Abstract
Background
In the setting of a national audit of acute stroke services, we examined the delivery of thrombolytic therapy for ischaemic stroke and whether current practice was achieving safe outcomes and consistent delivery for patients.
Method
Data obtained from the recent national stroke audit was compared against previous Irish audit, the most recent SSNAP UK stroke audit and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) study.
Results
Thrombolysis was provided in 27 acute hospitals throughout Ireland during the period assessed with 82% (22/27) providing 24/7 access, the remaining sites using redirect policies. Decision to thrombolyse was made by stroke trained consultants in 63% (17/27) of units, with general physicians and emergency medicine consultants covering the other units. Thrombolysis rate for non-haemorrhagic stroke was 11% (n = 80/742, CI 95% ±2.23) versus a 1% rate in the 2008 audit. Sites receiving patients through a redirect policy had the highest thrombolysis rate, an average of 24%. Nearly 30% of cases were thrombolysed on the weekend. Eighty-three percent of cases were managed in a stroke unit at some time during admission versus 54% of the national total cases. Thirty-seven percent of patients were ≥80 years old. The mortality rate was 11.3% versus the national mortality rate for non-thrombolysed ischaemic strokes of 10% (p > 0.5), and this is comparable to the SITS-MOST 2007 study 3-month mortality rate of 11.3% (p > 0.5).
Conclusion
Stroke thrombolysis is being effectively and safely provided in acute stroke services in Ireland despite regular involvement of non-specialist staff. There is still potential to improve thrombolysis rate.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Disorders TNIoN, Group Sr-PSS (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333(24):1581–1588
Wahlgren N, Ahmed N, Dávalos A, Ford GA, Grond M, Hacke W et al Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 369(9558):275–282
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317–1329
Horgan F, Murphy S, Hickey A, McGee H, O'Neill D (2009) Results from the first Irish National Audit of Stroke Care (INASC)—clinical audit. Cerebrovasc Dis 27:228
Health Do. Changing cardiovascular health: National Cardiovascular Health Policy 2010-2019. Government Publications, 2010–05. Report No.: 0-7557-7639-9
Central Statisitcs Office, Ireland, http://www.cso.ie (accessed 10 June 2017)
McElwaine P, McCormack J, Harbison J. National Stroke Audit 2015. Irish Heart Foundation (IHF) & Health Service Executive, 2016-02. Report No.: 978-1-78602-006-2
Lees KR, Ford GA, Muir KW, Ahmed N, Dyker AG, Atula S et al (2008) Thrombolytic therapy for acute stroke in the United Kingdom: experience from the safe implementation of thrombolysis in stroke (SITS) register. QJM 101(11):863–869
Scherf S, Limburg M, Wimmers R, Middelkoop I, Lingsma H (2016) Increase in national intravenous thrombolysis rates for ischaemic stroke between 2005 and 2012: is bigger better? BMC Neurol 16(1):1–6
Hillmann S, Wiedmann S, Fraser A, Baeza J, Rudd A, Norrving B et al (2015) Temporal changes in the quality of acute stroke care in five national audits across Europe. Biomed Res Int 2015:432497
Price CI, Clement F, Gray J, Donaldson C, Ford GA (2009) Systematic review of stroke thrombolysis service configuration. Expert Rev Neurother 9(2):211–233
McMeekin P, Wildman J, Ford GA, Vale L, Price CI (2015) Relative distributions: a novel method for examining trends between stroke onset and thrombolysis time. Stroke 46(5):1381–1383. doi:10.1161/STROKEAHA.115.008724
Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C et al (2016) Mechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 11(1):134–147
Ringelstein EB, Chamorro A, Kaste M, Langhorne P, Leys D, Lyrer P et al (2013) European Stroke Organisation recommendations to establish a stroke unit and stroke center. Stroke 44(3):828–840
Rudd AG, Irwin P, Rutledge Z, Lowe D, Wade D, Morris R et al (1999) The national sentinel audit for stroke: a tool for raising standards of care. J R Coll Physicians Lond 33(5):460–464
The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 379(9834):2352–63
Anderson CS, Robinson T, Lindley RI, Arima H, Lavados PM, Lee T-H, et al. Low-dose versus standard-dose intravenous alteplase in acute ischemic stroke. N Engl J Med 0(0):null
Acknowledgements
The validated data collection tools were used with the kind permission of RCPUK and the SSNAP team, in particular Prof A. Rudd.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest.
Electronic supplementary material
ESM 1
(DOCX 153 kb)
Rights and permissions
About this article
Cite this article
McElwaine, P., McCormack, J., Brennan, C. et al. Thrombolysis for stroke in Ireland: increasing access and maintaining safety in a challenging environment. Ir J Med Sci 187, 275–280 (2018). https://doi.org/10.1007/s11845-017-1661-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11845-017-1661-5