Adherence to guidelines by emergency medical services during transport of stroke patients receiving intravenous thrombolytic infusion

J Stroke Cerebrovasc Dis. 2013 Oct;22(7):e42-5. doi: 10.1016/j.jstrokecerebrovasdis.2012.03.018. Epub 2012 May 8.


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.

Keywords: Acute stroke; emergency medical services; guidelines; prehospital setting; thrombolysis; “drip and ship”.

MeSH terms

  • Aged
  • Brain Ischemia / drug therapy*
  • Emergency Medical Services / standards*
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / therapeutic use*
  • Guideline Adherence*
  • Humans
  • Infusions, Intravenous
  • Male
  • Middle Aged
  • Practice Guidelines as Topic*
  • Retrospective Studies
  • Stroke / drug therapy*
  • Thrombolytic Therapy / methods
  • Time Factors
  • Tissue Plasminogen Activator / administration & dosage
  • Tissue Plasminogen Activator / therapeutic use*
  • Transportation of Patients


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator