Yet again, in the “little things matter more” series of dull, but important, Emergency Department literature. TPA or no, what matters more in terms of their ultimate outcome is everything that happens down the line.
This is a retrospective review of consecutively-collected prospective registry data for acute ischemic stroke patients in Louisiana, looking at patients who were present in the ED during shift change. They simply reviewed and compared the outcomes of 366 consecutive patients, looking at good outcome, neurologic worsening, discharge status, and development of pneumonia.
There are, unfortunately, huge, irreconcilable differences between the shift-change and non-shift change groups – the group that was in the ED had milder strokes and was less likely to have TPA 9.5% vs. 4.5% – but still ended up developing more pneumonia. After their mathematical adjustments for various baseline differences, being present during shift change ended up with a five-fold increased odds of developing pneumonia, resulting in decreased likelihood of discharge to home or rehab. The authors attribute this primarily to non-adherence with stroke unit dysphagia precautions, which is probably reasonable. This is just retrospective and observational, but it probably identifies an important operations issue for the Emergency Department.
So, perhaps it does matter whether you give TPA or not – if TPA gets them out of the ED faster, that will help more than anything.
“Emergency Department Shift Change Is Associated With Pneumonia in Patients With Acute Ischemic Stroke”
http://stroke.ahajournals.org/content/42/11/3226.short