HONOLULU – Traditionally, acute ischemic stroke patients have been admitted to an ICU for administration of intravenous tissue plasminogen activator therapy. But it’s not necessary, according to Kisha C. Coleman.
Kisha C. Coleman
Instead, these patients can safely undergo intravenous TPA therapy in a well-prepared stroke unit with excellent clinical outcomes – and big cost savings, said Ms. Coleman, a nurse at the University of Alabama at Birmingham comprehensive stroke center.
She presented what she and her coinvestigators said is the largest-ever series of non–ICU-managed stroke patients treated with intravenous TPA. The series consisted of 302 consecutive patients admitted from the emergency department to the university’s nine-bed intermediate-level stroke unit for intravenous TPA therapy during 2009-2011. During this 3-year period, another 31 acute ischemic stroke patients were sent from the ED to the ICU because of hemodynamic or pulmonary instability.
The stroke unit has flexible staffing, and the nurses have undergone extensive training. Their capabilities include management of intravenous TPA therapy, administration of nicardipine infusions when warranted for blood pressure control, management of bilevel positive airway pressure ventilation, and noninvasive or direct central arterial line and hardwired cardiac monitoring.
The median National Institutes of Health Stroke Scale score at admission to the stroke unit was 9, with a median modified Rankin score of 3 at discharge. Ten percent of patients received nicardipine infusions.
The overall symptomatic intracranial hemorrhage rate was 3.3%, with a systemic hemorrhage rate of 2.9%. The volume of patients admitted to the stroke unit for intravenous TPA increased over time from 86 patients in 2009 to 107 in 2010 and 109 in 2011. Meanwhile, the incidence of symptomatic intracranial hemorrhage dropped from 4.7% the first year to 2.8% in each of the next 2 years.
"We attribute that to increased nurse efficiency over time in caring for these types of patients," Ms. Coleman said at the International Stroke Conference, sponsored by the American Heart Association.
No patients required a transfer from the stroke unit to the ICU for continued management. No TPA-related deaths occurred.
Hospital length of stay decreased from a median 9.8 days in 2009 to 6.4 in 2010 and 5.2 days in 2011, she continued.
The 31 patients admitted to the ICU from the emergency department during the study period and the 302 managed in the stroke unit had similar admission NIH Stroke Scale severity scores, symptomatic intracranial hemorrhage and systemic hemorrhage rates, and average lengths of stay.
A day in the ICU costs about $1,200 more than does a day in the stroke unit, she noted. The estimated cost savings resulting from avoided ICU days during this 3-year period was $362,400, even after adjustment for the expense of the additional training for nurses. And that figure is a conservative one that probably significantly underestimates the true savings, according to Ms. Coleman.
"Use of the ICU solely for management of TPA monitoring may constitute a significant overuse of system resources at an expense that is not associated with additional safety benefit," she concluded.
Beyond the sizable cost savings, another advantage of managing intravenous TPA therapy in the stroke unit rather than the ICU is continuity of care. These patients are admitted to and discharged from the stroke unit, she noted.
Ms. Coleman reported having no relevant financial conflicts.