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Alteplase Intravenous for the Treatment of Stroke – Adult - Inpatient

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1
Alteplase Intravenous for the Treatment
of Stroke – Adult – Inpatient –
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 5
METHODOLOGY ...................................................................................................................... 6
INTRODUCTION ....................................................................................................................... 7
RECOMMENDATIONS .............................................................................................................. 7
UW HEALTH IMPLEMENTATION ............................................................................................10
REFERENCES .........................................................................................................................11
APPENDIX A – INSTRUCTIONS FOR RECONSTITUTION .....................................................12
APPENDIX B – PHARMACIST ACUTE STROKE OPERATING PROCEDURE ......................13
CPG Contact for Changes: CPG Contact for Content:
Name: Philip Trapskin, PharmD, BCPS Name: Aaron Steffenhagen, PharmD, BCPS
Phone Number: (608) 263-1328 Phone Number: (608) 265-7168
Email Address: ptrapskin@uwhealth.org Email Address: asteffenhagen@uwhealth.org
Note: Active Table of Contents
Click to follow link
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Guideline Authors: Rachael Fleagle, PharmD; Aaron Steffenhagen, PharmD, BCPS
Coordinating Team Members:
Rachael Fleagle, PharmD – Pharmacy
Aaron Steffenhagen, PharmD, BCPS – Pharmacy
Luke Bradbury, MD – Stroke Team
Chris Whelley, MSN, CNRN – Stroke Team
Review Individuals/Bodies:
Cindy Gaston, PharmD, BCPS
Sheila Aton, PharmD
Committee Approvals/Dates:
Comprehensive Stroke Center Steering Committee – October 2014
Anticoagulation Committee – November 2014
P&T Committee – April 2015
Release Date: April 2015
Next Review Date: April 2017
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

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Executive Summary
Guideline Overview
This clinical practice guideline is intended to guide clinicians in the use of intravenous
alteplase for the treatment of diagnosed acute ischemic stroke in adults.
Target Population
Adult inpatients and emergency department patients.
Key Practice Recommendations
1. Dosing and administration of injectable alteplase
1.1. Appropriate use of alteplase for acute ischemic stroke
1.1.1. The door-to-needle time for alteplase administration should be
within 60 minutes of hospital arrival (Class I, Level of Evidence A)
1.1.2. Alteplase is indicated for patients within 3 hours of stroke symptom
onset based on characteristics described in Table 2.3 (Class I,
Level of Evidence A)
1.1.3. Alteplase can be used for patients within 3 to 4.5 hours of stroke
symptom onset based on characteristics described in Table 3.4
(Class IIb, Level of Evidence C)
1.1.4. In accordance with Administrative Policy 8.31, it is appropriate to
order and initiate alteplase (Level 4 medication) on general care
units and other patient care areas during a Code Stroke under the
care of the Code Stroke Team to ensure timely treatment.
1.2. Dosing3 (Class I, Level of Evidence A)
1.2.1. The recommended dose is 0.9 mg/kg (maximum 90 mg)
1.2.2. Administer 10% of the total dose as an initial intravenous bolus
over 1 minute via the smart infusion pump.
1.2.3. Immediately following the initial bolus, the remainder (90% of the
total dose) is given as an infusion over 60 minutes via the smart
infusion pump.
2. Monitoring
2.1. Starting upon administration of the alteplase bolus, monitor vital signs
(temperature and blood pressure) every 15 minutes x 8 (2 hours), then
every 30 minutes x 12 (6 hours), and hourly thereafter x 16 (16 hours) for
a total of 24 hours (Class IIa, Level of Evidence C).
2.1.1. Blood pressure should be maintained below 180/105 mmHg for at
least the first 24 hours after treatment with alteplase (Class I, Level
of Evidence B)
2.1.2. Labetalol 10 mg IV is reasonable as first line treatment for BP
>180/105 and may be repeated (Class IIa, Level of Evidence C)
2.1.3. If BP still uncontrolled, consider nicardipine infusion. Initiate at 5
mg/hour, titrated to desired effect (Class IIa, Level of Evidence C)
2.1.4. Identify and treat sources of hyperthermia (temperature >38C)
(Class I, Level of Evidence C)
2.2. Monitor for intracranial bleeding: Assess neurologic status using the
“UWHC Abbreviated NIHSS Flowsheet” every 15 minutes x 12 (2 hours),
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4
then every 30 minutes x 12 (6 hours), and hourly thereafter x 16 (16
hours) for a total of 24 hours3 (Class I, Level of Evidence C).
