What is the standard by which an individual hospitalist is expected to practice, especially concerning the administration of tPA?
In that regard—without a doubt—patient safety comes first. “Whenever there’s confusion in my mind, I always think … first, do no harm,” says Dr. Sachdeva. “If this is an urban area and other hospitalists are not [administering] tPA, then they are not expected to do so and that may not meet the standard of care for that area. Rural hospitals have successfully been giving tPA to patients with acute ischemic stroke.
The caveat here is that appropriate planning as well as training of caregivers has to take place prior to starting IV tPA administration. “Rural hospitals that have the IV tPA capability usually do so in collaboration with larger regional institutions, academic or otherwise, where services of neurologists and neurosurgeons are available,” says Dr. Sachdeva. “Size of the institution should not be an impediment to IV tPA administration.”
As baby boomers age, the demand for better stroke care will increase, and hospitals as well as caregivers need to be prepared to meet the expectations of patients.
David Thurber, MD, medical director of the Cary Hospital Medicine Service, a division of Wake Medical Center, Cary, N.C., speaks of the need for specialty backup at community hospitals.
“For those people who practice in community hospitals, including myself,” he says, “it’s like being the pitcher on a baseball team: If you can’t field the outfield, you shouldn’t be pitching the ball because there’s nobody out there to catch it. So if you can’t get the backup of a neurologist, or of a neurosurgeon in the case of hemorrhagic stroke, in my opinion you have no business pushing tPA. Your obligation is to try, as many community hospitals have done with invasive cardiac procedures, such as emergent use of percutaneous coronary artery intervention, to transfer the patient to a facility where those can be done in a timely fashion.”
What should hospitalists do if they are expected to administer tPA and are unsure of their skill level?
“I would take this issue back to the administration of the hospital,” says Dr. Sachdeva, “and come up with a plan where the neurologists or the emergency department physicians feel motivated to give tPA.”
The most important element to consider when making the decision of whether to administer tPA is the quality of the history. “If there is any doubt about the time or the mechanism of stroke onset, then as practitioners we are very well justified in not giving tPA,” says Dr. Sachdeva, who believes there are more lawsuits for not giving tPA than for giving it. But if you withhold tPA and justify the decision with appropriate reasoning, that certainly places the individual on steadier legal ground.
Training and Competence
Stroke management is not a universally strong topic in medical education. “Not every medical school requires a rotation in the neurosciences or exposure to stroke treatment,” says Dr. Goldstein, “and it’s the same thing in residency programs, depending on which residency program you go through, be it as an internist or as an emergency physician. … So it begins in medical school and follows through residency, but as we know, our training only begins in those formal settings. In medicine, training is a lifelong activity. Things change all the time. And it would [take] appropriate levels of continuing education directly related to cerebrovascular disease to be able to understand modern diagnosis and modern therapeutics.”
Another issue is whether an institution will receive patients for stroke treatment. “Just as hospitals credential people to [perform] procedures, not every hospital can offer every therapy to every patient at the same level,” says Dr. Goldstein. “The thing that is inappropriate is to force people to do things for which they’re not trained.”