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Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide
Published on: January 15, 2017
Patient-Centered Decision Support in Acute Ischemic Stroke: Qualitative Study of Patients' and Providers'
Carole Decker1, Emily Chhatriwalla2, Elizabeth Gialde2
1From the School of Nursing (C.D.) and Department of Biomedical and Health Informatics, School of Medicine (J.A.S.), University of Missouri-Kansas City; Cardiovascular Outcomes Research, Saint Luke's Hospital of Kansas City (C.D., E.C., E.G., B.G., D.S., J.A.S.); Department of Neurology, Geffen School of Medicine at UCLA (M.E.Q., E.C.) and UCLA Comprehensive Stroke Center (J.L.S.); Center for Advanced Brain and Neurological Care, University of Kansas Hospital (M.R.); US Medical Affairs, Cardiometabolism/Neuroscience, Genentech (E.C.); and Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (D.M.K.). c1decker@saint-lukes.org.
Background:
National guidelines endorse recombinant tissue-type plasminogen activator (r-tPA) in eligible patients with acute ischemic stroke to improve patients' functional recovery. However, 23% to 40% of ideal candidates with acute ischemic stroke for reperfusion are not treated, perhaps because of the difficulty in explaining the benefits and risks of r-tPA within the frenetic pace of emergency department care. To support better knowledge transfer and creation of a shared decision-making tool, we conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering r-tPA treatment.
Methods And Results:
A multidisciplinary team used qualitative research methods to identify informational needs and strategies for describing the benefits and risks of r-tPA in a clinical setting. Through focus groups (n=10) of stroke survivors (n=39) and caregivers (n=24) and individual interviews with emergency physicians (n=23) and advanced practice nurses (n=20), several themes emerged. Survivors and caregivers preferred a broader definition of a good outcome (independence, rather than no significant disability), simpler graphs as compared with detailed pictographs, and presentation of both population and individualized benefits (framed positively) and risk of receiving r-tPA. Some physicians expressed skepticism with the data and the ability to present risk/benefit information emergently, whereas other physicians and most advanced practice nurses thought such information would improve care. Physicians stressed the importance of presenting the risk of thrombolytic-related intracranial hemorrhage.
Conclusions:
This study suggests that a positively framed risk-benefit tool with graphical presentations of general and patient-specific risk estimates could support patients and providers in considering r-tPA for acute ischemic stroke.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01864928.
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