Bed rest or mobilization after rt-PA? A case-crossover study of factors influencing clinical decision making in stroke services

Background Acute stroke management is a dynamic field. Treatment with recombinant tissue plasminogen activator is standard care in Australia, but there are no evidence-based practice guidelines about first out of bed activity (mobilization) after recombinant tissue plasminogen activator. Aims To identify factors influencing clinicians' decisions to delay or allow mobilization. Methods Case-crossover design. Using hypothetical case vignettes, we explored the factors that clinicians consider when deciding to first mobilize a patient after recombinant tissue plasminogen activator. Acute stroke physicians and nurses from Australian hospitals known to treat with recombinant tissue plasminogen activator participated. Information about hospital recombinant tissue plasminogen activator protocols and perceived benefits and harms of mobilization after recombinant tissue plasminogen activator were also captured. Results Fifty-four clinicians, 52% senior nurses, and 48% senior physicians from all states of Australia participated. Of the factors influencing decisions about mobilization after recombinant tissue plasminogen activator, neurological decline (0 center dot 29; confidence interval 0 center dot 12, 0 center dot 46; P=0 center dot 001), neurological decline with symptomatic intracerebral hemorrhage (0 center dot 41; confidence interval 0 center dot 24, 0 center dot 59; P<0 center dot 0001), infection of uncertain cause (0 center dot 32; confidence interval 0 center dot 14, 0 center dot 50; P=0 center dot 001), severe chest infection (0 center dot 35; confidence interval 0 center dot 16, 0 center dot 53; P=0 center dot 0004), severe stroke (0 center dot 29; confidence interval 0 center dot 12, 0 center dot 46; P=0 center dot 001), drowsiness (0 center dot 47; confidence interval 0 center dot 29, 0 center dot 63; P<0 center dot 0001), and confusion (0 center dot 31; confidence interval 0 center dot 15, 0 center dot 47; P=0 center dot 0001) significantly influenced decisions. Falls risk was a common concern (85%). Conclusion Growing interest in development of clear protocols that guide first mobilization after recombinant tissue plasminogen activator prompted this study. We have identified factors that may influence decisions about when to allow patients to mobilize after recombinant tissue plasminogen activator. These, combined with emerging evidence of risks and benefits of early mobilization, should help protocol development in the future.