Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

doi:10.1016/j.jstrokecerebrovasdis.2016.09.008

Journal of Stroke and Cerebrovascular Diseases

Volume 26, Issue 1, January 2017, Pages 192-195

https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.09.008 Get rights and content

Background and Objective

The transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Delays pose an obstacle to time-sensitive stroke treatments and, therefore, increase the likelihood of exclusion from endovascular stroke therapy. This study aims to evaluate the impact of the Stroke Rescue Program, with its goal of minimizing interfacility transfer delays and increasing the number of transport times completed within 60 minutes.

Methods

The Stroke Rescue Program was initiated to facilitate the rapid transfer of AIS patients from regional primary stroke centers (PSCs) to the network's CSC. The transfer process was divided into 3 time elements: transport 1 time (initial phone call from the PSC until emergency medical service [EMS] arrival at the PSC), emergency department (ED) time (EMS PSC arrival to PSC departure), and transport 2 time (PSC departure to CSC arrival). The total transport time target was set at less than 60 minutes. Protocols and procedures were implemented with a focus on decreasing the ED time.

Results

Comparing baseline (preimplementation) quarter (n = 21) to postproject quarter (1 year later, n = 31), the percent transported within 60 minutes increased from 62% to 81%. A statistically significant improvement was seen for both median ED time (23 minutes versus 14 minutes; U = 171, P < .01) and median total transport time (56 minutes versus 44 minutes; U = 199, P < .05).

Conclusion

Interfacility transfer protocols minimizing the time paramedics spend in a PSC ED can significantly reduce total transfer time to a comprehensive stroke center.

Introduction

Comprehensive stroke centers (CSCs) provide acute ischemic stroke (AIS) patients with advanced diagnostic and treatment procedures that are not available at primary stroke centers (PSCs). These procedures include a higher level of medical and surgical care and endovascular stroke therapy (EST).¹ Indications for an immediate transfer to a CSC for stroke intervention include the following: (1) AIS patients with a baseline prestroke modified Rankin Scale score less than 2; (2) significant neurological deficits (National Institutes of Health Stroke Scale score of at least 6) that are thought to be attributable to a large intracranial arterial occlusion; (3) either not an intravenous (IV) tissue plasminogen activator (tPA) candidate or have not rapidly improved after IV tPA; and (4) still within 6 hours fromstroke symptom onset.² Patients with suspected or confirmed basilar artery occlusion, without large brainstem infarction, should also be considered for rapid transfer to a CSC even if last known well is beyond 6 hours.

Delays in transfer are a major contributing factor to the exclusion of otherwise eligible EST candidates.³ Studies show that the most favorable clinical outcomes following catheter-based stroke therapy are associated with shorter onset-to-recanalization times.4, 5, 6 Since multiple randomized controlled trials confirmed the benefit of EST compared to medical therapy alone, a significant focus has been on reducing door-to-groin puncture times. Rapid intervention was an inclusion criterion in the ESCAPE and SWIFT PRIME trials, and was defined as a computed tomography (CT)-to-groin puncture time of less than 60 and 70 minutes, respectively.7, 8 To optimize the benefit from catheter-based interventions, the transfer of AIS patients to a CSC must be rapid.

Here we describe the implementation of the “Stroke Rescue Program” as a performance improvement initiative created to minimize delays in the transportation of AIS patients to a CSC. Stroke rescue is defined as the rapid transfer of an AIS patient from a PSC to a CSC for the purpose of potential EST. We hypothesized that by dividing the transfer process into measurable time elements, and developing a protocol to reduce the time interval that the emergency medical service (EMS) provider spends in the PSC, transport times would improve.

Section snippets

Methods

The Stroke Rescue Program was created within a large metropolitan health system in New York to facilitate the rapid transfer of AIS patients from regional PSCs to the network's CSC. Sixteen PSC hospitals are included in the stroke referral network and a single EMS system provides transports. Patients who underwent stroke rescue to the CSC in the baseline quarter (before project implementation) were compared to patients transported in the quarter 1 year postproject initiation. There were no

Results

During the 18-month study period (3-month baseline quarter, 12-month implementation period, and 3-month postimplementation quarter), 128 patients underwent stroke rescue. The median PSC to CSC distance was 14.4 mi (range 3.0-32.1 mi). Ischemic stroke was confirmed in 116 (91%) patients, and 65 (51%) patients were “drip-and-ship” transports (IV tPA infusion during transport 2).

