Use of SMART IV Thrombolysis Criteria at Community Hospitals Is Safe (P04.074)

OBJECTIVE: To evaluate the safety of applying the SMART (Simplified Management of Acute Stroke using Revised Treatment) criteria to IV rt-PA patients from community hospitals transferring to a large Comprehensive Stroke Center (CSC). BACKGROUND: Thrombolysis rates remain low nationally (1-3%)¹. The SMART criteria expand rt-PA use by reducing exclusion criteria. When applied to all acute ischemic stroke (AIS) patients at a large CSC, the thrombolysis rate increased to 25-30%, with low symptomatic intracranial hemorrhage (sICH) rates². This study investigates the safety of applying these criteria to AIS patients who transferred from outside community hospitals. DESIGN/METHODS: Retrospective study of all AIS patients treated with IV rt-PA from 10/1/2008-8/1/2012 at the local CSC ED or an outside hospital before transfer to the CSC. Baseline characteristics, admission status, and stroke severity were obtained. Primary outcomes included NIHSS and discharge disposition. Safety was determined by sICH rate. RESULTS: 427 AIS patients received IV rt-PA. 213 were local and 214 transferred. sICH rate was 1%. Excluding expired patients, transfers had significantly higher mean NIHSS at both admission (8.2 vs. 6.7) and discharge (5.7 vs. 3.5). However, mean improvement in NIHSS was not significantly different between transfer vs. ED patients (p=0.213). Transferred patients were younger and had a higher mortality rate (14% vs. 6.6%, OR=2.32[1.19-4.5], p=0.011), but there was no significant difference in length of stay or number of patients being discharged to home or acute rehab (123 transfers vs. 141 EDs, OR=0.829[0.538-1.279], p=0.397). CONCLUSIONS: Applying the SMART criteria to patients receiving IV rt-PA via telemedicine or telephone before transfer to a CSC is safe. Transferred patients have more severe strokes and associated higher mortality consistent with the need for transfer, but were discharged to home and rehab at comparable rates. ¹ Ann Emerg Med. 2007; 50(2):99-107. ² Presented at AAN Annual Meeting; April, 2010; Toronto, Canada. Disclosure: Dr. Sorensen has nothing to disclose. Dr. Barazangi has received personal compensation for activities with Genentech, Inc. Dr. Wong has nothing to disclose. Dr. Chen has nothing to disclose. Dr. Rose has received personal compensation for activities with Boehringer Ingelheim as a speaker. Dr. Grosvenor has nothing to disclose. Dr. Bedenk has nothing to disclose. Dr. Tong has nothing to disclose.