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ER protocols, ischemic stroke, thrombolytic use, treatment delay



  1. Zanichkowsky, Rita
  2. Nascimento, Jennifer A.
  3. McCune, Marie
  4. Spencer, Cynthia
  5. Chukwuneke, Florence
  6. Wyrick, Tiana
  7. McCullough, Louise D.


ABSTRACT: Background: Despite significant efforts to improve thrombolytic use in the United States, only a small number of patients with ischemic stroke are currently treated. Although there are a number of contraindications to tissue plasminogen activator use, many patients are excluded because of the narrow therapeutic time window, which is determined by the "last known well" (LKW) time. However, it is unclear how the LKW is obtained and documented in the acute hospital setting. Methods: We surveyed hospitals throughout the Northeast region to determine if they had established protocols for documenting LKW times. Treatment rates as reported to Get with The Guidelines Stroke were then compared in hospitals with and without established protocols for documenting LKW times. Results: The majority of hospitals (73%) lacked established protocols for LKW documentation. Those without established protocols more often missed this variable when reporting to Get With The Guidelines-Stroke. Treatment rates were low overall (7%), although rates in patients who presented within 2 hours of symptom onset were high in hospitals whether they had an established protocol (86%) or not (87%). However, the lack of documentation of LKW is common and could influence the treatment rates if patients are erroneously excluded from treatment. Conclusions: Improved documentation of LKW times should be attempted. The addition of this variable to existing protocols could more accurately track the number of patients ineligible for treatment based on delayed presentation.