Abstract 174: Inter-facility Transfer Post IV rtPA and Protocol Adherence
Authors: Jones Robin R 
Published: July 2021

Background/Problem
Stroke is a common and serious health disorder, affecting approximately 795,000 people in the United States every year. Ischemic stroke accounts for approximately 87 percent of all strokes. Intravenous rtPA is used in the treatment of acute ischemic stroke. Following rtPA administration, blood pressure should be closely monitored and maintained less than 180/105 mm Hg. Evidence-based guidelines for the post rtPA management include monitoring of the blood pressure (BP) and neurological assessment every 15 minutes for the first 2 hours; then every 30 minutes for 6 hours; then hourly for 16 hours. Attention to and management of blood pressure is critical before, during and after the administration of rtPA. Telemedicine consults with stroke specialists has increased the number of ischemic stroke patients treated with intravenous rtPA at rural hospitals which in turn has increased inter-facility transfer of rtPA treated patients.

Objective
The primary objective was to determine the protocol adherence rate of pre-hospital personnel during transport of acute ischemic stroke patients treated with intravenous rtPA.

Methods
A quantitative, retrospective, non-experimental analysis of inter-facility transport documentation was conducted of all ischemic stroke patients treated with intravenous rtPA and transferred to the primary stroke center in western North Carolina between the dates of January 1, 2009 and December 31, 2010.

Results
yielded 45 patients from 14 referral hospitals. Mean age was 71.5. The range was 48 with minimum age of 45 years and maximum age of 93 years. The distance between referral hospital to stroke center range from 20.4 miles to 110.4 miles. The majority of transfers (44.5%) were from 3 hospitals, with a frequency range from 1 transfer to 8 transfers. The mode of transportation was either by county level Emergency Medical Services (51%), receiving hospital critical care transport (35%) or air medical (13%). Door to door transport time was compared to expected protocol adherence. Factors associated with positive protocol adherence include: air medical transport (
P
<.005); transporting with intravenous rtPA infusing en route (
P
<.001) and tendency towards positive adherence with transport times less than 60 minutes. A cross tabulation of adherence to protocol to discharge disposition was not statistically significant due to the small sample, however, there was noted tendency towards significance with 100% positive adherence to protocol in subjects discharged to a skilled nursing facility or expired. There was one case of documented intracranial hemorrhage at 24 hours post IV rtPA and was not associated with non-adherence. There were no documented cases of angioedema in the study sample. The findings suggest a correlation to protocol adherence and shorter transport times, rtPA infusing en route, and discharge status to skilled nursing facility or expired in the hospital. To positively affect patient outcomes all stroke care providers must be knowledgeable of evidence-based guidelines. Stroke centers need to provide oversight and training related to inter-facility transport of the rtPA treated patients to all transport personnel.