Thrombolysis in acute stroke: ongoing challenges based on a tertiary hospital audit and comparisons with other Australian studies

Abstract

Objective Intravenous thrombolysis with tissue plasminogen activator (tPA) improves patient outcomes in acute ischaemic stroke. Because its benefit is time-dependant, treatment delays must be minimised. The aim of the present study was to review patient characteristics, timeliness of tPA delivery and clinical outcome in patients receiving t-PA in a tertiary hospital stroke unit in Queensland, and to compare the findings with those of other Australian studies. Methods The present study was a retrospective study conducted between 1 January 2010 and 31 December 2012. Information was collected regarding demographics, stroke characteristics, timeliness of tPA delivery, clinical outcome, safety outcome and protocol deviation. Results Of 490 patients admitted with ischaemic stroke, 57 (11.6%) received tPA. Compared with other studies, the patients in the present study had more severe stroke (median National Institutes of Health Stroke Scale (NIHSS) score), more cardioembolic strokes and more patients receiving tPA between 3 and 4.5 h of symptoms onset. Median symptom onset to treatment time was 175 min and median door to needle time was 97 min. At 3 months, 21.1% of patients had died and 41.5% had a favourable outcome (modified Rankin scale ≤2). Symptomatic intracerebral haemorrhage occurred in 5.3% of patients and protocol deviations occurred in 21.1%. Overall, delivery and outcomes of tPA at the Princess Alexandra Hospital were comparable to those reported in other Australian studies of usual care. Several challenges and strategies for optimal thrombolysis were identified, with supporting evidence from selected Australian sites. Conclusion The proportion of eligible stroke patients who receive tPA in a timely manner remains less than ideal at our centre. More accurate patient selection and reductions in treatment delays serve as targets for quality improvement efforts that have broad applicability. What is known about the topic? Stroke unit care and tPA thrombolysis are two proven strategies to improve outcome in patients with ischaemic stroke. Although the stroke unit is gaining momentum of growth in Australia (especially in Queensland), little improvement has been achieved in thrombolysis rate and timeliness of treatment delivery, and little is known about the service delivery in Queensland because there are no published data. What does this paper add? This paper provides an extensive review of thrombolysis treatment in a tertiary Queensland hospital, adding to the understanding of treatment implementation. It also provides a complete and comprehensive review of treatment delay (including emergency department referral time and computed tomography to needle time, which have not been reported in other Australian studies), and a template for data collection to review treatment delay and outcome measurement in detail. It also compares findings with peer Australian studies (this has not been reported previously) and summarises potential strategies that could be adopted systemically. What are the implications for practitioners? Delivery of thrombolysis treatment in a timely manner remains a significant challenge to stroke physicians. All stroke units are encouraged to prospectively collect thrombolysis data in the format adopted in the present study for purposes of peer comparisons and shared learning.