Reduced monitoring after stroke found safe for low risk patients

Halving the number of times vital signs and neurological function are checked in low-risk patients after treatment for acute ischaemic stroke does not compromise care or recovery, according to new findings presented at the 11th European Stroke Organisation Conference in Helsinki, Finland.

Results from the Optimal Post rTpa-Iv Monitoring in Ischaemic Stroke Trial (OPTIMISTmain), simultaneously published in The Lancet, also showed that this approach also had flow-on benefits for nursing workflow and intensive care resources. The trial was led by Professor Craig Anderson from The George Institute for Global Health and UNSW Sydney, and Professor Victor C. Urrutia from Johns Hopkins University School of Medicine.

Professor Anderson said that guideline-recommended monitoring in the 24 hours after thrombolysis (clot-busting) treatment, originally developed in the 1990s, takes up considerable nursing time and intensive care unit (ICU) beds.

"As well as shifting nurses' attention away from other aspects of care, such as education, counselling, and supporting anxious family members, this level of monitoring disrupts patients' sleep and may not even be needed for those considered to be 'low risk'," he added.

To find out whether the frequency of monitoring could be safely reduced, researchers studied a total of 4,515 patients with acute ischaemic stroke across 8 countries. Patients were either monitored according to a low intensity protocol (19 assessments over 24 hours post-thrombolysis) or standard care (39 assessments).

In both groups, vital signs and neurological assessments were conducted every 15 minutes in the first two hours. Over the next eight hours, patients were monitored every two hours in the low-intensity monitoring group, versus every 30 minutes in the standard group. Up until 24 hours, the low-intensity group were checked every four hours, versus hourly monitoring in the standard group.

A comparable proportion of patients experienced a poor functional outcome (death or disability) after 90 days, with 31.7% (809 of 2552 participants) in the low-intensity group, and 30.9% (606 of 1963) in the standard monitoring group.

The occurrence of intracerebral hemorrhage (brain bleed) - the most serious complication of thrombolytic therapy - was low in both groups, seen in 0.2% of patients in the low-intensity group and 0.4% patients in the standard monitoring group. Serious adverse events were similar between the low-intensity and standard monitoring groups at 11.1% and 11.3%, respectively.

Professor Anderson said that this is the first study of this scale to show that low-intensity nursing is safe and effective in stroke care.

"Regular monitoring during the first hours of stroke onset is critical, but we felt that hourly check-ups may be unnecessary in the subsequent 24 hours. Our findings show that low-intensity monitoring is safe and does not compromise patient recovery, outcomes, or satisfaction with care.

"We expect this approach will be adopted by hospitals worldwide, especially where resources are constrained, as it can streamline care and enable nurses to spend more time on other important aspects of the complex care of these patients."

As well as freeing up nursing time, the protocol also improved availability of ICU beds, particularly in the USA where the proportion of patients admitted to ICUs was 30% lower among hospitals adopting low-intensity monitoring.

Professor Urrutia, senior author on the study and Medical Director of the Comprehensive Stroke Center at The Johns Hopkins Hospital, said that this new approach could support more resilient stroke care.

"This study was partly conducted during the COVID-19 pandemic, when healthcare resources were under extreme strain. While we may have overcome many of the pressures of that period, shortages in healthcare staff and hospital beds persist. We anticipate that a lower intensity monitoring system for eligible stroke patients will help alleviate the capacity challenges that continue to threaten high quality stroke care."

Stroke is the second leading cause of death and third most common cause of disability of all noncommunicable diseases worldwide. Acute ischaemic stroke is caused by decreased blood flow due to a clot blocking one of the large blood vessels in the brain. It comprises 65% of all stroke cases and at least one third of patients with ischemic stroke experience mild to moderate neurological impairment.

OPTIMISTmain was conducted in hospital sites across eight countries, including four high-income countries (Australia, Chile, UK, and the USA) and four low- and middle-income countries (China, Malaysia, Mexico, and Vietnam).