Obtaining History from Family Members for Alteplase Contraindications
The purpose of this Position Statement is to clarify the TeleSpecialists physician practice of due diligence before treatments associated with morbidity and mortality such as thrombolytics are administered.
In the experience of TeleSpecialists, practicing telemedicine across 24 states with monthly consult volumes of 11,000 patients, also supported by literature*, our view has been that one of the important risk factors for deadly hemorrhagic complication of thrombolytic treatment alteplase is accuracy of history of “Last Known Well”. It is the position of TeleSpecialists that there are aspects of EMS history obtained from the field, inclusive of “Last Known Well” and alteplase absolute contraindications which may need to be confirmed when possible. As a patient safety measure, we expect our physicians to do their due diligence and make an effort to obtain this history before thrombolytics are administered.
Stroke patient evaluations should be seen through a layered approach, with the initial assessments using quick screening tools (mCSS, BEFAST, etc.) to identify possible stroke patients, but as the evaluation evolves towards the neurologist who is making the ultimate decision about treatment, more time needs to be spent to confirm key historical features regarding information like last known well and presence of potential absolute contraindications. Given the short time frame EMTs are at the scene and other factors like the stress placed on caregivers due to a family member experiencing acute stroke symptoms, we understand all of this can potentially affect accuracy of information, TeleSpecialists physicians, as supported by the 2015 study, feel that it is often necessary to confirm the history, especially if accurate information cannot be obtained from the patient. This does not have any implication on the skillset of the EMTs at all whatsoever, but simply is a patient safety measure of due diligence for a treatment associated with significant morbidity and mortality.
To this end, we train our physicians to reach out to family, nursing home, etc. to obtain history when patients are not able to provide adequate history as confirmation of the information obtained from EMS.
This is an important patient safety practice endorsed and practiced by TeleSpecialists and majority of reputable stroke programs in the United States.
Dr. Nima Mowzoon
CEO and Founder of TeleSpecialists, LLC
* “Accuracy of First Recorded “Last Known Normal” Times of Stroke Code Patients” J Stroke Cerebrovasc Dis. 2015 Nov; 24(11): 2467–2473.