Thrombectomy window expanded for acute ischemic stroke
Updated comprehensive guidelines on early management of acute ischemic stroke from the American Heart Association (AHA) and the American Stroke Association (ASA) support expanding the window from mechanical thrombectomy up to 24 hours after stroke onset in highly selected patients, among other recommendations.
The guidelines replace the 2013 guidelines on this topic as well as all subsequent updates and are intended to summarize all of the most up-to-date evidence and recommendations in a single document. An independent evidence review committee performed systematic reviews of clinical questions that had been identified with the writing group, and the writing group considered these results when making its recommendations, the authors wrote. Two of the systematic reviews, one on dysphagia screening strategies and another on the accuracy of prediction instruments for diagnosing large-vessel occlusion, were published Jan. 25 by Stroke. The writing group also based its recommendations on the DEFUSE 3 trial (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution), a randomized trial comparing endovascular therapy plus standard medical therapy and standard medical therapy alone in patients 6 to 16 hours from known stroke onset, which was published Jan. 24 by the New England Journal of Medicine.
The guidelines address prehospital care, urgent and emergency evaluation and treatment with IV and intraarterial therapies, and in-hospital management, including secondary prevention measures. The recommendations apply only to adults and to those secondary prevention measures that are instituted appropriately during the first two weeks of stroke treatment, the authors wrote. Recommendations on cerebral venous sinus thrombosis are not included because this condition was covered in a 2011 scientific statement and no practice-changing evidence has been published on that topic since then, the guidelines said.
New recommendations include the following:
- When several IV alteplase-capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. Further research is needed.
- It may be reasonable to establish a secondary door-to-needle time goal of 45 minutes in at least 50% of patients with acute ischemic stroke treated with IV alteplase.
- Telestroke/teleradiology evaluations of acute ischemic stroke patients can be effective for correct IV alteplase decision making.
- Systems should be established so that brain imaging studies can be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy.
- Routine use of MRI to exclude cerebral microbleeds before administration of IV alteplase is not recommended.
- In selected patients with acute ischemic stroke within 6 to 24 hours of last known normal who have large-vessel occlusion in the anterior circulation, obtaining CT perfusion, diffusion-weighted MRI, or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria from randomized controlled trials showing benefit are being strictly applied in selecting patients for mechanical thrombectomy.
- In selected patients with acute ischemic stroke within 6 to 16 hours of last known normal who have large-vessel occlusion in the anterior circulation and meet other eligibility criteria from the DAWN trial (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) or from the DEFUSE 3 trial, mechanical thrombectomy is recommended.
- In selected patients with acute ischemic stroke within 6 to 24 hours of last known normal who have large-vessel occlusion in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable.
- Dysphagia screening before the patient begins eating, drinking, or receiving oral medications is reasonable to identify patients at increased risk for aspiration.
- Routine screening of patients with recent ischemic stroke for obstructive sleep apnea is not recommended.
- For patients who have a noncardioembolic acute ischemic stroke while taking antiplatelet therapy, switching to warfarin is not beneficial for secondary stroke prevention.
- For patients with acute ischemic stroke who qualify for statin treatment, in-hospital initiation of statin therapy is reasonable.
- For patients who smoke and have acute ischemic stroke, in-hospital initiation of high-intensity behavioral therapies is reasonable.
Editor's Note: On April 18, the AHA/ASA issued a correction deleting several sections of this guideline while preparing to clarify, modify, and/or update them. A revised guideline will be posted over the coming weeks, the AHA/ASA said.
Progress note template, lecture affected note quality, length
An educational session bundled with a progress note template improved interns' note quality and timeliness while decreasing note length, a recent study found.
The intervention included a brief educational session on documentation for residents and attendings and the implementation of an electronic progress note template, developed by a note-writing task force. The template design minimized autopopulation while encouraging clinicians to enter relevant data through free-text fields, prompts (e.g., “I have reviewed all the labs from today. Pertinent labs include . . .”), and drop-down menus. The end of the template also featured an inpatient checklist of key concerns and quality measures.
Researchers tested the effect of the intervention on interns' note quality, length, and timeliness at four academic internal medicine residency programs: the University of California (Los Angeles, San Francisco, and San Diego) and the University of Iowa. They collected 200 preintervention notes (from September to December 2013) and 199 postintervention notes (from April to June 2014), 70% of which used the template (interns were encouraged but not required to use it). Internal medicine teaching faculty rated notes using a tool comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Results were published online Jan. 19 by the Journal of Hospital Medicine.
After the intervention, the mean general impression score improved from 2.0 to 2.3 on a 1 to 3 scale (below average, average, or above average). Note quality also improved in the PDQI-9 (P<0.001 for all domains). In the competency questionnaire, the most improvement was seen in documenting only “relevant lab values and studies and removal of older data rather than importing all information” (29% preintervention vs. 63% postintervention; P<0.001). Other significant improvements were in notes being “concise yet adequately complete,” documenting a “relevant and focused physical exam,” and including an “updated problem list” and “mention of a discharge plan.”
Three of the four institutions documented the number of lines per note and the time each note was signed by the intern. The mean number of lines per note decreased by 25% after the intervention (361 vs. 265; P<0.001), and the mean time signed was about 1 hour and 15 minutes earlier in the day (3:27 p.m. vs. 2:10 p.m.; P<0.001).
During the postintervention period, notes that used the template were more likely than nontemplated notes to receive a higher mean impression score (odds ratio, 11.95; P<0.001) and a higher PDQI-9 sum score (odds ratio, 3.05; P<0.001), as well to be shorter and signed earlier.
The study authors noted limitations, such as the lack of blinding and the likelihood of bias among graders of the notes. They added that their research makes progress toward ACP's 2015 recommendations to improve note accuracy and develop automated tools that enhance documentation quality.