Tanzida Haque,Dr Asoke Datta
Stepping Hill Hospital
Consultant Stroke Physician, SNHSFT
Scientific Tracks Abstracts: J Neurol Neurophysiol
Introduction: Reperfusion therapy with Alteplase has made a dramatic change in the
management of acute ischemic stroke. Bleeding is one of the major complications of this
therapy. Despite exclusion criteria, patients still bleed as a complication of this medication.
Despite clearly agreed guidelines, clinical practice seems to differ widely amongst various
practitioners. Several areas of concern identified and attempted to be addressed in the last
audit since 2017. Loop closure audit undertaken to assess change in practice to enhance
patient care and safety.
Aim: The Loop Closure audit was to establish improvement on areas of previous underperformances, especially sub-optimal BP monitoring and to look additionally at other potential factors that might have contributed to recent concerns on increased incidence of bleed after thrombolysis.
Method: Data collected from patient's case notes and electronic record
Result: Post Thrombolysis BP Management is far from satisfactory with major deficit in standard. Hourly BP monitoring rate has been improved although BP measurement every 15 minutes post thrombolysis period has deteriorated from 85% to 60% . The rate of inappropriate referrals has dropped from 65% to 37%. More than 50% who bled did not have appropriate blood tests done (previously 60%). 60% of thrombolysed patients had NIHSS between 7—16 which shows the trend to have remained unchanged and which is also in keeping with national recommendation. 50% bled between 6-24 hours (previous 30%) and 27% bled after more than 24 hours (previous 55%). Death rate remains high in Post Thrombolysis bleed, around 40%. The mortality rate remains persistently higher. In the light of significant persistent mortality, we tried to establish additional causes that might have caused increased number of post thrombolysis ICH. Interestingly, with further vigilance, it becomes apparent that higher dose of Alteplase was administered on estimated/ guessed body weight in HASU which is potentially fatal. It is found in the audit that 3 out of 8 patients' weight was over- estimated in hyper acute stroke unit. In 3 patents, weight was not taken in the ward hence potentially could have been over- estimated. In only 1 patent, known actual body weight was used.
Conclusion: Whilst other variables remain unchanged, lack of improvement in loop closure might suggest additional contributory factors. Although the number of patients involved in our audit are likely to be too few to cast generalisation, clinicians must remain vigilant to explore other reasons that may explain lack of anticipated improvement in any loop closure audit which must be re-assessed again.
Tanzida Haque has completed MSc Public Health from University of the West of England, Bristol, UK and MBBS (Bachelor of Medicine and Bachelor of Surgery) from University of Dhaka. She is working as clinical fellow, Stroke medicine department, Stepping Hill Hospital, Stockport, Manchester. She is also actively involved in clinical trials (CONVINCE study) as co investigator in Stockport NHS FT. She is one of the young promising researchers and her reseach interest is stroke management, mental health for stroke survivours and old age psychiatry.