‘Drip and Ship’ Proves Safe for Stroke

“Drip and ship” is a safe way to manage patients with acute ischemic stroke, according to results from two separate studies.

A review of 145 ischemic stroke patients who began receiving an intravenous infusion of tissue plasminogen activator (TPA) at a community hospital, followed by transport to a regional primary stroke center, showed a 63% rate of good stroke recoveries and a 3% rate of spontaneous intracranial hemorrhage, Dr. Marilyn M. Rymer reported at the International Stroke Conference.

And a review of 129 acute ischemic stroke patients treated by “drip and ship” throughout Minnesota during October 2008–December 2009 showed that initiating a TPA drip at a community hospital and then shifting the patient to a regional center led to outcomes that were generally identical to those of 473 similar patients who received TPA at a primary center and remained there, Dr. Saqib A. Chaudhry and his associates reported in a poster at the meeting, which was sponsored by the American Heart Association.

Dr. Marilyn M. Rymer

The review by Dr. Rymer and her associates included 145 consecutive ischemic stroke patients who arrived at the Mid-American Brain and Stroke Institute at Saint Luke’s Hospital in Kansas City, Mo., in 2008-2010. They came from 63 referring hospitals, including 40 hospitals located more than 50 miles away from Saint Luke’s. In all, 29 of the referring hospitals had 25 or fewer beds, indicating that despite their small size, these community facilities had “pretty sophisticated emergency [department] staffing,” said Dr. Rymer, the institute’s medical director.

The shipped patients were an average of 68 years old, and their mean National Institutes of Health Stroke Scale score at admission to Mid-America was 10.4. On arrival, 14 (10%) of the shipped patients had blood pressure higher than 180/105 mm Hg, the maximum level recommended for treatment with IV TPA.

Among the 114 patients in the series who were assessed for their modified Rankin Scale (mRS) score at 90 days after their stroke, 72 patients (63%) had an mRS score of 0-2, a “good” outcome. (The 31 patients who were treated during 2008 did not have an mRS score available at 90 days.) Of all 145 patients in the series, 14% (20 patients) died.

Four of the 145 patients (3%) had a spontaneous intracerebral hemorrhage on arrival to the referral center, which in two cases resulted in death. One of these patients arrived with a blood pressure of 183/77 mm Hg; the other three intracranial hemorrhages occurred in patients with blood pressures below the limit for receiving TPA. Six patients (4%) received an inaccurate diagnosis when they were initially evaluated at a community hospital, but all six of these patients had “excellent” clinical outcomes.

These results show that immediate transfer of patients treated with IV TPA is “safe, with a low rate of spontaneous intracranial hemorrhage en route,” said Dr. Rymer, who is also a professor of medicine at the University of Missouri–Kansas City. “The 63% rate of good outcomes may, in part, relate to early treatment with IV TPA at the referring hospitals. Hospitals of every size and location can safely treat stroke patients with IV TPA if they have access to consultation and transfer agreements with experienced stroke centers,” she concluded.

The Minnesota study used data collected by the Minnesota Hospital Association; researchers identified patients with ischemic stroke and those treated with IV TPA who were then transported to a referral hospital according to the ICD-9-CM codes in their medical records, said Dr. Chaudhry, a researcher at the stroke research center of the University of Minnesota in Minneapolis.

Dr. Saquib A. Chaudhry

Among more than 21,000 patients with acute ischemic strokes who were seen at Minnesota hospitals during the 14-month study period, 602 received thrombolytic therapy at 30 different hospitals, with 129 (21%) undergoing “drip and ship” management at 13 of these hospitals, while the other 473 (79%) remained at the centers where they began treatment with IV TPA. The patients averaged about 70 years old, and nearly half were women.

Patient profiles of the shipped and unshipped patients were similar, as were most outcomes including in-hospital mortality and length of stay. The only significant difference in clinical outcomes between these two subgroups during hospitalization was in the rate of intracerebral or subarachnoid hemorrhage, which occurred in 9% of the patients who remained at the site where they first received TPA and in 3% of the shipped patients, a statistically significant difference.

“Drip and ship” was also substantially cheaper. Average hospital charges for the untransported patients ran more than $65,000, whereas patients managed by “drip and ship” had average hospitalization charges of just under $48,000, a statistically significant difference.

Dr. Rymer said that she has been a speaker for Genentech and Concentric Medical. Dr. Chaudhry and his associates had no disclosures.

 

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