Safety and Feasibility of a “Fast‐Track” Monitoring Protocol for Patients Treated With Intravenous Thrombolytic Therapy

Survivors want to know how many got to 100% recovery! If you're not measuring that you'll never get there, and just to make sure I'd have you all fired for incompetently not even understanding the only goal in stroke for survivors is 100% recovery!

“What's measured, improves.” So said management legend and author Peter F. Drucker 

Safety and Feasibility of a “Fast‐Track” Monitoring Protocol for Patients Treated With Intravenous Thrombolytic Therapy

Keiko A. Fukuda,

Kavit Shah,

Cynthia Kenmuir,

Derrick Barnagian,

Baraa Nawash,

Shashvat Desai,

Marcelo Rocha,

Matthew Starr,

Eileen Roach,

Stephanie Henry,

Bradley J. Molyneaux and

Ashutosh P. Jadhav

Originally published26 Mar 2024https://doi.org/10.1161/SVIN.123.001098Stroke: Vascular and Interventional Neurology. 2024;0:e001098

Abstract

BACKGROUND

Our health care systems continue to face significant strain due to chronically taxed intensive care resources. A subgroup of patients following thrombolytic stroke may not require prolonged intensive monitoring, alleviating some burden. Here, we describe the safety, feasibility, and utility of a Fast‐Track Protocol (FTP) for early deescalation of high‐acuity monitoring.

METHODS

We compared a prospective cohort of patients on the FTP at our stroke centers from April 2020 to February 2022 to a similar retrospective cohort. Those who presented with a National Institutes of Health Stroke Scale  <10 and without large‐vessel occlusion or flow‐limiting stenosis, intravenous antihypertensive use, and any hemodynamic or respiratory concerns were eligible. Primary outcomes included early neurologic deterioration, defined as worsening of National Institutes of Health Stroke Scale score of ≥4 points at 24 hours, parenchymal hemorrhage, and symptomatic intracranial hemorrhage.

RESULTS

Of 574 patients undergoing thrombolysis, 119 (21%) were eligible for the FTP. A total of 100 (88%) were included for analysis. The median±interquartile range hospitalization was 2.0±1.6 days. None of the 4 cases of early neurologic deterioration were due to hemorrhage. No symptomatic intracranial hemorrhages occurred, and no patients on the FTP were transferred back to the intensive care unit. Median±interquartile range 90‐day modified Rankin scale score was 1±1.

CONCLUSION

FTP is a safe and feasible strategy to triage intensive care unit patients and decrease unnecessary intensive care unit monitoring. This is important in a postpandemic era as intensive care unit resources continue to fluctuate. Future studies are needed to establish the optimal level of monitoring in patients following thrombolysis.

 

Patients who receive intravenous thrombolysis (IVT), irrespective of endovascular thrombectomy, are commonly monitored in a high‐acuity setting, such as an intensive care unit (ICU) typically in the United States, for a minimum of 24 hours with frequent assessments of vital signs and neurological examinations.¹ This ensures that patients receive close observation to detect any change in their neurological condition, which would warrant emergent medical or surgical intervention. However, many patients may not require such high‐resource monitoring, as is the practice with specialized stroke units in Europe.^{2, 3} Analyses of these stroke units show that they are more cost effective and reduce resource usage in the acute and long‐term care phases.^{4, 5} As reperfusion therapies also rapidly expand in the developing world, simplified and cost‐effective postreperfusion strategies are appealing to improve access and quality of stroke care in underresourced settings. The failure to develop stroke units, with reliance on ICUs instead, has posed significant challenges for US health care systems more recently. Specifically, the COVID‐19 pandemic changed the health care landscape, especially in critical care settings, due to the rapid rise in patient volumes, with nearly 100 million Americans suffering infection and >1 million deaths.^{6, 7} Health systems of care must adapt to the increased use of interventions for stroke treatment and the risk of future waves of infection, which continue to threaten intensive care resources.

Those who experience a National Institutes of Health Stroke Scale (NIHSS) decline of ≥4 points within 24 hours of IVT are defined as having early neurological decline (END).⁸ Furthermore, if the pathogenesis of END is secondary to an intracranial hemorrhage (ICH), this is defined as a symptomatic ICH (sICH).⁹ It is reassuring that this feared complication occurs in a minority of patients.^{10, 11, 12} Prior studies have shown that the majority (80%) of sICHs associated with intravenous tissue plasminogen activator occur within the first 12 hours of treatment.^{13, 14, 15} Several factors predict END and any ICH, including an untreated large‐vessel occlusion, higher baseline NIHSS score, uncontrolled hypertension, and hyperglycemia.^{16, 17, 18, 19} Moreover, the OPTIMIST (Optimal Post tPA IV Monitoring in Ischemic Stroke) safety trial found that all patients in their population with NIHSS score <10 on presentation without initial ICU needs remained clinically stable and could be safely monitored with a lower‐intensity protocol.²⁰ The ongoing OPTIMIST main trial continues to evaluate whether less intensive monitoring may be indicated in patients with mild neurological deficits.

Given the current landscape and these findings, we implemented a Fast‐Track Protocol (FTP) to permit early deescalation of high‐acuity clinical monitoring in a selected cohort of patients undergoing IVT. We sought to evaluate the protocol's safety, feasibility, and utility on our selected patient population.

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