2.3. Monitor for signs and symptoms of bleeding such as tachycardia, a
decrease in BP, pallor, or restlessness. Minor bleeding complications
include oozing from catheter insertion, venipuncture, or intramuscular
sites; gingival bleeding; hemoptysis; superficial hematoma; ecchymosis;
and purpura.7
2.4. Monitor for signs and symptoms of angioedema, especially if currently
taking an ACEI or ARB. (Class I, Level of Evidence B)
2.5. Supplemental oxygen should be provided to maintain O2 saturation >94%
for at least the first 24 hours after administration (Class 1, Level of
Evidence C)
2.6. Cardiac monitoring should be performed for at least the first 24 hours after
administration (Class I, Level of Evidence B) 3
Companion Documents
N/A
Pertinent UW Health Policies & Procedures
1. UWHC Administrative Policy 7.56 Acute Stroke Response
2. Pharmacist Acute Ischemic Stroke Response for “Code Stroke” Operating
Procedure
3. UWHC Administrative Policy 8.17 Administration of Medications
4. UWHC Administrative Policy 8.31 Guidelines for Hospital Location Specific
Administration of IV Medications
5. Alteplase and Tenecteplase Replacement Process for Mixed Unused/Non-
administered Product Operating Procedure
Patient Resources:
1. Health Facts for You - Stroke
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Scope
Disease/Condition(s):
Acute ischemic stroke
Intended Users:
ξ Registered Nurses
ξ Pharmacists
ξ Physicians
CPG objective(s):
Guidance for the use of intravenous alteplase for the treatment of ischemic stroke in
adult inpatients and adult emergency department patients.
Target Population:
Adults administered intravenous alteplase for the treatment of acute ischemic stroke
Interventions and Practices Considered:
Intravenous alteplase for the treatment of ischemic stroke.
Major Outcomes Considered:
Patient functionality at 90 days post-treatment.
Guideline Metrics:
Time to treatment of intravenous alteplase and vital sign monitoring as recommended.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Methodology
Methods Used to Assess the Quality and Strength of the Evidence:
A modified Grading of Recommendations Assessment, Development and Evaluation
(GRADE) developed by the American Heart Association and American College of
Cardiology (Table 1) has been used to assess the Quality and Strength of the Evidence
in this Clinical Practice Guideline.1
A literature search conducted in Pubmed was completed to include the following search
terms: ‘acute ischemic stroke,’ ‘ischemic stroke treatment,’ ‘alteplase stroke,’ ‘tPA
stroke,’ and ‘alteplase administration stroke’
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Introduction
The thrombolytic agent of choice for the treatment of acute ischemic stroke is alteplase.
It is imperative to minimize adverse effects and optimize patient outcomes by ensuring
safe and proper administration in the shortest amount of time from stroke onset to
needle time administration of alteplase. Patient-specific inclusion and exclusion criteria
must be thoroughly evaluated prior to alteplase administration to determine
appropriateness of thrombolytic therapy. The administration of alteplase requires strict
and intensive patient monitoring during and after the medication infusion.
Recommendations
1. Alteplase preparation for administration
1.1. The responding Code Stroke Pharmacist will ensure appropriate dose of
intravenous alteplase and prepare in the immediate patient care area
when instructed by a physician on the Stroke Team.
1.2. Alteplase reconstitution (Class I, Level of Evidence C)
1.2.1. Alteplase should be reconstituted in accordance with the
manufacturer’s package insert2 (Appendix A)
1.2.2. After reconstitution, remove the total “volume to be infused” (bolus
dose and infusion dose) from the vial using the syringe provided.
1.2.3. Place this “volume to be infused” in an empty sterile bag and label
the bag appropriately (example: alteplase 68 mg/68 mL).
1.2.4. No other medication should be added to infusion solutions
containing alteplase.
