Tissue Plasminogen Activator Prescription and Administration Errors within a Regional Stroke System

Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

BACKGROUND AND OBJECTIVES

To investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).

METHODS

We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3) was evaluated before (pre-MT) and after MT (final).

RESULTS

We included 588 patients (median age 75 years [interquartile range (IQR) 61-84]; 315 women [54%]; median NIH Stroke Scale score 16 [IQR 10-20]), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval [CI] 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 [IQR 23-55] vs 86 [IQR 70-110] minutes; p < 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4-4.1).

DISCUSSIONS

Tenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.

Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System

BACKGROUND

Even with global efforts to prevent medication errors, they still occur and cause patient harm. Little systematic research has been done in Norway to address this issue.

OBJECTIVES

To describe the frequency, stage and types of medication errors in Norwegian hospitals, with emphasis on the most severe and fatal medication errors.

METHODS

Medication errors reported in 2016 and 2017 (n=3557) were obtained from the Norwegian Incident Reporting System, based on reports from 64 hospitals in 2016 and 55 in 2017. Reports contained categorical data (eg, patient age, incident date) and free text data describing the incident. The errors were classified by error type, stage in the medication process, therapeutic area and degree of harm, using a modified version of the WHO Conceptual Framework for the International Classification for Patient Safety.

RESULTS

Overall, 3372 reports were included in the study. Most medication errors occurred during administration (68%) and prescribing (24%). The leading types of errors were dosing errors (38%), omissions (23%) and wrong drug (15%). The therapeutic areas most commonly involved were analgesics, antibacterials and antithrombotics. Over half of all errors were harmful (62%), of which 5.2% caused severe harm, and 0.8% were fatal.

CONCLUSIONS

Medication errors most commonly occurred during medication administration. Dosing errors were the most common error type. The substantial number of severe and fatal errors causing preventable patient harm and death emphasises an urgent need for error-prevention strategies. Additional studies and interventions should further investigate the error-prone medication administration stage in hospitals and explore the dynamics of severe incidents.

Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

Multidisciplinary acute stroke teams improve acute ischemic stroke management but may hinder trainees' education which in turn may contribute to poorer outcomes in community hospitals upon graduation. Our goal was to assess graduate neurology trainee performance independent of a multi-disciplinary stroke team in the management of acute ischemic stroke, tissue plasminogen activator (tPA)-related hemorrhage, and cerebral herniation syndrome.

METHODS

In this prospective, observational, single-center simulation-based study, participants (sub-interns to attending physicians) managed a patient with acute ischemic stroke followed by tPA-related hemorrhagic conversion leading to cerebral herniation. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society's Emergency Neurological Life Support protocols. The primary outcome measure was graduate neurology trainees' critical action item sum score. We sought validity evidence to support our findings by comparing trainees' performance across four levels of training.

RESULTS

Fifty-three trainees (including 31 graduate neurology trainees) and five attending physicians completed the simulation. The mean sum of critical actions completed by graduate neurology trainees was 15/22 (68%). Ninety percent of graduate neurology trainees properly administered tPA, 84% immediately stopped tPA infusion following patient deterioration, but only 55% reversed tPA according to guidelines. There was a moderately strong effect of level of training on critical action sum score (level 1 mean score [standard deviation (SD)] = 7.2 (2.8) vs. level 2 mean score (SD) = 12.3 (2.6) vs. level 3 mean score (SD) = 13.3 (2.2) vs. level 4 mean score (SD) = 16.3 (2.4), p < .001, R² = 0.54).

DISCUSSION

Graduate neurology trainees reassuringly perform well in initial management of acute ischemic stroke, but frequently make errors in the treatment of hemorrhagic transformation after thrombolysis, suggesting the need for more education surrounding this low frequency, high-acuity event. High-fidelity simulation holds promise as an assessment tool for acute stroke management performance.

Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke

BACKGROUND & PURPOSE

Alteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center.

METHODS

This was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared.

RESULTS

A total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p= 0.04).

CONCLUSION

The error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.

Provider Communication and Telepresence Enhance Veteran Satisfaction With Telestroke Consultations

BACKGROUND AND PURPOSE

Telestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke; however, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration.

METHODS

Patients who received a telestroke consultation were eligible for a phone interview 2 weeks later, including questions about technology quality, telepresence, and telestroke provider communication. Satisfaction scores ranged from 1 to 7 (higher=more satisfied) and for analyses were dichotomized as 6 to 7 indicating high satisfaction versus <6. Patient variables including stroke severity (measured by the National Institutes of Health Stroke Scale) were obtained from study records. Generalized estimating equation models were used to determine what factors were associated with patient satisfaction.

RESULTS

Over 18 months, 186 interviews were completed, and 142 (76%) reported high satisfaction with telestroke. Patients with more severe stroke were less likely to recall the consultation. Factors significantly associated with patient satisfaction were higher ratings of the technology (P<0.0001), telepresence (P<0.0001), provider communication ratings (P<0.0001), and overall Veterans Affairs satisfaction (P=0.02). In the multivariate model, telepresence (odds ratio, 3.10 [95% CI, 1.81-5.31]) and provider ratings (odds ratio, 2.37 [95% CI, 1.20-4.68]) were independently associated with satisfaction. Veterans who were satisfied were more likely to recommend the technology (P<0.0001).

CONCLUSIONS

Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with the telestroke consultation. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence could improve patient experience with telestroke consultation.