Pharmacists make a 12-minute difference

Image via Monash University.

Adding an emergency medicine pharmacist to a stroke call-out team showed a marked difference in treatment times

Researchers from Monash University’s Pharmacy Department (Faculty of Pharmacy and Pharmaceutical Sciences), the Department of Neuroscience (Central Clinical School) and Department of Epidemiology and Preventive Medicine (School of Public Health and Preventive Medicine) found that adding the pharmacist to the team provided an improvement in the average time to administer treatment (thrombolysis with alteplase, or recombinant tissue plasminogen activator rtPA) to a patient by 12 minutes.

“Thrombolysis with Alteplase (rtPA) improves functional outcome among selected patients after acute ischaemic stroke,” wrote Cristina Roman, Geoff Cloud and Michael Dooley in the Journal of Clinical Pharmacy and Therapeutics.

“Benefits are most pronounced with early intervention. Our aim is to assess door to needle time (DTNT) for acute stroke after a stroke call‐out redesign including addition of an emergency medicine (EM) pharmacist to the team.”

Monash noted that an Australian Stroke Foundation audit in 2019 found only about 30% of patients receive thrombolysis according to guidelines.

The researchers compared a retrospective cohort of stroke patients who received rtPA to a prospective cohort after stroke callout redesign in an adult major referral hospital in Melbourne.

“All patients who presented during EM pharmacist working hours and were thrombolysed in the ED for stroke from December 2011‐June 2014 pre and July 1st 2014‐August 2019 post were included,” they wrote.

“The primary outcome was DTNT [door to needle time]. Secondary outcomes included proportion of patients with a DTNT within 60 min, time to blood pressure (SBP) reduction, intracranial and extracranial bleeding, hospital length of stay (LOS) and mortality.”

The study involved 218 eligible patients: 64 pre-implementation of the redesigned callout team and 122 afterwards.

The team found that a multi-faceted approach to stroke design, including formal integration of the Emergency Medicine pharmacist into the acute stroke team was associated with improved DTNT for stroke thrombolysis.

“There was a significant association of time to thrombolysis (HR 1.61; 95% CI: 1.18–2.20; p = 0.003) with the intervention,” they wrote.

“Median DTNT improved from 73 (IQR 52–111) min to 61 (IQR 47–80) min (p = 0.012). Interrupted time‐series analysis did not demonstrate intervention at the single time‐point of implementation of the intervention to be associated with the improvement.”

First author of the study Cristina Roman, lead pharmacist in Emergency Medicine, The Alfred Hospital and PhD candidate at the National Trauma Research Institute, CCS, said that increasingly, she was being asked by nursing staff to assist with double-checking thrombolysis doses due to the high risk nature of the medication and the infrequency of administration.

 “When the acute stroke response system was redesigned, I advocated for the pharmacist to be formally integrated into the team to routinely assist staff with thrombolysis, which I’m now evaluating as part of my PhD project,” she said.

Professor Geoff Cloud, Head of the Stroke Clinic, Alfred Health and Group leader of the Stroke group, Department of Neuroscience, CCS, said that although emergency medicine clinical pharmacy is a strongly flourishing area of practice elsewhere including North America, emergency pharmacists are not commonly involved in the management of critically unwell patients in Australia.

“Their value as medication experts allows clinicians to focus on assessment and diagnosis of stroke and add to the efficiency and accuracy of care provided,” he said.


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