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Bringing Neurocritical Care to Rural Virginia: Considerations When Transitioning to Tenecteplase for Acute Ischemic Stroke

By Currents Editor posted 02-10-2023 18:55


By Ashley Asbell, PharmD
Benign Hematology/Critical Care Pharmacist Float
UVA Health, Charlottesville, VA

In August 2022, I started a new job as a pharmacist at a small, rural community hospital not too far from where I trained. I completed two years of pharmacy residency training at a large, urban academic medical center where I specialized in critical care, and it has now been over a year since the transition to tenecteplase occurred at my prior institution. I arrived at this new hospital mere weeks after their “go-live” for transitioning to tenecteplase for acute ischemic stroke. During orientation, I learned that the vascular neurologists at my prior institution served as the telestroke consult team for stroke alerts at my new practice site. I remember thinking it was interesting that their tenecteplase transition occurred more than a year later, even though the institutions shared the same neurologists. As I completed orientation, I wondered how the change to a tenecteplase at this rural hospital would compare to my experiences with tenecteplase implementation at an academic medical center. It became apparent immediately that this transition was quite different from my prior experience.

During residency I was fortunate to spend time within the neurocritical care realm through clinical learning experiences and longitudinal projects. I played an integral role in our institutional switch from alteplase to tenecteplase for treating acute ischemic stroke. My role focused on departmental training, which included reviewing supporting literature for this off-label use of tenecteplase and presenting updated workflows for medication procurement and bedside delivery. After more than a year of preparation, finally implementing the transition in 2021 was an exciting time for everyone involved.

After the transition to tenecteplase I spent several months training in the emergency department and neurocritical care unit. These critical care learning experiences allowed me to directly observe physicians, nurses, and pharmacists adjust to the switch. Unsurprisingly, one of the biggest adjustments came from the changes in compounding; compared to the bedside admixing tenecteplase provided, alteplase had been compounded in our sterile IV room and delivered to the bedside by the emergency department or neurology pharmacist. While sterile compounding took longer for the drug to reach the patient, there was never any question as to who was responsible for preparing the drug. Transitioning to tenecteplase meant there would always need to be someone present at the patient’s bedside who was proficient in dosing and admixing, regardless of the time of day.

Fortunately, having at least one emergency department pharmacist and one clinical pharmacist present 24/7 meant there was always a pharmacist on-site to facilitate drug preparation and delivery to the bedside when needed in addition to allowing for great continuity of care. The neurology pharmacists and vascular neurologists always had a wonderfully collaborative relationship, so everyone was on the same page to a “T” by the time tenecteplase was officially rolled out. The hospital’s medical emergency team (MET), which consists of nurses who provide the hospital with 24/7 emergency response coverage, also played a key role in the success of this initiative. Prior to the “go-live,” our MET nurses were also trained on tenecteplase dosing, admixing, and administration. This training ensured that there was always a knowledgeable provider at each stroke alert, even when a pharmacist wasn’t present. Looking back, I would say the transition went smoothly.

In observing the two different institutional implementations, standing out the most was the discrepancy between resources; as a smaller hospital, they did not have as robust of a pharmacy department, with coverage in the ED by a single pharmacist who was present from 8 AM to 5 PM on weekdays only. Additionally, the lack of a MET meant there was no guarantee that trained staff would be able to respond 24/7, a service we benefitted from at my prior hospital. I repeatedly heard of concerns from nurses that they weren’t comfortable with the dosing and reconstitution of tenecteplase, and they didn’t feel confident they would be able to manage it at the bedside when a pharmacist wasn’t present. This concern was heightened by the fact that, like many other hospitals, there was consistent turnover of nurses in the emergency department due to staffing shortages. Regular nurse turnover meant that as soon as one group of nurses were trained, there were many more to take their place who were also starting from square one. On top of that, there was a report about a typo in a consult note, where “tPA” was written instead of “TNK,” which caused a delay in thrombolytic administration. While this could have happened just as easily at my prior institution, we benefitted from having those same neurologists in-house and present at the time of the stroke alert. What was once a verbal “did you mean tenecteplase?”, or at the very least a simple page, was now a phone call that could take 5, 10, or even 15 minutes before correcting the error, in a situation where every second counts.

When pharmacy practices inevitably change—whether it be our preferred thrombolytic for acute ischemic stroke, the antiseizure medication we recommend as second-line therapy for status epilepticus, or anything in between—I think it’s important to recognize that each hospital will be affected differently. Of course, process changes will always look a little different from hospital to hospital: patient needs, staffing models, and provider preferences are just a few of the factors that make each hospital unique. However, major differences in resources between a large academic medical center and a small, rural community hospital will always exist. Examples of barriers are summarized in Table 1.

Barrier type

Hospital type


Mitigation strategy




Large numbers of staff to train

Consider online/virtual trainings to increase accessibility


Smaller pharmacy department = less likely to have 24/7 clinical pharmacy coverage

Consider small group, in-person trainings and hands-on competencies to improve confidence in bedside admixing


Increased staffing turnover as a result of the COVID-19 pandemic

Consider recurring training and a yearly or twice-yearly competency requirement for all staff who may admix tenecteplase

Consider fixing additional labeling to the product to aid in admixing/dosing




More layers within the approval process which slows transition from alteplase to tenecteplase

Prepare all necessary documents for implementation (proposals, procedure outlines, training and competency assessments, plans for stocking, etc.) ahead of time to streamline proposal process


Fewer (if any) neurocritical care trained practitioners in-house to assist in the development of a tenecteplase protocol

Consider reaching out to neurocritical care practitioners at nearby LAMCs that have already implemented tenecteplase at their institutions




Consulting vascular neurologists may not be present in-house if clarification is needed

Consider standardizing patient presentation to include the formulary thrombolytic for acute ischemic stroke when discussing with an off-site neurologist


Abbreviations of “TNK” and “tPA” commonly used over complete drug names, which may lead to errors

Avoid utilization of “TNK” and “tPA” during verbal and written communication, as recommended by the Institution for Safe Medical Practices (ISMP)*

*See ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations for more information1

Not every institution will have the luxury of a dedicated neurocritical care unit, or the presence of a large neurology department, or even around-the-clock pharmacist coverage. When academic medical centers make major pharmacotherapeutic changes in neurocritical care, smaller hospitals in the surrounding area may follow suit. Unique ideas for implementing initiatives at hospitals with fewer resources may be available in peer-reviewed journals and online magazines like Currents. You may also seek helpful ideas through professional organizations, networking, and social media. Likewise, if you developed a pharmacy-related neurocritical care protocol at a rural institution, please share your experiences. Let others know what worked well and what didn't. Remember that differences such as discrepancies in resources exist, and consider offering an outside perspective to possibly make those transitions easier and safer.


  1. Institute for Safe Medication Practices (ISMP). ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. ISMP; 2021.


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