By Sandy Keefe, MSN, RN
Posted on: October 21, 2009
www.nursing.advanceweb.com

Christine Block, BSN, RN, clinical program developer at the University of Cincinnati Neuroscience Institute at University Hospital, has long been impressed with the effect of tissue plasminogen activator (tPA) on patients with acute ischemic stroke. "I remember being part of the tPA clinical trials here in 1991-92, when patients would come to our unit with IVs containing either the tPA or a placebo," she said. "I was a staff nurse then and, even though the study was blinded, I could tell who had received the tPA and who hadn’t." 

A little over a year ago, the rule of thumb for the clot-buster tPA was to administer the drug within 3 hours of the onset of symptoms. Beyond that time, most experts believed, brain damage was a done deal and it didn’t seem like a good idea to add the risk of internal bleeding. 

Opening the Window 

Nurses specializing in emergency medicine and neurology were intrigued when European researchers demonstrated the effectiveness of tPA during a window extending 3 to 4 1/2 hours post-stroke. Known as the European Cooperative Acute Stroke Study 3 (ECASS 3), results showed tPA significantly improved clinical outcomes in selected patients with acute ischemic stroke in that later window, although it did increase the risk of symptomatic intracranial hemorrhage somewhat.¹

In May 2009, the American Heart Association/American Stroke Association issued a science advisory based heavily on the ECASS 3 findings. Noting delays in evaluation and initiation of therapy should be avoided, the panel still recommended treating eligible patients with tPA within 3 hours of onset of stroke when possible. However, they added, tPA may be administered to previously untreated patients in the 3- to 4 1/2-hour window unless they are more than 80 years of age, are taking oral anticoagulants, score more than 25 on the NIH Stroke Scale (NIHSS) or have a history of both stroke and diabetes.²

Raising the Bar

Barbara Senior, BSN, RN, clinical nurse manager of the stroke ICU at the University of Louisville Hospital in Kentucky, described how the recommendations are being integrated into practice. "The expanded time frame for tPA administration applies to a selective group of patients, and our neurointerventionalist and stroke neurologists will decide the best course of treatment," she said. "If the patient is appropriate for tPA, that’s one consideration; but the neurointerventionalist is usually able to remove the clot with [a minimally invasive catheter-based system.] Because the expanded time frame for tPA administration has not yet received FDA approval, we’re a little more hesitant to use that option." 

The new recommendations raise the bar for treatment of acute ischemic stroke. Patricia Penstone, RN, stroke coordinator at Henry Ford Hospital, Detroit, described the steady progress the facility’s Ford Acute Stroke Team (FAST) has made. "Nationally, only 2-5 percent of patients receive tPA, in large part because people don’t present within the 3-hour window originally recommended for the drug," she said. "Our tPA rate in 2008 was 6.7 percent, and from January to Sept. 15, 2009, we’ve increased that to 7.7 percent. Included in that number are four patients who received tPA during the extended window of 3 to 4 1/2 hours after the onset of symptoms." 

Clinicians from various hospital departments including stroke neurology, emergency department and satellite EDs, serve on a stroke quality group at Henry Ford Hospital. "We’ve shared the research and recommendations extending the time frame for tPA administration, while reminding them treatment should not be delayed," said Penstone. "Our goal for door-to-needle time [for tPA administration] is less than 60 minutes, based on the [National Institute of Neurological Disorders and Stroke] consensus conference. Sometimes that time is driven by the need to wait for [international normalized ratio results on patients who are taking anticoagulants, by the need for a CT angiogram or by medical complications such as seizures." 

Making a Difference 

Does tPA make a difference when given in the 3- to 4 1/2-hour window post-stroke? "Definitely!" said Penstone. "The data are clear: the patient who came in with an NIHSS of 6 was discharged home with a score of 2; the one who came in at NIHSS 8 was discharged to rehab with a score of 6; one came in with a score of 3 and was discharged home with a score of 0, no deficits; and the individual with an NIHSS of 11 had a more complicated course with seizures during his stay and was discharged to a [skilled nursing facility]." 

When patients present in the EDs at other facilities within the Henry Ford Health System, FAST members collaborate to ensure tPA is started before the transfer to the dedicated acute stroke unit at Henry Ford Hospital. "The infusion has usually run in by the time they arrive on our unit, but we do sometimes see patients with the tPA still running," said Penstone. "Sometimes we see an improvement in patient status right away, other times the next day and sometimes not until the following week. It all depends on the location and extent of the stroke." 

The University of Louisville Hospital has a telemedicine program with a robot that allows stroke specialists to collaborate with physicians in other hospitals. "Many stroke patients live in rural areas, so they may be given tPA in a community hospital before being flown here to our dedicated stroke ICU," said Senior. "It’s a truly amazing experience to watch the changes in patients as the tPA is running in. Sometimes they happen right before our eyes before the drip is even done, and we hope most symptoms will resolve within 24 hours of administration." 

That intensive nursing care pays off. "We haven’t seen any significant bleeding from tPA since our stroke ICU opened in April 2009," said Senior. "Our stroke-certified nurses watch very carefully for hemorrhagic conversions and we are able to detect complications very early on." 

Block shared a similar story. "Through the years, we’ve devoted much time and attention to educating other area hospitals on the appropriate administration of tPA to patients with ischemic stroke," she said. "Our mobile stroke team provides expertise to guide ED physicians through the decision-making process as well . and this has benefit for our community. Referring hospitals are becoming more aware of the need to administer tPA, so today, patients often come to us with the drug already onboard." 

Block recalled several recent patients who responded immediately to tPA. "I remember an 83-year-old woman who came in with complete right-sided paralysis and was walking to the bathroom 2 days later," she said. "She was able to go home on day 5 with only minor deficits. And we recently administered tPA to a man on our unit and were able to watch him improve over 2-3 hours." 

Public Awareness 

Community education is vital for changing outcomes for stroke patients. "Working at a tertiary care center that specializes in the care of patients with strokes, I’m aware of the extended time window for the administration of tPA," said Block. "However, that expanded time frame has not been well-publicized to potential patients and families, so there’s a lot of education still to be done." 

Clinicians at Henry Ford Hospital are also committed to providing preventive education to the community. "It’s not unusual for people to wait at home wondering whether their stroke symptoms are serious, and deciding when to seek medical attention," said Penstone. "Our goal is to educate the public about the signs and symptoms of stroke, and teach them to call 911 rather than having someone drive them to the ED. That immediate response will increase the number of people who can receive tPA." 

Senior has an ambitious goal to prevent complications from strokes. "We share a very straightforward message: Time saved is brain saved," she said. "Years ago, we taught the American public about the need for immediate care for heart attack symptoms, and we want them to learn the same thing about stroke symptoms." 

Sandy Keefe is a frequent contributor to ADVANCE. 

Reference 

1. Hacke W., et al. (2008, Sept 25). Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. New England Journal of Medicine, 359(13), 1317-1329.
2. Gregory, J. D. Z., et al. (2009, May 28). Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke, 40(8), 2945-2948.