2. Dosing and administration of injectable alteplase
2.1. Appropriate use of alteplase for acute ischemic stroke
2.1.1. The door-to-needle time for alteplase administration should be
within 60 minutes of hospital arrival3 (Class I, Level of Evidence A)
2.1.2. Alteplase is indicated for patients within 3 hours of stroke symptom
onset based on characteristics described in Table 2.3 (Class I,
Level of Evidence A)
2.1.3. Alteplase may be considered for patients within 3 to 4.5 hours of
stroke symptom onset based on characteristics described in Table
3.4 (Class IIb, Level of Evidence C)
Occasionally patients have received benefit from IV alteplase
outside of the inclusion and exclusion criteria outlined in Table 2
and Table 3. 5,6
2.1.4. In accordance with Administrative Policy 8.31, it is appropriate to
order and initiate alteplase (Level 4 medication) on general care
units and other patient care areas during a Code Stroke under the
care of the Code Stroke Team to ensure timely treatment.
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Table 2. Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke
Who Could Be Treated with IV Alteplase within 3 Hours of Stroke Symptom
Onset3
Inclusion criteria
- Diagnosis of ischemic stroke causing measurable neurological deficit
- Onset of symptoms <3 hours before beginning treatment
- Aged ≥18 years
Exclusion criteria
- Significant head trauma or prior stroke in previous 3 months
- Symptoms suggest subarachnoid hemorrhage
- Arterial puncture at noncompressible site in previous 7 days
- History of previous intracranial hemorrhage
- Intracranial neoplasm, arteriovenous malformation, or aneurysm
- Recent intracranial or intraspinal surgery
- Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
- Active internal bleeding
- Acute bleeding diathesis, including but not limited to:
ξ Platelet count <100 000/mm³
ξ Heparin received within 48 hours, resulting in abnormally elevated aPTT
greater than the upper limit of normal
ξ Current use of anticoagulant with INR >1.7 or PT >15 seconds
ξ Current use of direct thrombin inhibitors or direct factor Xa inhibitors with
elevated sensitive laboratory tests
- Blood glucose concentration <50 mg/dL (2.7 mmol/L)
- CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative exclusion criteria
Recent experience suggests that under some circumstances—with careful
consideration and weighting of risk to benefit—patients may receive fibrinolytic therapy
despite 1 or more relative contraindications. Consider risk to benefit of IV alteplase
administration carefully if any of these relative contraindications are present:
- Only minor or rapidly improving stroke symptoms (clearing spontaneously)
- Pregnancy
- Seizure at onset with postictal residual neurological impairments
- Major surgery or serious trauma within previous 14 days
- Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
- Recent acute myocardial infarction (within previous 3 months)
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Table 3. Additional Inclusion and Exclusion Characteristics of Patients with
Ischemic Stroke Who Could Be Treated with IV Alteplase within 3 to 4.5 Hours of
Stroke Symptom Onset3,4
Inclusion criteria
- Diagnosis of ischemic stroke causing measurable neurological deficit
- Onset of symptoms 3 to 4.5 hours before beginning treatment
Relative exclusion criteria
- Aged >80 years
- Severe stroke (NIHSS >25)
- Taking an oral anticoagulant regardless of INR
- History of both diabetes and prior ischemic stroke
2.2. Dosing3 (Class I, Level of Evidence A)
2.2.1. The recommended dose is 0.9 mg/kg (maximum 90 mg)
2.2.2. Administer 10% of the total dose as an initial intravenous bolus
over 1 minute via the smart infusion pump.
2.2.3. Immediately following the initial bolus, the remainder (90% of the
total dose) is given as an infusion over 60 minutes via the smart
infusion pump.
2.3. Administration
2.3.1. Before administration, confirm the order is in HealthLink and verify
the dose is correct in accordance with Administrative Policy 8.17.
2.3.2. Administer alteplase via a smart pump to ensure the medication is
infused appropriately.
2.3.3. Smart pump programming will administer the bolus dose over 1
minute and the infusion dose over 60 minutes
2.3.4. The infusion should run continuously, without interruption, except in
the event of an adverse reaction or concern for bleeding
complications
2.3.5. Near the end of the infusion, a 50 mL mini-bag of normal saline
should be connected to the tubing infusing the alteplase to ensure
the residual medication in the tubing is infused accordingly in the 60
minute period.
3. Monitoring
3.1. Starting upon administration of the alteplase bolus, monitor vital signs
(temperature and blood pressure) every 15 minutes x 8 (2 hours), then
every 30 minutes x 12 (6 hours), and hourly thereafter x 16 (16 hours) for
a total of 24 hours (Class IIa, Level of Evidence C).
