I'm sorry but the urgency they are trying to create to speed up tPA time is the wrong focus. A separate and just as important focus should be to find multiple ways to stop the neuronal cascade of death. And that will have to come from survivors. 17 years to find out that tPA is hard to implement is a colossal failure. Fire them and put survivors in charge if you want something done.
http://nho.sagepub.com/content/2/4/117.full?etoc
In the 17 years since the efficacy of intravenous tissue
plasminogen activator (tPA) for acute ischemic stroke was first
established,1 we have struggled to develop the infrastructures and systems of care that are necessary to deliver this therapy as quickly
and efficiently as possible.
Speed matters. Although delays in presenting
to the emergency department account for most of the unrealized potential
of thrombolysis,2
the time from when a patient arrives in the emergency department to
when the tPA infusion begins—the door-to-needle time—presents
a more readily accessible target for hospital-level
interventions. Pooled data from 6 randomized trials3 and analyses of large observational data sets4
consistently show that faster door-to-needle times are associated with
better patient outcomes. In fact, each 15-minute decrease
in door-to-needle time is associated with a 5% lower
odds of in-hospital mortality.4 Therefore, the American Heart Association: Target Stroke initiative has set a specific goal of raising the percentage of
patients treated within 60 minutes from the current level of 29% to over 50%.4
Precisely how to actually achieve this goal involves evaluating a variety of factors, but certainly one important consideration
is ensuring that appropriate staffing is available for these neurological emergencies. In this issue of The Neurohospitalist, Bhatt and Shatila examine the impact of neurohospitalists on door-to-needle times for acute ischemic stroke.5
The study includes data from 107 consecutive patients treated with
intravenous (IV) tPA at 2 community hospitals between
July 2009 and September 2011. The study was a natural
experiment of sorts: halfway though the study period, coverage for acute
stroke calls from the emergency department changed
from a rotating schedule of 4 community neurologists with shared
inpatient
and outpatient responsibilities to a neurohospitalist
model staffed by 2 inpatient-based neurologists. Occasional weekend
coverage continued to be provided by locums tenens and
community neurologists.
The primary finding was that among patients
treated with IV thrombolysis for stroke, 51% (24 of 47) of those
evaluated by
neurohospitalists were treated in 60 minutes or less,
compared with 15% (9 of 60) of those evaluated by nonneurohospitalists—a
difference that may be due, at least in part, to the
greater likelihood that a neurohospitalists is in hospital for an
emergency
in-person consultation.
Bhatt and Shatila are generally careful not
to assert a causal relationship between a neurohospitalist’s involvement
and faster
door-to-needle times, with the notable exception of
the article’s title. Such caution is warranted. First, there are likely
to be unmeasured confounders and secular trends at
play. For example, a t test comparing the mean performance of
the 2 groups may obscure a secular trend of improved door-to-needle
times over time.
Other analytic methods such as interrupted time series
analysis are often used to mitigate this possibility in other quality
improvement studies. Next, relevant details on how the
availability of neurohospitalists would actually impact the response
time are unavailable. These details would be
especially important to understand and evaluate because the acute stroke
response
involves interactions between multiple disciplines—not
just the neurohospitalist—and since shared knowledge and best practices
at the team- or hospital-level would be expected to
diffuse to the care of all patients over time. Finally, upward of 90%
of the observed difference was driven by the
performance of the neurohospitalist with specific certification in
vascular neurology—someone
with both the experience and interest to shepherd the
performance improvement seen here.
So can we attribute these improvements to
neurohospitalist staffing, to vascular neurology training, or perhaps to
the involvement
of a motivated, invested, and accountable champion for
change regardless of specialty? I would say that what probably matters
most is the watchful eye and the sustained involvement
of someone with an interest in improving these processes and outcomes—a
motivated neurohospitalist may be ideally situated to
take on this role.
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