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

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

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Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, and Hennepin County Medical Center, Minneapolis, Minnesota. Electronic address:



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.


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

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