Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Monday, February 17, 2014

Stroke: Initiative Cuts Time to tPA

Damn, when all you have is a hammer(tPA) everything looks like a nail. They are still making what I consider to be a failure in logic. They are assuming that faster reperfusion results in better recovery. That might be true but why aren't the results even better? They still have not identified that the neuronal cascade of death is a major problem. The damned goal is wrong, door-to-needle is not the goal, Saving neurons is the goal.
http://www.medpagetoday.com/MeetingCoverage/ISCCardioEdition/44338
An effort to shorten the time between when patients with acute ischemic stroke arrive at the hospital and when they receive intravenous thrombolytic therapy -- the door-to-needle time -- proved successful, researchers found.
The percentage of patients with a door-to-needle time of 60 minutes or less was 29.6% just before the "Target: Stroke" initiative was implemented at the beginning of 2010 and 53.3% in the third quarter of 2013 (P<0.0001), a clinically relevant improvement, according to Gregg Fonarow, MD, of the University of California Los Angeles.
At the same time, clinical outcomes improved and complications from the use of tissue plasminogen activator (tPA) fell, he reported at the International Stroke Conference here.
"While there have been concerns about potentially rushing the administration of tPA that could lead to inappropriate patient selection, dosing errors, and greater likelihood of complications, these findings actually suggest the contrary," he said at a press briefing. "More rapid reperfusion therapy is not only feasible, but can be achieved with actual reduction in complications and improved outcomes."
The benefits of tPA are highly dependent on treating patients as soon as possible, Fonarow said, but prior research showed that only 30% of patients receiving thrombolytic therapy were treated with a door-to-needle time of 60 minutes or less, a standard recommended by the American Heart Association/American Stroke Association.
The Target: Stroke initiative was developed to address that problem. It was offered to all hospitals that were already participating in the Get With the Guidelines-Stroke quality improvement initiative, and all accepted.
Target: Stroke was launched at the beginning of 2010 with the initial goal of having hospitals achieve door-to-needle times of 60 minutes or less in at least half of their patients. The initiative pushed 10 key strategies to speed treatment and provided hospitals with an implementation manual, clinical decision support tools, education, best practices from other centers, performance feedback, and opportunities for national recognition.
Among the 10 strategies were hospital pre-notification by emergency medical services, a rapid triage protocol and stroke team notification, and use of a single call/paging system for the entire stroke team.
The current analysis looking at the effect of the program included 27,319 patients treated before implementation, and 43,850 treated after, at 1,030 hospitals that were participating throughout the study period. Characteristics of the patients and hospitals were not different between the two time periods.
The median door-to-needle time dropped from 74 minutes at the end of 2009 to 59 minutes in the third quarter of 2013 (P<0.0001). In addition, the percentage of hospitals with door-to-needle times of 60 minutes or less in at least half of their patients rose from 15.6% to 46.7% over that same interval (P<0.0001).
Although the percentage of patients treated with the target door-to-needle time was trending upward before implementation of Target: Stroke, the rate of increase accelerated significantly when the program was put in place (from 1.36% to 6.2% per year, P<0.0001).
There was no control group, but Fonarow said it is unlikely that such a dramatic shift occurred on its own.
The improvements -- which were seen regardless of sex, race/ethnicity, age, and stroke severity -- were accompanied by gains in clinical outcomes, as well. In-hospital mortality dropped from 9.93% to 8.25%, and the percentage of patients discharged home rose from 37.6% to 42.7%.
The rate of symptomatic intracranial hemorrhage fell from 5.68% to 4.68% and the rate of any tPA complications declined from 6.68% to 5.5%, which Fonarow attributed to getting the drug to patients earlier when less ischemic damage has occurred to the brain and blocked vessel.
All of those changes remained significant after adjustment for patient and hospital characteristics.
In recognition of the fact that more work is needed to improve door-to-needle times even further, Fonarow and his colleagues have recently launched a second phase of the Target: Stroke initiative. The new effort will aim to continue to work with hospitals that haven't yet reached the goal of having at least half of their patients treated within the recommended interval and to push the top performing centers to even higher goals.

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