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Diagnosing acute stroke is a high-pressure decision. Treatment can stop brain damage, but if given inappropriately, it can dangerously increase the risk of bleeding in the brain. 

Because of this risk, the final decision to administer the clot-busting enzyme known as tissue plasminogen activator (tPA) is usually reserved for neurologists. But now a study published in Stroke has shown that residents with appropriate training can safely make the call, ensuring that effective treatment is delivered faster. 

Door-to-needle times, measured between a patient’s arrival and the administration of tPA, were reduced by 26 percent, from an average of 81 minutes to 60 minutes. 

“What’s critical here is ability to safely reduce door-to-needle time without unnecessarily increasing the risk of a brain hemorrhage,” says Jin-Moo Lee, MD, PhD, director of the cerebrovascular section in neurology at Washington University and Barnes-Jewish Hospital. “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 Hospital 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. 

Researchers compared 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,” says lead author Andria L. Ford, MD, a Washington University neurologist at Barnes-Jewish Hospital. 

Neurology residents at Barnes-Jewish Hospital 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.” 

Ford AL, et al. Resident-based acute stroke protocol is expeditious and safe. Stroke, vol 40 (4). 1512-1514 (2009). 
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