Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke?

Objective: To review the clinical outcomes of stroke patients treated with IV tissue plasminogen activator (tPA; alteplase) in a community setting and to compare outcomes when treatment was initiated by a neurologist or an em ergency department (ED) physician in telephone consultation with a neurolog ist and radiologist. Methods: Clinical information was prospectively collec ted for 43 stroke patients treated with IV tPA (alteplase) within a five-ho spital network of affiliated community hospitals. Blinded 3-month outcomes were obtained with telephone interview or patient visit. Results: Excellent functional recovery measured by a Modified Rankin score of 0 to 1 (42%), s ymptomatic intracerebral hemorrhages (7%), and mortality (16.3%) were simil ar to those reported by National Institute of Neurological Disorders and St roke (39%, 7.7%, 1.7.3%). After initial screening by an ED physician, 20 pa tients were directly examined by a stroke neurologist who then prescribed t PA. Twenty-three patients received tPA prescribed by an ED physician after telephone consultation with a neurologist and review of the head CT by a ra diologist. Functional outcome, symptomatic intracerebral bleeding rate, and mortality rate were similar between these groups. Door-to-needle time was similar. Protocol deviations were much higher when ED physicians prescribed the tPA compared to when neurologists did (30% versus 5%). These protocol deviations were reduced with staff education. Conclusions: The clinical res ults of the National Institute of Neurological Disorders and Stroke tPA Str oke Trial were replicated in this small series of patients treated in a com munity setting. Outcomes were similar whether the prescribing physician was a neurologist or an ED physician.