Abstract Body: Background: Patients with acute ischemic stroke (AIS) due to a large vessel occlusion (LVO) who present to a Primary Stroke Center and are eligible for endovascular stroke therapy (EVT) require rapid transfer to a facility capable of EVT. Nationwide 2023 Get with the Guidelines data suggest that only 20 percent of LVO patients are transferred for EVT within 90 minutes.
Purpose: To increase the proportion of cases with Door-In-Door-Out (DIDO) times less than 76 minutes from 30% (baseline performance) to over 50% (a goal set by leadership) by designing and implementing a multifaceted quality improvement initiative. Given that reduced transfer times correlate with enhanced cognitive efficiency, we aimed to reduce our median transfer time from 88 minutes to less than 76 minutes.
Methods: This retrospective cohort study was undertaken from 01/2021 to 06/2024 at a large community medical center in Northern California, part of an integrated health system with a system-wide tele-stroke program. Annual ED visits exceed 140,000 (second busiest in the state). We chartered a multidisciplinary work group and developed a bundle of interventions to address critical processes of care delivery (Figure 1).We implemented the bundle 07/2022. We reported DIDO times quarterly.
Results: The study included 80 patients from 1/2021-6/2024: 45 were women, 35 men, median age 75. The percentage of cases that met our target time objectives improved significantly across the study period (Figure 3). Following the initiative's implementation we met target DIDO metrics 80% of the time from 9/2022-12/2022 (n=8). We continued to exceed our 50% goal through 6/2024. Benchmarked against national performance metrics, we are at the top third percentile based on The Joint Commission first quarter 2024 reports.
Conclusion: Achieving more efficient patient transfers to comprehensive stroke centers for patients with an LVO requiring an EVT is feasible. It requires an interdisciplinary and coordinated approach, dissecting the processes at each intervention point from patient arrival to emergency medical services transport. Although having 911 services for transport is beneficial, decreasing patient arrival to teleneurology contact, improved communication through standardized documentation, handoffs, and implementation of checklists and debriefs have resulted in decreased delays and improved patient outcomes.