Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

Abstract P201: Octogenarian and Nonagenarian Outcomes Among Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
RAJAN R GADHIA ◽  
Farhaan S Vahidy ◽  
Tariq Nisar ◽  
Destiny Hooper ◽  
David Chiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Combined Treatment ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Acute Stroke Treatment ◽  
Iv Tpa

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kerrin Connelly ◽  
Rishi Gupta ◽  
Raul Nogueira ◽  
Arthur Yancey ◽  
Alexander Isakov ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Transport Protocol ◽  
Stroke Patients ◽  
Stroke Registry ◽  
The Public ◽  
State Office ◽  
Stroke Center ◽  
Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Laurie Paletz ◽  
Shlee Song ◽  
Nili Steiner ◽  
Betty Robertson ◽  
Nicole Wolber ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Quality Of Care ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Turnaround Time ◽  
Joint Commission ◽  
Stroke Patients ◽  
Number Of Patients ◽  
The Impact

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification. Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care? Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time. Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC). Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

scholarly journals Trends in hospital procedure volumes for intra-arterial treatment of acute ischemic stroke: results from the paul coverdell national acute stroke program

2020 ◽  
Vol 12 (11) ◽  
pp. 1076-1079
Author(s):  
Ganesh Asaithambi ◽  
Xin Tong ◽  
Kamakshi Lakshminarayan ◽  
Sallyann M Coleman King ◽  
Mary G George
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
High Volume ◽  
Favorable Outcome ◽  
Stroke Registry ◽  
The Usa ◽  
Low Volume ◽  
The Impact

BackgroundRates of intra-arterial revascularization treatments (IAT) for acute ischemic stroke (AIS) are increasing in the USA. Using a multi-state stroke registry, we studied the trend in IAT use among patients with AIS over a period spanning 11 years. We examined the impact of IAT rates on hospital procedure volumes and patient outcome after stroke.MethodsWe used data from the Paul Coverdell National Acute Stroke Program (PCNASP) and explored trends in IAT between 2008 and 2018. Patient outcomes were examined by rates of IAT procedures across hospitals. Specifically, outcomes were compared across low-volume (<15 IAT per year), medium-volume (15–30 IAT per year), and high-volume hospitals (>30 IAT per year). Favorable outcome was defined as discharge to home.ResultsThere were 612 958 patients admitted with AIS to 687 participating hospitals within the PCNASP during this study. Only 2.9% of patients (mean age 68.5 years, 49.3% women) received IAT. The percent of patients with AIS receiving IAT increased from 1% in 2008 to 5.3% in 2018 (p<0.001). The proportion of low-volume hospitals decreased over time (p<0.001), and the proportions of medium-volume (p=0.007) and high-volume hospitals (p<0.001) increased between 2008 and 2018. When compared with medium-volume hospitals, high-volume hospitals had a higher (p<0.0001) and low-volume hospitals had a lower (p<0.0001) percent of patients discharged to home.ConclusionHigh-volume hospitals were associated with a higher rate of favorable outcome. With the increased use of IAT among patients with AIS, the proportion of low-volume hospitals performing IAT significantly decreased.

Abstract 2268: Trends In Reasons For Non-eligibility For tPA

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Xin Tong ◽  
Mary G George
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Advanced Age ◽  
Stroke Patients ◽  
Rapid Improvement ◽  
Nihss Score ◽  
Mild Stroke ◽  
Over Time ◽  
Iv Tpa

