Introduction: Target:Stroke recommends pre-mixing intravenous tPA before brain imaging for high likelihood acute ischemic stroke (AIS) patients, allowing the drug to be available immediately after the decision to treat is made. However, premixing tPA is rarely practiced despite potential benefits of improving door-to-needle time.
Hypothesis: We describe our experience developing criteria to eliminate avoidable wasting of the drug by identifying patients most likely to benefit from pre-mixed tPA and compare rates of wasted tPA before and after criteria development. We hypothesized this would result in a substantial reduction in wasted tPA.
Methods: On 4/1/14, our Comprehensive Stroke Center instituted a series of interventions to reduce door-to-needle times, including pre-mixing tPA for AIS patients presenting within the tPA treatment window. Seven vials of pre-mixed tPA were wasted over the next five weeks, revealing the need for specific criteria to guide the medical decision to order tPA prior to brain imaging. A multi-disciplinary team examined cases of wasted pre-mixed tPA through peer review and determined four would have been avoided if criteria identified patients ineligible for tPA pre-mixing. Revised criteria were implemented for ordering pre-mixed tPA on 6/1/14.
Results: Our revised criteria restricted pre-mixing tPA for patients taking anticoagulants, or presenting with a decreased level of consciousness, elevated blood pressure, headache, nausea, vomiting, or advanced stage cancer. Between 6/1/14-6/1/15, there has been one case of non-avoidable wasting, and no cases of avoidable tPA wasting.
Conclusions: While pre-mixing tPA does not incur financial risk as drug manufacturers replace unused vials without cost, stroke centers remain wary of wasting the drug. We believe succinct criteria can reduce avoidable tPA waste, allowing health care providers to remain fiscally responsible while ensuring AIS patients are treated as fast as possible.