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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.

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:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? Precise
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. 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

  • Primary Outcome: Rate of tPA administration
    • 26.3% EM physicians and 39.2% neurologists (p=0.006)
  • Secondary Outcomes:
    • No statistical difference in mRS score at discharge

1. Single Center: This was a single center study that may have a unique practice pattern limiting its external validity to other practice environments. As someone who practices in a rural environment, we transport our stroke patients “code stroke” to a higher level of care or use telemedicine with a neurologist who decides on tPA administration.

2. Retrospective Study: This was a retrospective single-center study and results demonstrate association not causation. There could be unmeasured confounders responsible for the observed differences in the results.

3. When Thrombolysed: The neurologists led the team Monday to Friday during business hours. There could be differences that were not measured on nights, weekends and holidays. The baseline NIHSS score was one-point different at baseline between the two cohorts. We know that the severity of the stroke at presentation has a strong influence on the final outcome. We also don’t know if the radiology coverage after hours and on weekends was different.

4. Time to Thrombolysis and Mimics:  tPA was administered statistically earlier in the neurologist led stroke team. Previous studies have shown time is not brain and it is possible they were thromoblysing more TIAs or stroke mimics as mentioned by Dr. Hoffman on his SGEM Xtra episode. This could bias the study toward benefit of tPA. Despite this potential bias there was no statistical difference in mRS score at discharge.

5. Harms: Limited data was captured with regards to harm. There were more deaths (mRS 6) and mortality at discharge with neurologist led teams but this was not statistically significant. They provided no information on intracranial hemorrhage, symptomatic intracranial hemorrhages or other bleeds. It is hard to evaluate the net patient efficacy without this information on adverse events. Even if there was a small signal of benefit with neurologists led teams it could be offset by an increase in harms/adverse events. Given the data provided we do not know what the net impact was in this retrospective, single-center study.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Neurologists led stroke teams give tPA more often but it did not result in statistically significant better patient-oriented outcomes in this study.

Case Resolution: Based on this study you can reassure the patient that the lack of a neurologist led stroke team may decrease her chances of getting thrombolysis (clot busting drug) but that will probably not affect her outcome.

Dr. Chuck Shepard

Clinical Application: It appears that while a “neurologist led stroke team” may be important for other reasons, it appears that in the absence of one only decreases the chance of getting tPA but doesn’t affect the outcome. It is unsure how a neurologist led stroke team would impact outcomes in the new era of endovascular treatment (EVT).

What Do I Tell My Patient? You appear to be having a stroke and we have a system in place to treat your stroke even though the neurologist is not here at this moment.  We will take good care of you and the evidence is that your outcomes will be just as good as if the stroke team was led by a neurologist in our hospital.

Keener Kontest: Last weeks’ winner was Dr. Cindy Bitter an Assistant Professor of Emergency Medicine from Washington, University in St. Louis. She knew dogs have 300 million olfactory receptors in their nose.

Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.