Background: Use of IV tPA has increased over time, as has the adherence to the NQF endorsed performance measure for receipt of IV tPA within 3 hours. Little is known about trends in the reasons for patient ineligibility for IV tPA. This study examines trends in reasons for not providing IV tPA over time and by race and gender among acute ischemic stroke patients in the Paul Coverdell National Acute Stroke Registry (PCNASR), a quality improvement program for acute stroke implemented by state health departments. Methods: There were 13,164 PCNASR patients enrolled from 2008- 2010 with a clinical diagnosis of acute ischemic stroke with documentation of LKW and who arrived within 2 hours of LKW. Cochran-Armitage tests were used to test for trend on accepted reasons for not providing IV tPA within 3 hours of time last known well (LKW). Chi-square tests were used to test for differences among reasons between men and women and between non-Hispanic whites and minorities. Multiple reasons for not giving tPA could be selected. Results: Among 13,164 acute ischemic patients admitted between 2008 and 2010 with documentation of LKW and who arrived within 2 hours of LKW, 3781 (28.7%) received IV tPA, 7284 (55.3%) had documented reasons for not receiving IV tPA, and 2099 (16.0%) did not receive IV tPA. Contraindications to IV tPA, advanced age, rapid improvement and inability to determine eligibility increased over time. Mild stroke decreased over time. Conditions with warning, advanced age, limited life expectancy and family refusal were more common in women; mild stroke and rapid improvement were more common in men. Contraindications were more common in minorities; advanced age, mild stroke and rapid improvement, and family refusal were more common in non-Hispanic whites. When advanced age was selected, 46.6% of patients were over age 90 and 3.4% were under age 80. When stroke too mild was selected, 44.8% of patients had missing NIHSS scores, 42.1% of scores were 0-4, 8.8% were 5-9, and 4.3% were ≥ 10. The three most common reasons for not providing tPA were rapid improvement (40.9%), mild stroke (33.0%), and contraindications (29.2%) in 2010. Conclusions: More than half of ischemic stroke patients arriving within 2 hours of LKW were ineligible to receive IV tPA. There was little use of advanced age for patients under age 80. Documentation of stroke too mild was not substantiated by an NIHSS score in nearly half of patients. Better documentation of NIHSS score should be provided.

DWI Lesion Characteristics As A Predictor For Outcome In Acute Stroke Patients Treated By IV-tPA

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
H Aref ◽  
S Farag ◽  
S Helmy ◽  
H Mahmoud
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Type ◽  
P Value ◽  
Stroke Patients ◽  
Tissue Type Plasminogen Activator ◽  
Type Plasminogen Activator ◽  
Iv Tpa

Abstract Background Thrombolysis with tissue-type plasminogen activator (IV-tPA) is a well-proved, widely used treatment in acute ischemic stroke patients, many predictors of functional outcome have been proposed as Age, vascular risk factors, initial clinical evaluation on admission using National institute of health stroke scale(NIHSS), functional state of patient(b.L) baseline before stroke and 3 months (3m) after stroke using modified Rankin stroke scale (MRS)and the most controversial Diffusion weighted image characteristics (volume, heterogeneity) Objective To evaluate DWI MRI characteristics (volume, heterogeneity) as a predictor for outcome in Acute stroke patients treated by IV-tPA Patients and Methods This study will be done on a sample of 100 acute ischemic stroke Egyptian patients receiving intra-venous tissue -type plasminogen activator presenting to Ain-Shams university hospitals Results Highly statistically significant (p-value &lt; 0.001) Positive correlation (r = 0.394) between volume (DWI) and MRS (3m) post discharge in studied patients, No statistically significant (pvalue &gt; 0.05) relation between heterogeneity and other studied parameters (MRS, NIHSS D & ADC values) in studied patients Conclusion DWI infarct volume is a predictor for outcome in acute ischemic stroke patients treated by tPA

Abstract WP246: Acute Ischemic Stroke Patients With a Primary Language Other Than English Do Not Have Significantly Increased Door-to-Needle Times for Intravenous TPA

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalie T Cheng ◽  
Elizabeth A Cahill ◽  
Tomas Tesfasilassie ◽  
Molly M Burnett ◽  
Lara Zimmermann ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Family Member ◽  
San Francisco ◽  
Primary Language ◽  
Stroke Patients ◽  
Discharge Disposition ◽  
Clinical Records ◽  
Iv Tpa