Comparing the baseline quarter (n = 21) to the postimplementation quarter (n = 31), a statistically significant

Discussion

Dividing the AIS patient transfer process into 3 distinct time elements with focused efforts on the ED time resulted in a statistically significant decrease in the total transfer time. This finding was primarily due to the significant reduction in the median time spent by the EMS in the referring ED. The observed decrease in ED time may have been secondary to improved EMS training, and reduction in the time spent retrieving clinical information and managing noncritical medications.

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Cited by (21)

Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago
2021, Annals of Emergency Medicine
Citation Excerpt :
Second, early initiation of a telestroke consultation and seamless and more standardized communication with the receiving comprehensive stroke center (eg, pager, hotline) could lead to earlier decision to transfer, earlier ambulance request and arrival, and improved comprehensive stroke center readiness. Third, a “grab and go” approach between primary stroke center clinicians and the transfer ambulance team of patient information documents, perhaps with an electronic hand-off tool, could potentially minimize transfer ambulance time at the primary stroke center.33 A small study in Rhode Island recently demonstrated that door-in-door-out times at primary stroke centers could be lowered by 40 minutes (104 versus 64 minutes) after implementation of a structured protocol that included large vessel occlusion screening, bundled CT/CT angiography for high-suspicion large vessel occlusion patients, ambulance dispatch prior to CT angiography confirmation of large vessel occlusion, and remote imaging review by the comprehensive stroke center.31
Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers.
We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models.
Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]).
Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.
Delays to Initiate Interfacility Transfer for Patients Transported by a Critical Care Transport Organization
2021, Air Medical Journal
Citation Excerpt :
Despite this, there is a scarcity of literature on the time interval before the decision to transfer. This interval has been commented on in the setting of acute myocardial infarction or ischemic stroke but in the context of land transfer, short transfer distances, and the aforementioned pathology that have clearly elucidated protocols for transfer.15,16 These studies are in contrast to our study in which the disease pathology is heterogeneous with longer transfer distances, making the time intervals difficult to compare.
The time to initiate an interfacility transfer is an important and understudied cause of delay to definitive management. This study identifies characteristics associated with delays to initiate interfacility transfer of critically ill patients.
We performed a retrospective cohort study of adult patients who underwent interfacility transfer by a provincial critical care transport organization over a 3-year period. The primary outcome was the time to initiate interfacility transfer. Quantile regression explored the impact of patient, environmental, and institutional characteristics.
In total 11,231 patients were included. Cardiac (+1.45 hours), gastrointestinal (+3.28 hours), respiratory (+4.90 hours), or sepsis (+3.03 hours) reasons for transfer; vasopressor requirements (+2.31 hours); and evening time (+3.67 hours) were associated with longer times to initiate interfacility transfer at the 90th quantile. Neurologic (−1.45 hours), obstetric (−1.56 hours), or trauma (−3.14 hours) reasons for transfer; Glasgow Coma Scale < 8 (−0.98 hours); blood transfusion requirement (−1.47 hours); and smaller sending sites were associated with shorter times to initiate transfer.
The time to initiate interfacility transfer represents a modifiable delay in a patient's transport journey. This study highlights important patient, environmental, and institutional characteristics associated with increased time to initiate transfer. Collaboration between transport organizations and hospitals in developing regional bypass criteria and prearranged transfer agreements may help facilitate timely patient transfer.
Prehospital stroke management in the thrombectomy era
2020, The Lancet Neurology
Citation Excerpt :
Additionally, this protocol increased rates of patients with favourable outcomes (modified Rankin Scale [mRS] score ≤2) from 25% (12 of 48 patients) without to 50% (11 of 22 patients; p=0·04) with absolving the complete protocol.61 Similarly, training paramedics about time awareness significantly reduced median transport times from 56 min to 44 min.62 Several referral strategies for patients with large vessel occlusion exist in case the nearest hospital offering stroke treatment does not offer endovascular treatment.
