Adherence to Guidelines by Emergency Medical Services During Transport of Stroke Patients Receiving Intravenous Thrombolytic Infusion

Abstract

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). It remains controversial whether the settings within the emergency medical services (EMS) transport are adequate for IV rt-PA infusion. We sought to determine EMS adherence to guidelines during the transport of drip and ship AIS patients treated with IV rt-PA while being transferred to comprehensive stroke centers (CSCs) and the effect of nonadherence on outcome upon discharge. A retrospective evaluation of patients transferred to our CSC was conducted to determine the rates of adherence to quality parameters during EMS transport with infusion of IV rt-PA. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 1 upon discharge. Among the 40 patients studied (55% men; mean age 71.9 ± 13.9 years), 38 patients received vital sign monitoring at 10- to 20-minute intervals. The mean transit time was 37.7 ± 20.2 minutes. Of the 39 patients with blood pressure (BP) monitoring, 7 patients had at least 1 episode of BP elevation above the recommended parameters (>180/105 mm Hg); only 1 of those was treated with an antihypertensive agent. Five of the 40 patients were considered to have worsened between the outside ED and CSC ED evaluations without IV rt-PA discontinuation during transfer. The rate of favorable outcome of patients who had interim neurologic deterioration without discontinuation of IV rt-PA or BP >180/105 mm Hg without antihypertensive treatment was similar to those who experienced neither event (41.7% and 35.7%; P = .736). Efforts are required to improve EMS adherence to guidelines in patients receiving IV rt-PA during EMS transport in anticipation of broader use of the "drip and ship" paradigm.