Smaller hospitals can implement tPA treatment

( Although treatment of stroke patients with tissue plasminogen activator is used mostly at large hospitals, a new study found ways to implement the treatment at community hospitals in Michigan.

Data from 22 hospitals show that tPA use more than doubled in the 11 hospitals that were randomly chosen to get the extra help, versus a smaller increase in 11 hospitals that served as controls. Some hospitals even surpassed national targets for tPA use that large stroke centers do not always reach, reported researchers with the University of Michigan Health System’s Department of Emergency Medicine, Department of Neurology and Stroke Program.

Across the U.S., fewer than 2% of stroke patients receive tPA even though more than 11% are candidates for the treatment. The gap largely arises from time limits on use of tPA and delays in getting patients to bigger hospitals.

The investigation — called INSTINCT, for INcreasing Stroke Treatment through INterventional Change Tactics — demonstrates that tPA can be used safely and appropriately in the community hospital setting, and that more work needs to be done to expand public access to the only treatment approved by the Food and Drug Administration to reverse the effects of stroke.

Although improvement at the targeted community hospitals was statistically significant, it was not as large as hoped for, the researchers said. But the findings suggest relatively low-cost and low-tech interventions can improve local stroke care.

“This study suggests that community hospitals can evaluate and treat enough emergency stroke patients to keep their teams’ treatment skills sharp, but are of a size that creates rapid lines of communication and stable physician and nurse teams,” Phillip Scott, MD, the study’s lead author and an associate professor of emergency medicine at the U-M Medical School, said in a news release.

“This may facilitate rapid, safe stroke diagnosis and care. Four of the hospitals that received the educational intervention achieved tPA use rates of 5% to 8% of all stroke patients, compared to only one of the control hospitals. That’s a rate that many large medical centers strive to reach.”

The researchers started by collecting baseline data on stroke treatment from 2005 and 2006 at the participating hospitals, all of which were in the lower of peninsula of Michigan and were chosen at random from among hospitals with at least 100 stroke discharges per year. Hospitals could hold primary stroke center designation, as granted by The Joint Commission, but could not be tertiary academic comprehensive stroke centers.

The size of the study, with 557 stroke patients treated after intervention began, makes it one of the largest tPA studies in the world, the researchers said.

After the sites were randomized, the researchers offered continuing medical education classes at the hospitals, workshops at U-M and other support, including 24-hour phone consultation availability, to the hospitals chosen to receive the intervention.

The study findings were complicated by the fact that one of the hospitals enrolled in the trial became an academic stroke center after the study began. When it and its matched hospital were excluded from the analysis, the remaining hospitals showed enough of an impact from the educational effort to be statistically significant: a 105% increased use of tPA over baseline.

“We essentially saw a doubling of tPA usage, using standard technologies for education and support,” Scott said. “Importantly, the increase was achieved safely. This shows we can translate the knowledge of effective stroke treatment into a community setting.”

The study, funded by the National Institute of Neurological Disorders and Stroke at the National Institutes of Health, is scheduled for publication in The Lancet Neurology. The study abstract is available at