Background: Rapid administration of intravenous alteplase (IV tPA) leads to better outcomes, but language barriers have the potential to introduce delays and to hinder effective communication with patients and collateral historians during the acute evaluation. Hypothesis: Acute ischemic stroke patients with a non-English primary language will have significantly longer door-to-needle times for IV tPA. Methods: We abstracted information on primary language for all adults that received IV tPA for acute ischemic stroke in the emergency department of an academic referral center in San Francisco, CA, from February 2008 to May 2015. Approximately 38% of San Francisco residents speak a language other than English at home. Primary language was determined from the electronic medical record and was confirmed by reviewing specific documentation in subsequent speech therapy evaluations and admission notes. Age, sex, race, presenting NIHSS, aphasia as a presenting symptom, whether the patient was accompanied to the emergency department by a family member or caregiver, discharge disposition, and door-to-needle (DTN) administration time for IV tPA were abstracted from clinical records and quality improvement registries. Results: A total of 237 patients received IV tPA for acute ischemic stroke in the emergency department during the study period. Median age was 76 years (IQR 64-86), 53% were female, and median DTN time was 62 minutes (IQR 48-86). A total of 34% of patients had a primary language other than English (20% Cantonese, 6% Russian, 3% Spanish). These patients were more likely to be older (median age 80 vs. 73 years, p = 0.001), to be accompanied by a family member or caregiver (80% vs. 59%, p = 0.003), and to have a higher NIHSS (median 9 vs. 11, p = 0.03), but DTN times were similar among English and non-English primary language speakers (median 62 vs. 62, p=0.88) and short-term outcomes were not significantly different (in-hospital mortality 9% English primary language vs 14% non-English primary language, p=0.27; discharge to home 43% vs 32%, p=0.16) . Conclusions: At a center serving a multiethnic population, a patient’s primary language did not appear to predict DTN times for acute ischemic stroke.

Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Nancy D Papesh ◽  
James Gebel
Keyword(s):  
Acute Stroke ◽  
Care Center ◽  
Tertiary Care ◽  
Cleveland Clinic ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Stroke Treatment ◽  
The Impact ◽  
Iv Tpa

Background: The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009. Hypothesis: We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase. Methods: Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test). Results: IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158). Conclusions: Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.

Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Lindsay Olson-Mack ◽  
Jacqueline Reardon ◽  
Elton Hedden ◽  
Rowena Carino ◽  
Cynthia VanWyk ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Nurse Practitioner ◽  
Treatment Effectiveness ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Assessment And Treatment ◽  
Iv Tpa

Background and Purpose: Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times. Methods: The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives. Results: Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year. Conclusions: Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.

scholarly journals Why Stroke Patients Don’t Receive T-PA? An Analysis of Patient Eligibility: Implications for Improving Clinical Impact by Increasing Future Treatment Numbers

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 372-372
Author(s):  
Philip A Barber ◽  
Jinijin Zhang ◽  
Andrew M Demchuk ◽  
Michael D Hill ◽  
Andrea Cole-Haskayne ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Stroke Registry ◽  
Specific Protocol ◽  
Stroke Type ◽  
Ischemic Attack

P183 Background T-PA is an effective treatment of acute ischemic stroke within 3 hours. However, the success of t-PA on reducing disability is dependent on it being accessible to more patients. We identified the reasons why patients with ischemic stroke did not receive intravenous t-PA and assessed the community impact of the therapy in a large North American city. Methods Consecutive patients with acute ischemic stroke were identified in a prospective stroke registry at a teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke admitted to one of three other hospitals during the study period were identified. The Oxford Community Stroke Program Classification was used to record stroke type. Results Of 2165 stroke patients presenting to the emergency department 1179 (54.5%) were diagnosed with ischemic stroke, 31.7% with intracranial hemorrhage, and 13.8 % with transient ischemic attack. 84/339 (29%) patients were admitted within 3 hours of stroke received intravenous t-PA. The major reasons for exclusion for stroke patients presenting within 3 hours were mild stroke (20%), clinical improvement (18.6%), and specific protocol exclusions (11.5%). Delay in presentation to emergency department excluded 840/1179 (71%). 1817 ischemic stroke patients were admitted to Calgary hospitals during the study period of which 4.6% received intravenous t-PA. Generalization of the Calgary experience to other Canadian communities suggests the benefit from t-PA for ischemic stroke may be substantial with an additional 460 independent survivors per annum. Conclusion The effectiveness of t-PA can be improved by understanding why patients are excluded from its use. The eligibility of patients for t-PA must increase by promoting health education programs and by developing organized acute stroke care infrastructure within the community.

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