Background Reperfusion with endovascular thrombectomy (EVT) improves functional outcomes for acute ischemic stroke patients with large vessel occlusion (LVO). According to the American Heart Association's Target Stroke Guidelines, when an LVO stroke patient presents to a non‐thrombectomy capable hospital, the time from hospital arrival until transfer out for EVT (door‐in‐door‐out DIDO time) should not exceed 90 minutes. However, the average DIDO time in the United States in 2023 was 174 minutes. We report DIDO times within our hospital system pre‐ and post‐implementation of a protocolized system‐wide LVO transfer process. Methods Our hospital system consists of seven spoke hospitals and two hub hospitals which perform EVT. LVO stroke patients presenting to spoke hospitals are emergently evaluated, treated (including intravenous thrombolysis), and triaged via telestroke by a university‐based stroke team. The stroke team, in conjunction with a multidisciplinary neurointerventional team, also determine if the patient would benefit from EVT and should be emergently transferred..Pre‐implementation, the LVO transfer process was initiated and driven by each spoke hospital on a case‐by‐case basis in coordination with the system operations center (SOC). As part of a hospital system quality improvement initiative, a unified regional LVO transfer model was implemented. Key interventions included: 1) assigning one hub hospital to be the primary transfer destination for each spoke hospital, 2) the SOC was no longer required to confirm the availability of a post‐procedure inpatient bed prior to initiating transfer, and 3) assigning transfer coordination tasks (e.g., arranging emergency transportation and alerting the neurointerventional team) to specific provider, nursing, and support staff roles. We retrospectively reviewed all LVO patients who were transferred for EVT between 1/8/2022‐8/14/2023. The regional LVO transfer model was implemented 8/28/2023. Exclusion criteria were: code stroke not activated, contrast allergy, or obtaining MRI. We report patient demographics descriptively (Table 1). To assess DIDO times pre‐ and post‐implementation, we utilized Wilcoxon Rank‐Sum testing. Results 70 LVO patients pre‐implementation and 55 LVO patients post‐implementation met our inclusion criteria. Patient characteristics, including age, sex, race, and baseline NIHSS, are summarized in Table 1. Median DIDO time decreased from 117 minutes to 90 minutes (P < 0.001) following implementation of the regional LVO transfer model. The interquartile range decreased from 48 minutes to 24 minutes post‐implementation, reflecting decreased variability in the transfer process. Conclusion Implementation of a standardized, protocol‐driven regional LVO transfer model across our hospital system significantly reduced DIDO times. image
Kesavan et al. (Sat,) studied this question.