Acute stroke treatment improved by adding emergency pharmacist to the team

Does adding an emergency medicine pharmacist improve acute stroke care? The answer is Yes, by an average of 12 minutes. A well known saying in the field of neurology is ‘time is brain’ and for this particular study it couldn’t be more true, as every minute a stroke sufferer isn't treated, more damage takes place.

Researchers from the 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) have found that by adding an emergency pharmacist to the acute stroke call-out 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.

Most people would be familiar with the F.A.S.T. test recommended by the Stroke Foundation, based on evidence that early intervention can save a person’s life. In the clinical context of management for acute stroke, both the Australian and American Heart / American Stroke Association guidelines recommend providing thrombolysis within 60 minutes of arrival to hospital. Thrombolysis improves functional outcomes for patients so its effective practice is of paramount importance. But in Australia, an audit by the Australian Stroke Foundation in 2019 found that only approximately 30% of patients receive thrombolysis according to the guidelines.

Therefore, what is needed to maximise treatment effectiveness for patients are innovative approaches in acute stroke care procedures.

One such approach was a study published online last month (Roman et al, 2021), which looked at the difference in door-to-needle time (DTNT) between two groups of patients with ischaemic stroke, a retrospective cohort who received thrombolysis as per usual care and compared with a prospective cohort who received the intervention, e.g. addition of an emergency pharmacist after a re-design of the acute stroke response system (in July 2014, see figure).

Professor Geoff Cloud, Head of the Stroke Clinic, Alfred Health and Group leader of the Stroke group, Department of Neuroscience, CCS, commented that although emergency medicine clinical pharmacy is a strongly flourishing area of practice elsewhere, such as 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."

First author of the study Ms Cristina Roman, lead pharmacist in Emergency Medicine, The Alfred Hospital and PhD candidate at the National Trauma Research Institute, CCS, was increasingly getting 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. She said, “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.”

The collaborative 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.

As of August 2020 the Emergency Medicine pharmacist has begun to chart all medications required for patients, including intravenous blood pressure medications, thrombolysis and initiation of secondary prevention in line with the Partnered Pharmacist Medication Charting (PPMC) model of care at The Alfred Hospital.

The Alfred Hospital provides emergency and trauma care to approximately 70,000 adult patients a year, being one of the largest hospitals in Australia. Professor Biswadev Mitra, from the Emergency and Trauma Centre, The Alfred Hospital, who led the study said, “We are confident this will also help to reduce delays to care and improve safety.”

The team hopes that further work, including quantifying pharmacist activities in a stroke callout to explore direct impact, external validation and the cost‐effectiveness of 24 hour emergency medicine pharmacist attendance at stroke calls, will provide the necessary evidence to demonstrate the potential value of integrating an emergency medicine pharmacist into acute stroke care.

See more: Roman, C., Cloud, G., Dooley, M. and Mitra, B. (2021), Involvement of emergency medicine pharmacists in stroke thrombolysis: A cohort study. J Clin Pharm Ther. https://doi.org/10.1111/jcpt.13414