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A successful treatment strategy includes analyzing process and identifying missed eligible patients24,25

Examine discharge data
Review files of patients with a discharge diagnosis of acute ischemic stroke (AIS)

Identify missed eligible patients
Determine eligibility according to Activase prescribing information

Compile reasons for non-treatment
Analyze trends for non-treatment of missed eligible patients

Share findings at regular team meetings
Develop strategies to help identify and treat all eligible patients

Execute quality improvement strategies
Continually track performance and outcomes, refine strategies

Frequent causes for slower treatment with Activase include difficulties in determining patient eligibility, delayed diagnoses, and in-hospital delays, which can add over 25 minutes to the door-to-needle time and negatively impact patient outcomes.

Based on your metrics, what is the common reason for not treating with Activase?

Analyze process Analyze outcomes
Analyze process

Door-to-Needle (DTN) time

Delays in DTN time can impact patients.2

AIS is a serious medical emergency. Multiple parallel processes can help expedite treatment for patients with AIS who are eligible for Activase with or without subsequent mechanical thrombectomy.6,26-29

Activase® (alteplase) AIS Door to Needle time

*Certain patient evaluations and diagnoses may be performed using telestroke services.27,29,31

†In centers without capabilities to perform mechanical thrombectomy, patients should begin receiving Activase before being transferred for treatment at an experienced stroke center.

CT=computed tomography; CTA=computed tomography angiogram; ED=emergency department; EMS=emergency medical services; LVO=large vessel occlusion.

What's your DTN target?

Find out if your team is aligned with time‑saving recommendations from Target: Stroke30

Five time-saving strategies employed by world-class hospitals to reduce DTN time include27:

  1. Overall emergency medical services prenotification
  2. Neurology evaluation via secure telecommunication en route
  3. Transfer directly to imaging – multiple assessments occur in parallel and patient bypasses ED bed
  4. Point-of-care laboratory testing
  5. Administering Activase immediately after CT excludes a hemorrhagic stroke
Analyze outcomes

Identifying missed eligible patients

Evaluating all patients with AIS is a better way to view and understand the full AIS patient pool at your institution. Healthcare professionals may have differing criteria when evaluating appropriateness for Activase treatment, based on:

  • The label Indication, Contraindications, and Warnings and Precautions
  • Individual hospital protocols
  • Personal treatment philosophy

Constant evaluation of processes implemented within an institution can have a meaningful impact in identifying missed eligible patients.

How do you use metric to identify missed eligible patients? What tools do you use?

Use stroke program initiatives to track All-AIS

Tracking every patient discharged from your hospital with a confirmed AIS diagnosis, tracking All-AIS, is a way to increase knowledge of the patient pool. It can provide valuable insights into understanding why patients at your institution may or may not be treated and help identify potential gaps.

  • What are the most common reasons for not treating with Activase and how do these reasons align with Activase prescribing information-based eligibility criteria?
  • Does this report reflect the institution's current stroke treatment protocol?
  • How does your pool of AIS patients fit within protocol and guidelines criteria?

Reach out to your Get With The Guidelines (GWTG) representative for help with GWTG reports

Reasons for non-treatment may already be tracked at your institution. Hospitals using GWTG must document reasons for non-treatment for all AIS patients who did not receive Activase. Consider evaluating GWTG reports such as, Reasons for no intravenous Activase, illustrated in the sample below, as they can provide insights into critical trends regarding your patient pool.

Overall AIS Treatment Rate

When evaluating ALL‑AIS, does patient eligibility reflect what is currently in your hospital protocol? Is anything surprising?

How confident are you that non-treated patients were excluded for the right reasons?

NEXT: Review stroke program initiatives to establish a stroke system of excellence

DID YOU KNOW?

  • Evaluating and improving processes, such as door-to-needle time, may lead to higher rates of Activase treatment of appropriate patients.2,15
  • Hospitals are constantly striving to improve their stroke process. Review the case studies presented in this section to learn more.
Resources

Visit the resource center for more information on the treatment of AIS patients with Activase.

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IMPORTANT SAFETY INFORMATION & INDICATIONS

Indications

Activase® (alteplase) is indicated for the treatment of acute ischemic stroke. Exclude intracranial hemorrhage as the primary cause of stroke signs and symptoms prior to initiation of treatment. Initiate treatment as soon as possible but within 3 hours after symptom onset.

