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UCLA leading the way for improved stroke treatment

UCLA’s “Target: Stroke” is national quality-improvement program that has significantly improved the outcome of stroke patients at hospitals throughout the nation
UCLA’s “Target: Stroke” is national quality-improvement program that has significantly improved the outcome of stroke patients at hospitals throughout the nation
Robin Wulffson, MD

UCLA’s “Target: Stroke” is national quality-improvement program that has significantly improved the outcome of stroke patients at hospitals throughout the nation. It was conceived by UCLA faculty and is conducted in collaboration with the American Heart Association/American Stroke Association. A new UCLA study, which reports the benefits of the program, appears in the April 23 edition of JAMA, the Journal of the American Medical Association.

The investigators evaluated the program at more than 1,000 participating hospitals and found that the administration of the clot-dissolving drug, tissue plasminogen activator (tPA), quickly (ideally within the first 60 minutes after a patient arrives at a hospital emergency department) is of critical importance for not only saving the patient’s life but also significantly preserving their brain function and reducing disability.

The intravenous injection of tPA is currently the only Food and Drug Administration (FDA)–approved treatment that has been shown to improve outcomes for patients suffering acute ischemic stroke, which affects some 800,000 Americans annually. (An ischemic stroke is the most common type of stroke and is the result of an obstruction of an artery leading to or within the brain. A hemorrhagic stroke is the result of the rupture of a blood vessel.)

The investigators found that at participating hospitals, the average time it took to administer tPA to patients decreased from 74 minutes to 59 minutes. As a result, patient outcomes were improved: reduced mortality, fewer treatment complications, and a greater likelihood that patients would return home after leaving the hospital instead of being transferred to a skilled nursing facility for advanced rehabilitation.

First author Dr. Gregg C. Fonarow explained, “These findings reinforce the importance and clinical benefits of faster administration of intravenous tPA. Through this national initiative, more patients were able to be treated with this beneficial therapy and in a safer, more effective fashion.” Dr. Fonarow is UCLA’s Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA.

The study authors stress that the benefits of tPA in acute ischemic stroke are extremely time-dependent For more than a decade, guidelines have recommended administering the treatment within 60 minutes of hospital arrival; however, despite the evidence, recommendations, and prior efforts, a previous study by the same research team found that less than 30% of eligible patients were receiving the medication in that first hour. The “Target: Stroke” program was launched in 2010 to address this issue; it provides 10 key “best practice” strategies to facilitate timely tPA administration, including: earlier notification to hospitals from emergency services in the field that a stroke victim is on the way; rapidly conducting and interpreting CT scans at the hospital to identify candidates for tPA; pre-mixing tPA medication for high-likelihood candidates; and other specific protocols and other tools.

For the study, the investigators reviewed data on 71,169 stroke patients treated with tPA at 1,030 hospitals participating in “Target: Stroke.” They compared time-to-treatment and the frequency of complications before the initiative launched (2003–09) and after its implementation (2010–13). They found that in addition to the 15-minute decrease in average time-to-treatment (from 74 to 59 minutes), the percentage of patients treated within the recommended time period increased from less than one-third to more than one-half. In addition, before the initiative, 9.95 of patients died in the hospital; following its implementation, that percentage decreased to 8.3%, marking a statistically significant change.

Another finding of the study was that patients treated using the initiative’s strategies were less likely to develop bleeding within the brain, which can be a complication of tPA treatment in certain types of strokes. The “Target: Stroke” protocol stresses that patients should undergo a CT scan upon arrival at the hospital, before the administration of tPA; this procedures will determine the risk of such bleeding.

Many factors are involved in quick, effective and safe stroke treatment, noted study co-author Dr. Jeffrey L. Saver, a professor of neurology and director of the Comprehensive Stroke Center at the David Geffen School of Medicine at UCLA. He explained, “Time lost is brain lost in acute stroke. A key message of this study is that the ‘Target: Stroke’ program enables hospitals to speed tPA treatment and improve patient outcomes. We hope that more US hospitals caring for acute stroke patients will join this innovative and highly effective program.”

Dr. Fonarow noted that the team also found that more patients were able to be treated with tPA after the implementation of the initiative. Before the program was instituted, only 64.7% of eligible patients were treated with tPA. After initiation of “Target: Stroke,” this percentage increased to 85.2% percent. Treatment improvement occurred among all study patients. The percentage of patients, who were evenly distributed between males and females, was 72. Almost 75% were Caucasian, 14% were African American, and 6% were Hispanic.

Patients’ independence also improved after implementation of “Target: Stroke”. After initiation of the program, more patients maintained the ability to walk without assistance. In addition, 42.7% were able to return home after leaving the hospital rather than being transferred to a skilled nursing facility; before the initiative, only 37.6% were discharged to their home.

At present, more than 1,500 US hospitals are participating in the program. The authors note that no previous initiative for improving timeliness of tPA treatment for acute ischemic stroke has had the size, scope, depth or clinical impact of “Target: Stroke.” Dr. Fonarow added that these improvements in care, patient safety, and clinical outcomes were able to be achieved on an entirely volunteer basis, with little to no extra cost among participating hospitals.

In the near future, a second program will be launched. “Target: Stroke Phase II,” has the goal of further improving the speed of tPA administration. The investigators will identify additional best-practice strategies and evaluate which patient, hospital and system factors account for the greatest improvement in timely treatment for acute ischemic stroke.

Dr. Saver noted that another strategy for effective treatment is to identify the onset of stroke. He suggests being aware of four stroke warning signs that can be easily remembered with the acronym FAST: Face: Ask the person to smile. Does one side of the face droop? Arms: Ask the person to raise both arms. Does one arm drift downward? Speech: Ask the person to repeat a simple phrase. Is their speech slurred or strange? Time: If you observe any of these signs, call 9-1-1 immediately.

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