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Delay in TPA use after stroke still a frequent problem: failure to call 911 cited as factor in nearly 5-hour delay prior to hospital admission. (3-Hour Window for Treatment).

PHOENIX, ARIZ. -- Time continues to be the major hurdle preventing ischemic stroke patients from getting the brain-saving, clot-busting drug tissue plasminogen activator.

The biggest delay comes between onset of the stroke and completion of a 911 call, researchers reported at the 28th International Stroke Conference.

An unenlightened public contributes to lost time, but primary care physicians also could do more to boost the low percentage of people eligible for tissue plasminogen activator (TPA) who actually get the drug, Dr. Camio R. Gomez of the University of Alabama, Birmingham, said at a press briefing.

"When people have these [seemingly] minor symptoms, what they do is call their primary doctor. Unfortunately, their primary care doctors do not tell them to call 911, they tell them, 'Come to my office,' " he said.

Ensuing delays partially explain the average gap of 4 hours, 48 minutes between stroke onset and arrival at the hospital that Dr. Gomez and his associates found in a study of 147 patients treated within the Stoke Transportation Emergency Program (STEP) in the Birmingham region.

Previous research conducted by Dr. Larry Goldstein and his associates at Duke University, Durham, N.C., showed that 88% of stroke patients who called their primary care physician rather than 911 were seen the same day, but just 10% were then admitted to the hospital (Arch. Intern. Med. 160[19]:2941-46, 2000).

In order to improve functional outcomes of ischemic stroke patients without increasing mortality TPA must be administered within 3 hours of the onset of symptoms. A CT scan must be done first to rule out intracranial hemorrhage.

In some cases, Dr. Gomez said, there is no way to reduce the time between symptom onset and a call for emergency help. The six-county STEP network in Alabama, for example, contains many rural farming communities. Elderly persons who live alone far from town may be unable to get to the phone for many hours before someone arrives to check on them.

Still, there are many ways to speed up the use of TPA.

In Alabama and many other states and regions, central stroke networks now operate in conjunction with emergency dispatchers and first responders so that patients can be directed to the nearest available center with a CT scan, specialized personnel, and TPA. If a community hospital has CT scanning available only from 8 a.m. to 5 p.m., it can be part of a stroke network until 5 p.m., when dispatchers know to divert stroke patients elsewhere.

"If you don't have a CT scan up and running, there's absolutely no sense in bringing that patient there," Dr. Gomez said at the meeting, also sponsored by the American Stroke Association.

Other communities are also refining systems to accelerate stroke care:

* In Boston, a comprehensive review of stroke response in 304 cases showed that, on average, 35 minutes could be gained if emergency medical technicians notified a hospital from the scene that it would be receiving a stroke patient soon. This "heads up" dramatically improved the speed with which a patient could be assessed in the emergency room and sent to the CT scanner, simply because members of a stroke team could be notified ahead of time.

Also in Boston, dispatchers now handle stroke as a top-priority emergency on par with cardiac arrest or a gunshot wound. On-scene emergency medical technicians have been instructed to "load and go," that is, to administer basic life support and transport the patient as quickly as possible, rather than spending time at the scene administering advanced life support.

* In Houston, TPA use has increased from 7.1% of patients to 11.3% of patients with implementation of a communitywide stroke network that emphasizes public recognition of warning signs, improved paramedic response and designation of six hospitals as stroke centers.

Of concern, coordinator Anne W Wojner, Ph.D., noted that three other hospitals declined to participate, one because of the nursing shortage and two because "stroke does not reimburse well."

Even when the system works perfectly, a large tertiary care center is reimbursed a maximum of $5,800 for ischemic stroke. Yet TPA costs $2,200 per dose, and costs for a CT scan, specialized personnel, and standard stroke care run far more.

* In Cincinnati, a population-based study of 2,263 patients showed no racial or gender disparities in TPA delivery but a disappointing rate of usage overall, said Dr. Dawn Kleindorfer of the University of Cincinnati, In 1993-1994, when TPA was used experimentally 2.5% of hospitalized ischemic stroke patients received the drug in Cincinnati. In 1999, 3 years after its approval by the Food and Drug Administration, just 3.7% of patients got TPA.
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Author:Bates, Betsy
Publication:Internal Medicine News
Date:Apr 1, 2003
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