SGEM#290: Neurologist Led Stroke Teams – Working 9 to 5

Date: April 21st, 2020 Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Guest Skeptic: Dr. Chuck Sheppard is an attending Emergency Department Physician at Mercy Hospital in Springfield, Missouri and the medical director for Mercy Life Line air medical service.  He has been practicing in Emergency Medicine for over 40 years and involved in EMS services for over 30 years. Case: 56-year-old female with sudden onset of left arm and leg weakness with slurred speech presents to the emergency department (ED). She was last seen well two hours prior. Her past medical history includes hypertension and type II diabetes. She is not on any anticoagulation except ASA. There is no previous history of stroke. The neurology led stroke team is not available and you wonder if that will affect her outcome. Background: Treatment for acute ischemic stroke has been debated between neurologists and emergency physicians for years now. A recent PRO/CON debate on the subject was published in CJEM April 2020 with Dr. Eddy Lang and myself. It was the legend of emergency medicine, Dr. Jerome Hoffman that really raised the concern about the lack of evidence for using thrombolytics in acute ischemic stroke. He was interviewed on an SGEM Xtra segment called No Retreat, No Surrender. We have covered acute ischemic stroke many times on the SGEM. SGEM#29: Stroke Me, Stroke Me SGEM#70: The Secret of NINDS SGEM Xtra:Thrombolysis for Acute Stroke SGEM Xtra: Walk of Life SGEM#269: Pre-Hospital Nitroglycerin for Acute Stroke Patients? Clinical Question: Does the presence of a neurologist led stroke team affect the likelihood of receiving tPA and does that improve a patient-oriented outcome? Reference: Juergens et al. Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke. Proc Baylor Univ Med Center Oct 2019 Population: All patients presenting to the ED meeting stroke activation criteria Intervention: Neurologist led stroke team Comparison: No neurologist led stroke team Outcomes: Primary Outcome: Rate of tPA administration Secondary Outcomes: Door-to-needle times, modified Rankin Scale (mRS) at discharge, change in National Institutes of Health Stroke Scale (NIHSS), and discharge disposition Authors’ Conclusions: “Emergency physicians administered significantly less thrombolytics than did neurologists. No significant difference was observed in outcomes, including mRS and admission-to-discharge change in NIHSS. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Precise Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Results: There were 415 stroke activations during the study period (Jan 1, 2015 to June 30, 2016). Of those activations, 153 (37%) were managed by the neurologist led team and 262 (63%) were treated by emergency physicians. The median age was early 60’s with slightly more female patients in the cohort. Three-quarters arrived by EMS and the median NIHSS score was 7 for the EM physicians and 6 for the neurologists. The diagnosis was hemorrhagic stroke (~10%), ischemic stroke (~70%), neurological/psychiatric (~15%) and other (~5%). Key Result: Neurologists gave tPA 13% more often than EM physicians