Abstract 2878: Compliance to Guidelines by Emergency Medical Services in “Drip and Ship” Patients with In-transit Intravenous Thrombolytic Infusion

Abstract

Background: The “drip and ship” paradigm among acute ischemic stroke (AIS) patients has resulted in expansion of thrombolytic treatment in patients eligible for intravenous (IV) recombinant tissue plasminogen activator (rt-PA). However, it remains controversial whether the settings are adequate for IV rt-PA infusion within the EMS transport by emergency medical technicians (EMTs). Objective: To determine compliance to guidelines during transport of AIS patients treated with IV rt-PA using “drip and ship” paradigm while being transferred to comprehensive stroke centers (CSCs) from referring facilities and determine its effect on outcome upon discharge. Methods: A retrospective evaluation of patients transferred to our CSCs from June 2009 to July 2011 was conducted to determine the quality of care provided by EMTs after IV rt-PA was initiated at referring facilities. Quality parameters audited include frequency of blood pressure (BP) monitoring, interventions for elevated BPs, and discontinuation of IV rt-PA in the event of neurologic deterioration. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 at time of discharge. Results: Among the 30 patients included in this study (53% men, mean age 72.6±14.2 years), 28 patients received vital sign monitoring at 10 to 20 minute intervals; the other two either underwent monitoring at less frequent intervals or did not receive any vital sign monitoring. The mean transit time was 37.4±16.9 minutes. Of the 29 patients with BP monitoring, 9 patients had at least one episode of BP above the recommended parameters (>180/105 mmHg) while being treated with IV rt-PA; only one of those was treated with an anti-hypertensive agent. No neurologic deterioration was reported during transit by EMS but 3 of the 30 patients were considered to have worsened between the outside ED and CSC ED evaluations. The rates of favorable outcome between patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mmHg without treatment was similar to those who experienced neither event (50% and 45%, p=0.55). Conclusion: Efforts are required to improve compliance to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of “drip and ship” paradigm.