Abstract 20: Patient Characteristics and Outcomes among Early-Arriving Acute Stroke Patients for Whom Alteplase Was Dispensed but Not Administered
Introduction: Best practice recommendations such as the AHA Target Stroke campaign suggest that IV tPA be dispensed as early as possible prior to final clinical decision when evaluating stroke patients at high likelihood of tPA eligibility. This practice may reduce door to needle times. We sought to determine the patient characteristics, outcomes and reasons for non-treatment among this selected group of individuals presenting to our stroke service. Methods: During the period of April 2007 till June 2014, 4170 patients presented to our hospital with acute Ischemic stroke, and 1152/4180 (28%) presented within 4 hours of last seen well (LKW). Using our hospital’s GWTG database and pharmacy logs, we identified all tPA treated cases as well as those in whom tPA was dispensed but not given. Categorical variables were compared using chi- square test and continuous variables were compared using Student t-test and Wilcoxon rank sum test. Results: Of 382 patients for whom tPA was dispensed, 239 (62.6%) ultimately received tPA. Compared to tPA treated patients, the 143 untreated patients in this cohort were more likely to have a history of previous stroke, present with weakness or language disturbance, and had a lower median NIHSS (Table). Untreated patients were more likely to be transferred from another hospital than to present directly from the scene, had a shorter median time from ED arrival to tPA dispensed, were less likely to undergo intra-arterial thrombolysis but had similar rates of home discharge and mortality. The most common reasons for non-treatment were mild symptoms (28%), rapid improvement (15%) and arriving after “drip and ship” (8%). In multivariate analysis, only lower NIHSS [aOR 0.93 per point (0.90, 0.97), p<0.001] and arrival via emergency medical services from scene [aOR 0.40 (0.24, 0.66), p <0.001] were independently associated with non-treatment. Conclusion: Delays in tPA initiation are common, and reduce health outcomes after thrombolysis. In our study, early dispensing of tPA prior to the final eligibility assessment produced an overall rate of tPA treatment of >60%. This conversion rate suggests that early tPA dispensing in high likelihood candidates is appropriate and supports the use of this strategy. Reasons for non-treatment were similar to those in unselected patients.