title: Drip and ship thrombolytic therapy for acute ischemic stroke: use, temporal trends, and outcomes.
abstract: OBJECTIVE
  Interhospital transfer after use of intravenous tissue-type plasminogen activator (tPA) in acute stroke (drip and ship) is increasingly frequent. Small studies have suggested that drip and ship tPA is safe and increases rates of tPA use; however, little is known about real-world practice patterns. We sought to evaluate temporal trends in drip and ship tPA use and to compare the patient and hospital characteristics with that of conventional (front door) thrombolysis.
  
  
  METHODS
  We analyzed data from 44 667 patients with ischemic stroke treated with intravenous tPA ≤3 hours of symptom onset in the Get With The Guidelines-Stroke program from April 2003 to October 2010 in 1440 hospitals. The main outcomes were the frequency of drip and ship tPA use over time, the characteristics of patients treated, and in-hospital outcomes, treatments, and complications.
  
  
  RESULTS
  Among 44 667 patients treated with tPA, the drip and ship method was a common method (n=10 475; 23.5%), the use of which increased in parallel with the traditional tPA method over time. Patients treated by the drip and ship method differed significantly from front-door patients, with lower National Institutes of Health Stroke Scale scores when recorded (n=35 467). Crude in-hospital mortality (10.9%) and symptomatic intracranial hemorrhage (5.7%) in patients treated by the drip and ship method were slightly higher compared with those in front-door patients, and these differences persisted after risk adjustment.
  
  
  CONCLUSIONS
  Drip and ship tPA is common, used in 1 in 4 patients treated with tPA in the United States. Modest differences in mortality and symptomatic intracranial hemorrhage may be because of patient selection bias, post-tPA care differences, or unmeasured confounding. The drip and ship paradigm may facilitate widespread tPA use in patients with acute stroke.
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.). kevin.sheth@yale.edu.
authors: Kevin N
authors: KN
authors: Sheth
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.).
authors: Eric E
authors: EE
authors: Smith
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.).
authors: Maria V
authors: MV
authors: Grau-Sepulveda
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.).
authors: Dawn
authors: D
authors: Kleindorfer
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.).
authors: Gregg C
authors: GC
authors: Fonarow
authors: From the Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, Yale University School of Medicine, New Haven, CT (K.N.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.V.G.-S.); Department of Neurology, University of Cincinnati, Ohio (D.K.); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA (G.C.F.); and Department of Neurology, Institute for Heart, Vascular and Stroke Care, Massachusetts General Hospital, Boston (L.H.S.).
authors: Lee H
authors: LH
authors: Schwamm
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy*; D003625:Data Collection; D004632:Emergency Medical Services / Q000458:organization & administration; D005260:Female; D006782:Hospitals, Special; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
keywords: emergency medicine; stroke; tissue-type plasminogen activator