of tPA use. Medical teaching hospitals also had higher rates.

The Joint Commission (TJC), a nonprofit organization that certifies or accredits health care institutions, introduced its PSC certification program in collaboration with the American Stroke Association in late 2003. Since then, 499 hospitals in 43 states have achieved certification.

Data obtained from TJC and the American Hospital Association revealed that of 200 PSCs certified within the past 2 years, 72.7% of eligible patients received tPA (those treated within 180 minutes of a stroke). The longer a PSC was in the certification program, the higher its tPA participation rate. Hospitals in their second certification cycle achieved a 78.6% IV tPA participation rate, and those certified for a third 2-year cycle achieved 94.4% participation.
Among teaching hospitals in their first certification cycle, the rate of IV tPA use for eligible patients was 81% compared with 70% of nonteaching hospitals.

Still, “too small of a percentage” of PSCs are giving tPA according to the recommended guidelines, said Dr Alberts. He said the commission also acknowledges that some PSCs are not utilizing tPA to its full potential in eligible patients. One of the weaknesses of the PSC accreditation process is that hospital stroke procedural data are largely self-reported, said Dr Alberts.

Aaron Izenberg, MD, with the University of Toronto, also analyzed the relationship between hospital arrival and treatment times in acute stroke thrombolysis and found a paradox: The earlier that stroke patients arrived at the hospital, the longer they wait to receive tPA.²

Dr Izenberg’s group analyzed 5 years of data from 13 stroke centers in Canada obtained from the Registry of the Canadian Stroke Network. In 1411 patients with ischemic stroke, the median onset-to-arrival time was 1.0 hours and the median “door-to-needle” time was 1.3 hours. Door-to-needle time was inversely related to onset-to-arrival time. Median door-to-needle times were 1.3 hours for patients arriving under 1 hour, 1.2 hours for those arriving from 1 to 2 hours, and 0.9 hours for those arriving from 2 to 3 hours. The odds of receiving tPA within 60 minutes of arrival were significantly greater for every 30-minute delay in onset-to-arrival time.

Stroke outcomes are better with earlier thrombolysis, and the benchmark for tPA administration is less than 60 minutes from hospital arrival, said Dr Izenberg. “Treating physicians must resist this tendency to delay thrombolysis for early-arriving patients, especially as the treatment window extends beyond 3 hours.”

References:

References

1. Alberts MJ, Range J, Ann Watt A, et al. Impact of Joint Commission certification of primary stroke centers on the administration rate of IV tissue plasminogen activator for ischemic stroke [S04.002]. Scientific Sessions: Acute Stroke Care, American Academy of Neurology Annual Meeting, April 28, 2009.
2. Izenberg A, Silver F, Hill M. Earlier hospital arrival in acute stroke is associated with delayed tPA administration [S04.006]. Poster Session: April 28, 2009.