Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Barriers to the use of tissue Plasminogen Activator in the Emergency Department
Setting: Survey of Rhode Island EM Physicians
Wagner, JC, D.O., Domingo, E, D.O., Zabbo, CP, D.O.
Kent Hospital, Department of Emergency Medicine, Warwick, RI
BACKGROUND: Although the use of tPA in the setting of acute ischemic stroke is
currently the only therapy available to be given in the ED, it is still controversial (due to
risk of hemorrhage) in the emergency medicine community as to whether tPA is the
standard of care. The objective of this study was to determine the potential barriers to
the use of tissue Plasminogen Activator (tPA) in the emergency department (ED) setting
for the treatment of acute ischemic stroke. The goal was to identify areas where
educational efforts should be focused in order to increase tPA use in the ED and
address bias on the part of practicing emergency physicians towards administration of
tPA in the setting of acute ischemic stroke.
METHODS: Two hundred three (203) emergency physicians in the state of Rhode
Island were sent an electronic survey. A confidential, self-administered, pilot-tested
survey assessing demographics, practice environment, attitudes, and beliefs regarding
tPA use in acute ischemic stroke were used. Descriptive statistics was used as the
method for data analyses. Main outcome measures assessed belief in a legal standard
of care, clinical experience with tPA, likelihood of use in an ideal setting, comfort in use
with and without a neurologist, typical reasons for reluctance of the use of tPA and
thoughts for the increase use of tPA in the ED setting.
RESULTS: Forty-two surveys were completed (gross response rate 20.7%). Ninetyseven
percent indicated access to using tPA in the acute ischemic stroke setting.
Eighty-seven percent indicated use of tPA is the standard of care. Eighty-five percent
indicated they are comfortable using tPA, with fifty-nine percent indicating previous
experience influences their decision to use tPA. Major reasons for reluctance of the use
of tPA were the risk of hemorrhage (62%), followed by family reluctance (18%), lack of
clinical experience with tPA (13%) and lack of proven neurologic benefit (13%). Twentysix
percent indicated no reluctance to the use of tPA. Thirteen of the forty-two (31%)
respondents are not at a designated stroke center and of that, 62 % have access to a
stat neurologic consult.
CONCLUSIONS: Our survey, even with a small rate of return, was able to reproduce
similar responses about the major barrier to the use of tPA, risk of hemorrhage. The
next step in facilitating the use tPA in the ED is to understand what prevents its use. We
have identified multiple barriers during this survey. The most common responses
included having more involvement of neurology, lowering the hemorrhagic risk and more
research.