Acute stroke management has been revolutionised by evidence of the effectiveness of thrombectomy. Because time is brain in stroke care, the speed with which a patient with large vessel occlusion is transferred to a thrombectomy-capable centre determines outcome. Therefore, each link in the stroke rescue chain, starting with symptom onset and ending with recanalisation, should be streamlined. However, in contrast to inhospital delays, prehospital delays are unchanged despite substantial efforts in quality improvement. Furthermore, thrombectomy is offered by only a few, usually distant, specialised centres and not by the many other, usually nearer, hospitals. To take maximum advantage of the first so-called golden hours after stroke, and because of the difficulty of on-scene triage decision making with respect to the target hospital offering the required level of care, the focus of stroke research has shifted to the prehospital setting. Current research focuses on the effects of public education, implementation of protocols for emergency medical services for streamlining clinical investigations and accurate triage, use of preclinical scales for stroke recognition, and deployment of novel technical solutions such as smartphone applications, telemedicine, and mobile stroke units.
Time Intervals for Direct Versus Transfer Cases of Thrombectomy for Stroke in a Primarily Rural System of Care
2020, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
The southeastern United States has a higher rate of stroke mortality than the rest of the country, but the data on rural stroke care in this region is sparse. Thus far, most studies evaluating delays in stroke care have been conducted in mainly urban areas.7-10 In order to improve stroke care in rural regions, it is important to identify the potential delays in rapid response by emergency medical services (EMS) and transport of patients to appropriate medical centers with stroke treatment capabilities.
Background: Early treatment is the key to a successful recovery for ischemic stroke patients. From time of onset, a patient's chances of permanent disability only increase until they can receive reperfusion intervention. Objective: We sought to identify potential delays that occur during evaluation and treatment of patients in a rural regional health system. Methods: We conducted a single-center retrospective review of all patients that arrived at our comprehensive stroke center (CSC) between July 2011 and March 2017, and received thrombectomy, with or without prior treatment with intravenous recombinant tissue plasminogen activator. Results: One hundred and fifty-four patients met our criteria for inclusion. Patients were divided into 2 groups: Direct (patients brought to our CSC from scene) and Transfer (patients taken to an outside hospital then transferred to our CSC). The median time to CSC for Direct patients was 82 (range: 15-863) minutes after onset of symptoms, compared to 237 (range: 98-1215) minutes for the Transfer group. The median time for Transfer patients to reach an outside hospital was 74 (range: 5-840) minutes, with an additional average time of 90 minutes in the outside hospital prior to transferred to our CSC. Conclusions: Based on our findings, patients brought directly to our CSC saved a significant amount of time, which may improve functional outcomes. Both groups (Direct and Transfer) spent a similar amount of time between last known normal and emergency medical services arrival, highlighting the need for increased awareness among the public to activate the stroke system of care.
Emergency medical services for acute ischemic stroke: Hub-and-spoke model versus exclusive care in comprehensive centers
2019, Journal of Clinical Neuroscience
Citation Excerpt :
The key to efficiency in such models is rapid inter-facility transfer [20]. Although real world data from Australia demonstrated long transfer times between hospitals, similar analyses in New York have highlighted effective solutions to time barriers [18]. However, these prior studies have significant methodologic drawbacks.
The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers.
We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) with inpatient case-fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and simulate a randomized trial.
During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, −0.1% to 9.0%), rate discharge to a facility (Adjusted difference, −2.3%; 95% CI, −5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, −2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy.
Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting.
Door-in-door-out times for patients with large vessel occlusion ischaemic stroke being transferred for endovascular thrombectomy: A Victorian state-wide study
2023, BMJ Neurology Open

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Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center

Background and Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Recommendations for comprehensive stroke centers: a consensus statement from the brain attack coalition

Stroke

2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professions from the American Heart Association/American Stroke Association

Stroke

Transfer delay is a major factor limiting the use of intra-arterial treatment in acute ischemic stroke

Stroke

Catheter-based interventions for acute ischemic stroke

Eur Heart J

Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial

Radiology

Analysis of workflow and time to treatment on thrombectomy outcome in the ESCAPE randomized controlled trial

Circulation

Randomized assessment of rapid endovascular treatment of ischemic stroke

N Engl J Med

Stent retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke

N Engl J Med