title: Adherence to guidelines by emergency medical services during transport of stroke patients receiving 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). 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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, and Hennepin County Medical Center, Minneapolis, Minnesota. Electronic address: ganesh785@gmail.com.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Asaithambi
authors.forename: Saqib A
authors.initials: SA
authors.lastname: Chaudhry
authors.forename: Ameer E
authors.initials: AE
authors.lastname: Hassan
authors.forename: Gustavo J
authors.initials: GJ
authors.lastname: Rodriguez
authors.forename: M Fareed K
authors.initials: MF
authors.lastname: Suri
authors.forename: Adnan I
authors.initials: AI
authors.lastname: Qureshi
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy*; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019983:Guideline Adherence; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014187:Transportation of Patients
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator