Hell, I got tPA in 90 minutes from onset of stroke, still not fast enough for full recovery and then my doctors DID NOTHING to solving these 5 causes of the neuronal cascade of death in the first week and let hundreds of million to billions of neurons die!)
Longer door-in-door-out times linked to worse stroke outcomes
Key takeaways:
- The cohort included 22,410 patients with acute ischemic stroke.
- Hospitals that transferred patients had a median DIDO time of 121 minutes.
- 75.8% of patients received endovascular therapy after transfer.
Patients with ischemic stroke whose door-in-door-out times exceeded 90 minutes had lower odds for endovascular therapy and greater odds for complications and worse functional outcomes, according to data published in The Lancet Neurology.
System-level strategies that optimize patient evaluation and accelerate interhospital transfer may improve outcomes, Shyam Prabhakaran, MD, MS, chair of neurology, University of Chicago Biological Sciences Division, and colleagues wrote
“This study is the product of 10+ years of research interest in stroke systems of care led by this group and others,” Prabhakaran told Healio. “We previously noted the effect of transfer delay on endovascular therapy (EVT) receipt in a single health system in Chicago.”
That work led to a study among five Chicago hospitals that evaluated factors connected with door-in-door-out (DIDO) time.
“However, the link to functional outcomes have been sparse,” Prabhakaran said. “So, this group worked to analyze the GWTG-Stroke database to assess the relationship of DIDO time and disability in stroke patients transferred for EVT.”
The retrospective cohort study used data from 22,410 adults (median age, 70 years; 50.1% women; 73.9% white) with acute ischemic stroke transferred from one acute care hospital to another for endovascular therapy.
Upon arriving at the second hospital, these patients had a median National Institutes of Health Stroke Scale (NIHSS) score of 14. The median DIDO time from the first hospitals was 121 minutes (interquartile range = 89-175).
Patients who are eligible for endovascular therapy should have a DIDO time of 90 minutes or less, based on guidelines from the American Heart Association and American Stroke Association.
DIDO times were 90 minutes or less for 26.3% of the patients (n = 5,894), 91 to 180 minutes for 50.4% (n = 11,303), 181 to 270 minutes for 13.4% (n = 3,011), and more than 270 minutes for 9.8% (n = 2,202).
Additionally, 37.7% (n = 8,448) of the full cohort received intravenous thrombolysis at the first hospital, 0.4% (n = 92) received it at the second hospital, and 75.8% (n = 16,976) received endovascular therapy at the second hospital.
Across these timeframes, patients exhibited similar demographics, risk factors and admission characteristics. However, the researchers noted that patients with faster DIDO times had higher NIHSS scores. They also were less likely to present during off hours, and their last known well-to-ED arrival times were shorter.
“This is the first time we have been able to quantify the harm from delays in interhospital transfer,” study author Regina Royan, MD, MPH, assistant professor in the department of emergency medicine, University of Michigan, told Healio.
“Patients who had longer DIDO times were less likely to get endovascular therapy and more likely to have worse disability after their stroke,” Royan said.
Adjusted odds ratios for a 1-point increase in discharge modified Rankin scale (mRS) score included 1.29 (95% CI, 1.2-1.37) for 91 to 180 minutes, 1.49 (95% CI, 1.36-1.64) for 181 to 270 minutes and 1.7 (95% CI, 1.53-1.89) for more than 270 minutes.
Similarly, adjusted odds ratios for independent ambulation at discharge included 0.85 (95% CI, 0.78-0.93) for 91 to 180 minutes, 0.74 (95% CI, 0.66-0.83) for 181 to 270 minutes and 0.67 (95% CI, 0.58-0.77) for more than 270 minutes.
Adjusted odds ratios for ultimately receiving endovascular therapy included 0.71 (95% CI, 0.65-0.79) for 91 to 180 minutes, 0.5 (95% CI, 0.44-0.57) for 181 to 270 minutes and 0.35 (95% CI, 0.3-0.4) for more than 270 minutes.
Finally, adjusted odds ratios for a lack of complications after reperfusion therapy included 0.85 (95% CI, 0.77-0.95) for 91 to 180 minutes, 0.84 (95% CI, 0.72-0.98) for 181 to 270 minutes and 0.74 (95% CI, 0.61-0.88) for more than 270 minutes.
Based on these findings, the researchers called upon regional stroke systems of care and hub-and-spoke networks to improve efficiency and minimize DIDO times at hospitals that transfer patients with ischemic stroke elsewhere.
This study did not specifically examine obstacles to improving DIDO times, but previous studies have suggested that several factors are important, study author Brian Stamm, MD, MSc, clinical assistant professor, department of neurology, University of Michigan, told Healio.
These factors include “rapid identification of stroke symptoms in the initial emergency department; workflows that bundle all necessary brain imaging to avoid delays in returning for imaging later; and optimizing ambulance availability to transport the patient between the two hospitals,” Stamm said.
“Dr. Prabhakaran’s NIH-funded clinical trial, called Hospital Implementation of a Stroke Protocol for Emergency Evaluation and Disposition (HI-SPEED), seeks to further understand the major barriers and test interventions to improve DIDO times,” he continued.
The researchers also suggested that these hospitals could eliminate the need to transfer these patients via prehospital protocols that identify who is most likely to receive endovascular therapy and transport them to the nearest facility that can perform thrombectomies.
“Certainly, we all would love it if every patient was transported to the appropriate destination every time,” Prabhakaran said.
However, several factors make this unrealistic. “Thrombectomy capable centers are resource intensive and cost-prohibitive for many smaller facilities, especially in rural areas,” he said.
Also, the use of clinical assessments alone in prehospital assessment of stroke yields errors such as false positives and negatives.
“Approximately one-third of stroke patients arrive by walk-in, not EMS, to the closest hospital, which may not be thrombectomy capable,” Prabhakaran said.
Finally, up to a quarter of patients with stroke get worse in the hospital after they arrive, or they develop stroke once they are in the emergency room or admitted to the hospital.
“For these reasons, it is highly unlikely that we will be able to reduce inter-hospitals transfers to zero,” Prabhakaran said.
“Yet, there are opportunities to reduce it further by educating communities to recognize stroke symptoms and call 911, having prehospital protocols and destination routing policies based on severity assessment, and development of novel blood-based tests to diagnose stroke more accurately in the field,” he said.
(You're wrongly pushing responsibility onto patients! IT IS YOUR RESPOSIBILITY FOR 100% RECOVERY REGARDLESS OF TIME PRESENTED! Leaders solve the problems in front of them, you're obviously NOT A LEADER, when you use excuses like this!)
The researchers called for additional research into direct associations between DIDO times and functional outcomes in the long term as well as into whether interventions designed to reduce DIDO times would improve these outcomes.
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