title: Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings.
abstract: BACKGROUND
  In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients.
  
  
  METHODS
  We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined.
  
  
  RESULTS
  We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% (n = 10) and SH rate was 2.9 (n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for 'avoided' ICU days, and hospital LOS decreased significantly (p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3.
  
  
  CONCLUSIONS
  IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.
authors.affiliation: Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center & Australian Catholic University, Sydney, Australia. Address: UTHSC CON 920 Madison, Suite 532, Memphis, TN 38163, USA.
authors.forename: Anne W
authors.initials: AW
authors.lastname: Alexandrov
authors.affiliation: Blue Cross/Blue Shield of Alabama, Birmingham, Alabama.
authors.forename: Kisha C
authors.initials: KC
authors.lastname: Coleman
authors.affiliation: Department of Neurology, Poitiers University Hospital, Poitiers, France.
authors.forename: Paola
authors.initials: P
authors.lastname: Palazzo
authors.affiliation: Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Reza Bavarsad
authors.initials: RB
authors.lastname: Shahripour
authors.affiliation: Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Andrei V
authors.initials: AV
authors.lastname: Alexandrov
keywords: cost savings; functional outcome; safety; stroke units