ACEP Clinical Policies Committee to Develop Independent tPA Policy

The ACEP Board Directors accepted a recommendation last week from its Clinical Policies Committee to begin working on a tPA policy exclusive to ACEP instead of a joint project with the American Academy of Neurology.

The 2013 Council had asked that ACEP reconsider its current “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department,” which had been developed with the AAN and published in February 2013.

After an open 60-day comment period in early 2014 and a subcommittee review of the comments and literature findings, the Clinical Policies Committee recommended to pursue an independent policy, which will include updated evidence and grading criteria. The Board unanimously approved this recommendation.

Once the draft is developed, it will be available for members to review and comment for 60 days prior to the Committee’s presentation to the Board. An estimated timeline was not available.

Additionally, the Board confirmed its commitment to the clinical policy development process and agreed to add three methodologists to the committee, additional meetings, and another staff person to ensure a robust review process.

  1. #1 by Craig Weeke,MD, FACEP - July 5th, 2014 at 07:46

    I do not feel that the current medical literature supports the use of TPA. That being said our neurology colleagues feel that TPA is indicated in acute ischemic stroke. I feel that a neurologist should be the individual to order the TPA after seeing the patient, not the emergency physician.

  2. #2 by Rick Bukata - July 5th, 2014 at 19:57

    Please consider the fact that nobody, or certainly not a significant number of physicians, want ACEP to develop a policy on this contentious matter. Essentially forcing the issue to be TPA “yes” or TPA “no” will only force EPs into a box that they don’t want to be in. The evidence has been reviewed ad nauseum. Those against will remain against and those for will remain for. This should not be a matter of straining to get the evidence to lean one way or the other. ACEP should listen to the members — there is not an overwhelming concusses to embrace a pro TPA stance — save face and drop the matter.

  3. #3 by David E. Wilcox, MD, FACEP - July 11th, 2014 at 07:06

    A Policy accurately discussing both the pro and con data interpretations, and thereby allowing individual physician member interpretation and decision making, would not be detrimental.

    The issue is not to have a Policy coercing individual members into a position of being forced to practice against their best professional judgement.

  4. #4 by David T Schwartz - July 17th, 2014 at 08:42

    It seems unwise to promulgate such a firm Level A practice recommendation on the single randomized controlled trial (RCT) that showed benefit of tPA (NINDS 1995) in which only 168 patients were treated with tPA. It’s true that study constitutes the highest Class 1 strength of evidence, it is still a small number of patients on which to base such a definitive recommendation that will have such wide impact. There are many examples of treatments that seemed beneficial in one RCT, but were then disproven in another RCT. By wording ACEP’s policy recommendation as to “offer tPA” seems merely to be a hedge.

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