Activase is indicated for use in acute myocardial infarction (AMI) for the reduction of mortality and reduction of the incidence of heart failure.

Limitation of Use: The risk of stroke may outweigh the benefit produced by thrombolytic therapy in patients whose AMI puts them at low risk for death or heart failure.

Activase is indicated for the lysis of acute massive pulmonary embolism (PE), defined as:

  • Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments.
  • Acute pulmonary emboli accompanied by unstable hemodynamics, e.g., failure to maintain blood pressure without supportive measures.

Important Safety Information

Contraindications

Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit: current intracranial hemorrhage (ICH); subarachnoid hemorrhage; active internal bleeding; recent (within 3 months) intracranial or intraspinal surgery or serious head trauma; presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms); bleeding diathesis; and current severe uncontrolled hypertension.

Do not administer Activase to treat acute myocardial infarction or pulmonary embolism in the following situations in which the risk of bleeding is greater than the potential benefit: active internal bleeding; history of recent stroke; recent (within 3 months) intracranial or intraspinal surgery or serious head trauma; presence of intracranial conditions that may increase the risk of bleeding; bleeding diathesis; and current severe uncontrolled hypertension.

Warnings and Precautions

Bleeding

Activase can cause significant, sometimes fatal internal or external bleeding, especially at arterial and venous puncture sites. Avoid intramuscular injections and trauma to the patient. Perform venipunctures carefully and only as required. Fatal cases of hemorrhage associated with traumatic intubation in patients administered Activase have been reported. Aspirin and heparin have been administered concomitantly with and following infusion with Activase in the management of acute myocardial infarction and pulmonary embolism. The concomitant administration of heparin and aspirin with and following infusions of Activase for the treatment of acute ischemic stroke during the first 24 hours after symptom onset has not been investigated. Because heparin, aspirin, or Activase may cause bleeding complications, carefully monitor for bleeding, especially at arterial puncture sites. Hemorrhage can occur 1 or more days after administration of Activase, while patients are still receiving anticoagulant therapy. If serious bleeding occurs, terminate the Activase infusion, and treat appropriately.

In the following conditions, the risks of bleeding with Activase are increased and should be weighed against the anticipated benefits: recent major surgery or procedure; cerebrovascular disease; recent intracranial hemorrhage; recent gastrointestinal or genitourinary bleeding; recent trauma; hypertension; acute pericarditis; subacute bacterial endocarditis; hemostatic defects including those secondary to severe hepatic or renal disease; significant hepatic dysfunction; pregnancy; diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions; septic thrombophlebitis or occluded AV cannula at seriously infected site; advanced age; and patients currently receiving oral anticoagulants, or any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location.

Hypersensitivity

Hypersensitivity, including urticarial / anaphylactic reactions, have been reported after administration of Activase. Rare fatal outcome for hypersensitivity was reported. Angioedema has been observed during and up to 2 hours after Activase infusion in patients treated for acute ischemic stroke and acute myocardial infarction. In many cases, patients received concomitant angiotensin-converting enzyme inhibitors. Monitor patients treated with Activase during and for several hours after infusion for hypersensitivity. If signs of hypersensitivity occur, e.g. anaphylactoid reaction or angioedema develops, discontinue the Activase infusion and promptly institute appropriate therapy (e.g., antihistamines, intravenous corticosteroids, epinephrine).

Thromboembolism

The use of thrombolytics can increase the risk of thrombo-embolic events in patients with high likelihood of left heart thrombus, such as patients with mitral stenosis or atrial fibrillation. Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE. Consider the possible risk of re-embolization due to the lysis of underlying deep venous thrombi in this setting.

Cholesterol Embolization

Cholesterol embolism, sometimes fatal, has been reported rarely in patients treated with thrombolytic agents; the true incidence is unknown. It is associated with invasive vascular procedures (e.g., cardiac catheterization, angiography, vascular surgery) and/or anticoagulant therapy.

Coagulation Tests May be Unreliable during Activase Therapy

Coagulation tests and/or measures of fibrinolytic activity may be unreliable during Activase therapy unless specific precautions are taken to prevent in vitro artifacts. When present in blood at pharmacologic concentrations, Activase remains active under in vitro conditions, which can result in degradation of fibrinogen in blood samples removed for analysis.

Adverse Reactions

The most frequent adverse reaction associated with Activase therapy is bleeding.

Please see the full Prescribing Information for additional Important Safety Information and Instructions for Use.

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