Door-in-Door-Out Times at Referring Hospitals and Outcomes from Hemorrhagic Stroke

ABSTRACT Background Guidelines recommend DIDO (Door-In-Door-Out) time 270 mins, OR 1.83 1.58, 2.11; vs DIDO < 90 mins as reference; P<.0001), but these associations became statistically non-significant in the adjusted analyses. Similar results were seen for mRS at discharge in SAH patients. In both ICH and SAH patients, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of in-hospital mortality. Conclusion DIDO times were inversely related to in-hospital mortality, ability to ambulate independently at discharge, but not discharge mRS for patients with ICH and SAH. These findings may suggest that a longer period of stabilization in the initial ED may be associated with better outcomes from hemorrhagic stroke and that current interhospital transfer protocols currently expedite transfer of the sickest patients. Prospective studies are needed to balance ED stabilization with arrival at a definitive destination in patients with hemorrhagic stroke. KEY POINTS Question Is Door-In-Door Out time at a transferring hospital associated with global disability at hospital discharge (modified Rankin Score (mRS))for patients with intracranial hemorrhage? Findings In this cohort study using a large nationwide quality improvement database, increasing DIDO time was associated with greater odds of mRS 0-3 vs 4-6 at discharge in the unadjusted analyses for both ICH and SAH patients, but these associations became statistically non-significant in the adjusted analyses. In both ICH and SAH patients, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of in-hospital mortality in both the unadjusted and adjusted analyses. Meaning These findings may suggest that a longer period of stabilization in the initial emergency department (ED) may be associated with better outcomes from hemorrhagic stroke and that current interhospital transfer protocols tend to expedite transfer of the sickest patients. Prospective studies are needed to determine whether early or delayed transport with ED stabilization is optimal for care of patients with hemorrhagic stroke.