As detailed in this FOAMcastini, ACEP just released a draft of an updated clinical policy on tPA for acute ischemic stroke. This came in the wake of years of controversy over the aggressive position taken in the 2012 clinical policy.
While FOAMcast is not an interview style podcast, we felt compelled to get some perspective on Emergency Physicians a little more experienced than ourselves. Here we interview:
Dr. Ryan Radecki (@emlitofnote), Assistant Professor, University of Texas – Houston
- We don’t know who best benefits from tPA so elucidating which patients are “carefully selected” may get hard.
- See his response to the policy on his blog here
Dr. David Newman (#draftnewman), Associate Professor of Emergency Medicine, Mount Sinai Hospital
- The process for ACEP clinical policy creation seems to work. The constituency expressed concern and the college listened and went back and re-created the policy from the bottom up.
- This policy reflects a move from content expert to methodologists which better reflects the evidence compared with opinions (and is the standard per USPSTF).
Dr. Anand Swaminathan (@EMSwami), Assistant Professor of Emergency Medicine, NYU
- Inclusion of more rigorous methodology and review of evidence.
- May be perceived as too “soft” by tPA supporters. This policy may not overtly change practice but may open up avenue of conversations.
Dr. Ken Milne (@thesgem), Chief of Staff at South Huron Hospital
- When looking at “carefully selected” patients, as noted in the policy, remember to use the Evidence Based Medicine trifecta of evidence, patient values, and clinical expertise. In isolation, one component is not sufficient.
- Previous discussions of NINDS, and the Cochrane tPA article