Stroke: Training residents for stroke treatment safely reduces door-to-needle times
Neurology residents at Barnes-Jewish Hospital in St. Louis have shown that with appropriate training they can safely make the call to initiate stroke therapy, ensuring that effective treatment is delivered faster, according to a study published online this month in Stroke.

Door-to-needle times, measured as the time between a patient's arrival and the administration of tissue plasminogen activator (tPA), were reduced by 26 percdent, from an average of 81 minutes to 60 minutes, researchers from Washington University School of Medicine in St. Louis wrote.

"What's critical here is the ability to safely reduce door-to-needle time without unnecessarily increasing the risk of a brain hemorrhage," said Jin-Moo Lee, MD, PhD, director of the cerebrovascular section in neurology at Washington University and Barnes-Jewish. "What we've shown is that with proper training, feedback and supervision, residents are more than capable of making this complex decision safely."

For the study, which began in 2004, neurology residents at Barnes-Jewish started taking an annual three- to four-hour mini-course on use of tPA. The course taught them how to appropriately choose candidates for tPA and how to administer it. After residents were given the authority to administer tPA, a committee of medical faculty and staff met monthly to review the case of every patient evaluated for stroke treatment, giving residents feedback on their decision-making.

The researchers assessed the results by comparing the outcomes and complications of stroke patients treated by residents from 2004 to 2007 against the same data for stroke patients treated by attendings and fellows from 1998 to 2002. There was no significant increase in negative outcomes, including bleeding in the brain, and door-to-needle times were notably shorter for patients treated by residents.

"It makes sense--residents are always in house, and if they can make a direct decision on treatment without waiting for an attending or a fellow to respond to a pager, then the treatment time is going to be shorter," said lead author Andria Ford, MD, a Washington University neurologist.

Neurology residents at Barnes-Jewish continue to regularly train in tPA usage and to have the authority to administer tPA.

Given an academic medical center where the resources exist to expand resident training and provide regular feedback, Lee thinks the model can be applied "across the board--not just to neurologists in training but to emergency department physicians in training, for example."