Barbour Julia, Hushen Patricia, Newman George C, Vidal Jennifer
Department of Pharmacy, Einstein Medical Center Philadelphia, Philadelphia, PA, United States.
Department of Neurology, Einstein Medical Center Philadelphia, Philadelphia, PA, United States.
Am J Emerg Med. 2022 Jan;51:358-362. doi: 10.1016/j.ajem.2021.11.015. Epub 2021 Nov 16.
Time is a critical metric in the emergency department (ED) for acute ischemic stroke and thrombolytic therapy. National guidelines have emphasized tracking time from stroke onset to treatment and decreasing door to needle (DTN) time [1, 2]. Multidisciplinary teamwork is encouraged but, there is limited evidence demonstrating the value of the pharmacist on the stroke response team. The goal of this study is to compare DTN times in the ED with or without a pharmacist at bedside and examine the impact on subsequent patient outcomes.
This was a single-center retrospective cohort study. Investigators identified patients who presented to the ED between August 2016 - May 2020 with signs of ischemic stroke and subsequently received intravenous alteplase. Patients were excluded if they refused alteplase or received alteplase off-campus before being transferred. Pharmacist documentation of clinical interventions was used to identify participation on the stroke response team. The primary outcome was median DTN time. Secondary outcomes included severity of deficits measured by the National Institutes of Health Stroke Scale (NIHSS), hospital length of stay (LOS), 90-day Modified Rankin Scale (mRS), incidence of intracranial hemorrhage (ICH), and inpatient all-cause mortality.
Of the 164 patients included, 31 had an emergency medicine pharmacist at bedside (EMP group) and 133 did not (No EMP group). The median DTN time was significantly shorter at 35 min EMP [interquartile range (IQR) 29-44] vs 42 min No EMP [IQR 34-55]; p = 0.003. The number of cases achieving a DTN time of 30 min or less was significantly higher when a pharmacist was involved (35.5% vs.16.5%; p = 0.018) as well as the number of patients receiving alteplase within 45 min (80.7% vs. 57.1%; p = 0.015). NIHSS scores at discharge were lower in the EMP group (2 [IQR 0-5] vs. 4 [IQR 0-8.25]; p = 0.049). In patients with magnetic resonance imaging (MRI) confirmed stroke, a difference was not observed in the secondary outcomes.
Patients with an emergency medicine pharmacist as part of their stroke response team had significantly lower DTN times. A higher proportion of these cases met benchmark DTN times less than 45 min and 30 min. An emergency medicine pharmacist on a stroke response team has the potential to improve patient care.
在急诊科，时间对于急性缺血性中风和溶栓治疗而言是一个关键指标。国家指南强调要记录从中风发作到治疗的时间，并缩短门到针（DTN）时间[1,2]。虽然鼓励多学科团队合作，但仅有有限的证据证明药剂师在中风应对团队中的价值。本研究的目的是比较急诊科中有或没有床边药剂师时的DTN时间，并研究其对后续患者结局的影响。
这是一项单中心回顾性队列研究。研究人员确定了2016年8月至2020年5月期间到急诊科就诊且有缺血性中风迹象、随后接受静脉注射阿替普酶治疗的患者。如果患者拒绝使用阿替普酶或在转院之前在院外接受了阿替普酶治疗，则将其排除。通过药剂师的临床干预记录来确定其是否参与中风应对团队。主要结局是DTN时间中位数。次要结局包括通过美国国立卫生研究院卒中量表（NIHSS）测量的缺损严重程度、住院时间（LOS）、90天改良Rankin量表（mRS）、颅内出血（ICH）发生率以及住院全因死亡率。
在纳入的164例患者中，31例有急诊医学药剂师在床边（EMP组），133例没有（无EMP组）。EMP组的DTN时间中位数显著更短，为35分钟[四分位间距（IQR）29 - 44]，而无EMP组为42分钟[IQR 34 - 55]；p = 0.003。当有药剂师参与时，达到DTN时间30分钟及以内的病例数显著更多（35.5%对16.5%；p = 0.018），以及在45分钟内接受阿替普酶治疗的患者数也更多（80.7%对57.1%；p = 0.015）。EMP组出院时的NIHSS评分更低（2[IQR 0 - 5]对4[IQR 0 - 8.25]；p = 0.049）。在磁共振成像（MRI）确诊中风的患者中，次要结局未观察到差异。
有急诊医学药剂师作为中风应对团队一员的患者，其DTN时间显著更短。这些病例中更高比例达到了小于45分钟和30分钟的DTN基准时间。中风应对团队中的急诊医学药剂师有改善患者护理的潜力。
