Stroke Patient Transfer Times Longer Than Recommended

Pauline Anderson

August 18, 2023

The median interhospital transfer time for stroke patients needing targeted therapy is 174 minutes, which is longer than the recommended 120 minutes, results of a new US registry-based study show.

The study also uncovered age, racial, and gender disparities in transfer times.

Dr Shyam Prabhakaran

The study exposed transfer delays in US stroke systems that "dramatically" affect patients, study author Shyam Prabhakaran, MD, professor and chair of neurology, University of Chicago, told Medscape Medical News. "There are effective treatments for stroke, and many, many patients are getting them too late or not at all because of delays."

To reduce such lags, "we need to really be proactive like we have been in other processes," for example, improving "door to needle" time, he added, referring to time to administer thrombolytic therapy.

The findings were published online August 15 in JAMA.

Stroke patients who present at hospital emergency departments (EDs) often need to be transferred to another institution to access time-dependent therapies, including intravenous (IV) thrombolysis and endovascular therapy, as well as neurosurgical or neurocritical care services. The recommended time from initial check-in at the ED to such a transfer ― the door-in, door-out time ― is less than 120 minutes.

Understanding disparities and modifiable factors associated with door-in, door-out times could help reduce delays in interhospital transfer times, the researchers write.

The study included US hospitals participating in the Get With the Guidelines–Stroke registry, a national database for voluntary quality improvement maintained by the American Heart Association/American Stroke Association. About a third of the move than 6000 hospitals in the US are part of this registry.

The analysis included 108,913 patients (mean age, 66.7 years; 71.7% White; 50.6% men) who had a stroke between January 2019 and December 2021 and were transferred from 1925 hospitals to another acute care hospital. Most patients had initially presented to teaching hospitals (62.9%), in urban areas (68.5%), and during the COVID-19 pandemic (59.6%).

Of the total patients who were transferred, 67,235 had acute ischemic stroke, and 41,678 had hemorrhagic stroke. The most common reasons for transfer were advanced stroke care (70.7%), evaluation for endovascular therapy (20.3%), and IV thrombolysis management (10.8%).

Priming the ED

Emergency Medical Services (EMS) prenotification, by which ambulance staff alert the receiving hospital that a patient suspected of having had a stroke is en route, was used in 43.9% of patients overall. Although not performed uniformly, this protocol is recommended, because it "primes the emergency room to get their teams ready and move their patient more efficiently," said Prabhakaran.

The median door-in, door-out time, the primary outcome, was 174 minutes overall: 178 minutes for patients with hemorrhagic stroke; 201 minutes for those with ischemic stroke (and other); and 132 minutes for those with ischemic stroke who were eligible for endovascular therapy.

Prabhakaran noted that patients eligible for endovascular therapy are "very identifiable" through imaging, which can pick up large-vessel occlusions. This helps explain their relatively short transfer time.

On the other hand, ischemic stroke patients who are not candidates for endovascular therapy may need additional workup and treatment, including CT angiogram and IV thrombolysis, so the decision-making is "not as straightforward," and this may affect transfer time, he said.

Patients with hemorrhagic stroke have relatively fast door-in, door-out times, possibly because imaging shows immediately whether the patient has a hemorrhage, and guidelines recommend emergency transfer of such patients to centers with dedicated stroke expertise, which significantly streamlines the transfer algorithm for such patients.

Lagging Behind Target

For only 27.3% of patients was the door-in, door-out time within 120 minutes. "This shows the degree to which current hospital performance lags behind the recommended time and gives us a motivation and rationale to pursue a large-scale initiative to get hospitals to try to reduce these times," commented Prabhakaran.

Characteristics that were significantly associated with longer door-in, door-out times included the followng: age 80 years or older vs those aged 18–59 years (14.90 minutes longer; 95% CI, 12.32 – 17.47 minutes), female vs male (5.21 minutes; 95% CI, 3.55 – 6.86 minutes), Black non-Hispanic vs White non-Hispanic (8.21 minutes; 95% CI, 5.67 – 10.75 minutes), and Hispanic vs White non-Hispanic (5.37 minutes; 95% CI, 1.77 – 8.97 minutes).

Urban hospital location was also significantly associated with prolonged door-in, door-out times. This might be because city hospitals have more resources to use for patients, which could delay the transfer, said Prabhakaran.

The study took place during part of the COVID-19 pandemic, when many hospitals were unable to accommodate transfers. This likely contributed to some delays picked up by the study, said Prabhakaran.

Aside from being White and being eligible for endovascular therapy, having a National Institutes of Health Stroke Scale (NIHSS) score greater than 12 was also linked to having a door-in, door-out time of 120 minutes or less, as was having EMS prenotification.

Aiming to Tackle Barriers

The research team will be investigating ways to reduce transfer delays, aiming to "protocolize this in a standardized way that tackles many of the barriers we think affect this door-in-door-out process," said Prabhakaran.

This should start with EMS prenotification and should include standardized screening for stroke upon ED arrival, protocols for moving patients to imaging, and rapid communication with the receiving center, he said.

While the current door-in, door-out target is a maximum of 120 minutes, that could be reduced to 90 minutes and perhaps even 60 minutes, he added. "The door to needle time used to be 60 minutes as a goal; now it's 30 minutes."

Missing or incomplete data were a limitation of the study; for example, the NIHSS score wasn't available for 21.4% of the study sample, and for nearly half of patients, variables related to vascular imaging were missing. Other limitations included the fact that hospitals participating in the Get With the Guidelines–Stroke registry have an interest in improving stroke care; some potential determinants of door-in, door-out time, such as distance to a comprehensive stroke center and bed availability, were not considered in the analysis; and an association between door-in, door-out times and clinical outcomes was not evaluated.

Extremely Important Data

Commenting on the study, Michael Mullen, MD, associate professor of neurology, Lewis Katz School of Medicine, Temple University, and director of the stroke program at Temple University Hospital, said the data "are extremely important," as they highlight important disparities in stroke care.

"Get With the Guidelines has a track record of success as a tool to quantify, trend, and improve stroke care," said Mullen. "Hopefully these data can be leveraged for future quality improvement programs to reduce door-in, door-out time overall and to reduce or eliminate the observed disparities."

Mullen noted that the study doesn't provide the level of detail needed to understand why stroke transfer delays occur. The reasons are likely multifactorial and may vary by region and hospital.

Because race and gender disparities exist in other areas of stroke care ― and medical care in general ― "it's certainly possible that implicit and explicit bias and structural racism are contributing factors," he added.

And although the authors attempted to account for factors such as geographic region and hospital characteristics, "systematic differences in where people live and the hospitals and healthcare systems that care for them may be driving some of these disparities," said Mullen.

He agreed it's difficult to know how much the COVID-19 pandemic influenced the results, given the strain placed on the entire healthcare system during that time.

Prabhakaran has received grants from National Institute of Neurological Disorders and Stroke and the Agency for Healthcare Research and Quality and personal fees from UpToDate. Mullen is an American Heart Association volunteer.

JAMA. Published online August 15, 2023. Full text

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