3.1.1. Blood pressure should be maintained below 180/105 mmHg for at
least the first 24 hours after treatment with alteplase (Class I, Level
of Evidence B)
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10
3.1.2. Labetalol 10 mg IV is reasonable to consider as first line treatment
for BP >180/105 and may be repeated (Class IIa, Level of Evidence
C)
3.1.3. If BP still uncontrolled, consider nicardipine infusion. Initiate at 5
mg/hour, titrated to desired effect (Class IIa, Level of Evidence C)
3.1.4. Identify and treat sources of hyperthermia (temperature >38C)
(Class I, Level of Evidence C)
3.2. Monitor for intracranial bleeding: Assess neurologic status using the
“UWHC Abbreviated NIHSS Flowsheet” every 15 minutes x 8 (2 hours),
then every 30 minutes x 12 (6 hours), and hourly thereafter x 16 (16
hours) for a total of 24 hours3 (Class I, Level of Evidence C).
3.3. Monitor for signs and symptoms of bleeding such as tachycardia, a
decrease in BP, pallor, or restlessness. Minor bleeding complications
include oozing from catheter insertion, venipuncture, or intramuscular
sites; gingival bleeding; hemoptysis; superficial hematoma; ecchymosis;
and purpura.7 (Class I, Level of Evidence C).
3.4. Monitor for signs and symptoms of angioedema, especially if currently
taking an ACEI or ARB. (Class I, Level of Evidence B)
3.4.1. At the first signs and symptoms of oropharyngeal swelling,
administer diphenhydramine 50 mg IV once, ranitidine 50 mg IV
once, and dexamethasone 10 mg IV once for infusion reaction
(Class IIa, Level of Evidence C)
3.5. Supplemental oxygen should be provided to maintain O2 saturation >94%
for at least the first 24 hours after administration (Class 1, Level of
Evidence C)
3.6. Cardiac monitoring should be performed for at least the first 24 hours after
administration (Class I, Level of Evidence B) 3
4. Alteplase Kits
4.1. Alteplase Kits are maintained and stocked by the pharmacy department
4.2. The responding Code Stroke Pharmacist will obtain an Alteplase Kit and
prepare IV alteplase in the immediate patient care area when instructed by
a physician on the Stroke Team. (Appendix B)
UW Health Implementation
Potential Benefits/Harms:
The dosing, administration, and monitoring instructions for alteplase are complex.
Implementation of this clinical practice guideline will provide a consistent approach to
ensuring the safe and efficacious use of alteplase in acute ischemic stroke. It is
understood that occasionally patients will not match the conditions and parameters
considered in this guideline. This guideline is not intended to supersede the clinical
judgment of the treatment team in determining the risk/benefit of alteplase
administration to inpatients.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Implementation Plan/Tools
This clinical practice guideline will be posted on U-Connect and linked within medication
order records for alteplase in the treatment of acute ischemic stroke.
All pharmacists, physicians, and neurology residents involved in Code Stroke response
will receive education on this guideline.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients.
References
Internal References
1. UWHC Administrative Policy 7.56 Acute Stroke Response
2. Pharmacist Acute Ischemic Stroke Response for “Code Stroke” Operating
Procedure
3. UWHC Administrative Policy 8.17 Administration of Medications
4. UWHC Administrative Policy 8.31 Guidelines for Hospital Location Specific
Administration of IV Medications
5. Alteplase and Tenecteplase Replacement Process for Mixed Unused/Non-
administered Product Operating Procedure
External References
1. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC, Jr. Scientific evidence
underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831-
841.
2. Activase [package insert]. San Francisco, CA: Genentech; 2012.
3. Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management
of patients with acute ischemic stroke: a guideline for healthcare professionals
from the American Heart Association/American Stroke Association. Stroke.
2013;44(3):870-947.
4. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours
after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
5. De Keyser J, Gdovinová Z, Uyttenboogaart M, Vroomen PC, Luijckx GJ.
Intravenous Alteplase for Stroke: Beyond the Guidelines and in Particular Clinical
Situations. Stroke. 2007;38(9):2612-2618.
6. American Association of Neuroscience Nurses. Guide to the Care of the
Hospitalized Patient with Ischemic Stroke. American Association of
Neuroscience Nurses. 2012;2nd Ed.:1-38.
7. Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous
alteplase and outcome in stroke: an updated pooled analysis of ECASS,
ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375(9727):1695-1703.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

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Appendix A – Instructions for Reconstitution
Acute Ischemic Stroke
THE TOTAL DOSE FOR TREATMENT OF ACUTE ISCHEMIC STROKE SHOULD NOT
EXCEED 90 mg. (NOTE: Vial contains 100 mg/100 mL)
The recommended dose is 0.9 mg/kg (not to exceed 90 mg total dose) infused over 60 minutes with
10% {(0.09 mg/kg (max 9 mg)} of the total dose administered as an initial intravenous bolus over 1
minute via the smart pump.
Reconstitution should be carried out using the transfer device provided, adding the contents of the
accompanying 100 mL vial of Sterile Water, to the contents of the 100 mg vial of alteplase powder.
Slight foaming upon reconstitution is not unusual; standing undisturbed for several minutes is usually
sufficient to allow dissipation of any large bubbles. 100 mg VIALS DO NOT CONTAIN VACUUM.
1. Use aseptic technique throughout.
2. Remove the protective flip-caps from the vial of alteplase and Sterile Water (SW).
3. Open the package containing the transfer device.
4. Remove the protective cap from one end of the transfer device and keeping the vial of SW upright,
insert the piercing pin vertically into the center of the stopper of the vial of SW first.
5. Remove the protective cap from the other end of the transfer device. DO NOT INVERT THE VIAL
OF SW.
6. Holding the vial of alteplase upside-down, position it so that the center of the stopper is directly over
the exposed piercing pin of the transfer device.
7. Push the vial of alteplase down so that the piercing pin is inserted through the center of the alteplase
vial stopper.
8. Invert the two vials so that the vial of alteplase is on the bottom (upright) and the vial of SW is upside-
down, allowing the SW to flow down through the transfer device (approximately 0.5 mL of SW will
remain in the diluent vial). Approximately 2 minutes are required for this procedure.
9. Remove the transfer device and the empty SW vial from the alteplase vial.
10. Swirl gently to dissolve the alteplase powder. DO NOT SHAKE.
11. After reconstitution remove the “Volume to be infused”{includes bolus dose (0.09 mg/kg (max 9
mg) plus the infusion dose (0.81 mg/kg (max 81 mg)} from the vial using syringe(s) provided.
12. Place this “Volume to be infused” in an empty sterile bag and label the bag appropriately
(example: alteplase 68 mg/68 mL).
13. The provider administering the drug should program the smart pump to administer the bolus
dose over 1 minute, and the infusion dose to be infused over 60 minutes.
*Near the end of the infusion a 50 mL mini-bag of normal saline should be connected to the tubing
infusing the alteplase to ensure the residual medication in the tubing is infused accordingly in the 60
minute period.
No other medication should be added to infusion solutions containing
alteplase.
If alteplase is taken out of the AcuDose and not used, please return the drug to the AcuDose. This will
credit the charge to the patient.
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Appendix B – Pharmacist Acute Stroke Operating Procedure
I. PURPOSE: This operating procedure will encompass the administration of alteplase
intravenously for acute ischemic stroke in the emergency department, inpatient units,
and procedure areas within UWHC. Decentral pharmacists with staffing
responsibilities for the Emergency Department, Neuro-ICU, or overnights, will be
involved with this operating procedure. The scope and goals of this operating
procedure is four-fold:
a. Reduce medication errors and adverse events related to thrombolytic therapy for
ischemic stroke.
b. Facilitate rapid treatment with alteplase by means of pharmacists preparing
patient specific dose at bedside.
c. Reduce medication costs by eliminating preparation of alteplase that is not
administered or charged appropriately.
d. Ultimately to minimize adverse effects and optimize patient outcomes by
ensuring safe and proper administration in the shortest time from stroke onset to
needle time of alteplase.
II. FORMS: Reference the Compounding Database Product Control Sheet – “Alteplase
Kit” – for details on the kit content.
III. DEFINITIONS – none
IV. PROCEDURE
a. Pharmacist Paging Coverage
i. When a “Code Stroke” is activated, the “Stroke Pharmacist” group pager
#0309 will be activated which includes pager #9828, #5108, #7588 and
#7057.
ii. The initial “Code Stroke” page that is sent to the entire Stroke Team will
state “Code Stroke, please call 2-0000” or something similar ONLY the
responding neurology stroke resident will call back to the emergency
code line at 2-0000. Subsequent pages may be sent to the entire Stroke
Team as means of communication to all.
iii. The paging system is not able to differentiate individual pharmacist
pagers according to time, resulting in all 4 pagers being activated for each
“Code Stroke.” Only the pharmacist indicated as follows is responsible
for responding.
iv. The Nights Critical Care/Adult ICU pharmacist (pager #7057) will receive
the communication pages to serve as back-up if needed.
v. Monday through Friday (non-holidays)
1. 0700-2300 ED Pharmacist pager #9828
2. 2300-0700 Nights ED/PEDS/F44 Pharmacist pager #5108
vi. Saturday/Sundays/Holidays
1. 0700-1330 Neuro ICU Pharmacist pager #7588
2. 1330-2200 ED Pharmacist pager #9828
3. 2200-0700 Nights ED/PEDS/F44 Pharmacist pager #5108
b. Pharmacist Responsibilities/Expectations for “Code Stroke”
i. Physically respond to the patient care location for all Code Strokes called
with verbal confirmation between the designated responding stroke
resident and pharmacist.
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ii. If determined to leave the area, the pharmacist will provide the stroke
resident with their direct pager contact or the Code Stroke Pharmacist
group pager #0309.
iii. Ensure appropriate dose of intravenous alteplase and prepare at patient
bedside just prior to administration when ordered.
iv. Serve as an independent double check for this “High Alert Medication”
and ensure electronic MAR documentation by the nurse is accurate
related to administration time.
v. Educate the patient care nurse of proper dosing and administration of
alteplase.
vi. Serve as a medication resource to the stroke team and facilitate
acquisition of medications needed during a “Code Stroke.”
vii. Ensure appropriate patient charging is completed for alteplase when
administered.
viii. When applicable, inform the decentral pharmacist caring for the patient if
alteplase is administered.
c. Billing
i. When alteplase or other medications are administered during a “Code
Stroke” when a pharmacist is involved, the responding pharmacist will
ensure the patient is appropriately charged.
ii. For patients that are admitted to the ED, when an “Alteplase Kit” is
dispensed from the patient’s profile via the South ED AcuDose (AcuDose
#2), this will create an appropriate charge to the patient.
iii. Alternatively for inpatients, the Kit may be obtained from the other
locations as listed in section IV.d. After the prescriber enters the
medication order, (the pharmacist should NOT enter for the prescriber)
upon electronic order verification the pharmacist should ensure
appropriate charging of the medication. Other medications administered
or ordered during a “Code Stroke” will be charged by means of the usual
process for the patient care area.
d. Alteplase Kits Location/Availability
i. Par of 1 and max of 2 Kits will be maintained in the South ED AcuDose
(ED AcuDose #2), with the pharmacist ensuring restocking when used if
depleted supply to zero during a “Code Stroke.”
ii. Par of 1 and max of 2 Kits will be maintained in the MedCarousel in
Central Pharmacy.
iii. The Alteplase Kit content can be referenced in the Compounding
Database Formulas.
iv. One Kit will be maintained in the F8/4 Neuro-ICU pharmacist work area
within the designated Pharmacist Locked Stock drawer, with the
pharmacist ensuring restocking when used.
v. Selection and obtainment of an Alteplase Kit should be from the location
that meets the immediate needs of the patient depending upon your
location. The “Alteplase Kit” located in the South ED AcuDose may be
obtained for inpatients by custom expiring the Kit, and then billing the
patient via the electronic medical record if used. Also note that the Kits
prior to reconstitution are able to be sent via pneumatic tube system if
needed.
V. REFERENCES AND RELATED POLICIES, PROCEDURES – UWHC Administrative
Policy 7.56 Acute Stroke Response and Pharmacy Operating Procedure – Alteplase
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and Tenecteplase Replacement Process for Mixed Unused/Non-administered
Product
VI. COORDINATION:
a. AUTHORED BY: Aaron Steffenhagen, PharmD, BCPS, Pharmacy Manager,
Patient Care Services and Emergency/Disaster Preparedness
b. REVIEWED BY: Michelle Thoma, PharmD, Pharmacy Manager, Patient Care
Services and Compliance
c. COMMITTEE APPROVAL BY: UWHC Pharmacy Inpatient Managers Committee
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org