Association of Component Strategies of the Target Stroke Phase 3 Nationwide Quality Improvement Program With Accelerated Door-to-Puncture and Door-In-Door-Out Times for Ischemic Stroke Endovascular Thrombectomy in the United States

BACKGROUND: The Target Stroke Phase III program is a national quality improvement initiative led by the American Heart Association, which sought to improve the quality of care for patients with acute stroke undergoing acute reperfusion therapy including endovascular thrombectomy (EVT). METHODS: A retrospective, observational cohort study was performed using data from the American Heart Association Get With The Guidelines-Stroke Program between January 1, 2017, and March 31, 2022. Three categories of patients were analyzed: (1) patients who arrived directly at the thrombectomy hospital and had EVT, (2) patients who were transferred in from a nonthrombectomy hospital and had EVT, and (3) patients at a nonthrombectomy hospital who were potentially eligible for EVT, received intravenous thrombolysis, and were transferred out. The primary end point of this study for thrombectomy hospitals was door-to-puncture time. RESULTS: In direct-arriving EVT patients, 2 Target Stroke Phase III strategies were independently associated with shorter door-to-puncture time: (1) alerting the neurointerventional team based on emergency medical services prenotification (-21.9 [95% CI, -42.5 to -1.3] minutes) and (2) performance of a brain computed tomography and computed tomography angiography in all patients presenting ≤24 hours from time last known well (-6.6 [95% CI, -11.8 to -1.5] minutes). In transfer-in EVT patients, 2 Target Stroke Phase III strategies were independently associated with a shorter door-to-puncture time: (1) increased use of stroke screening tools (-3.5 [95% CI, -6.4 to -0.6] minutes per 25% increase in use of the screening tool) and (2) increased use of a camera during telestroke consultations (-5.8 [95% CI, -10.7 to -0.9] minutes per 25% increase in camera use). CONCLUSIONS: Several Target Stroke Phase III strategies are associated with more timely care, which are distinctly different for thrombectomy and nonthrombectomy hospitals and for patients arriving by emergency medical services compared with interfacility transfer.