Abstract P270: Simulating the Effects of Door-In-Door-Out Interventions

Abstract

Introduction: Acute stroke (AS) is a highly time sensitive treatment condition affecting approximately 800,000 people/year in the US. Most AS patients receive care at a primary stroke center (PSC), but some require more advanced treatments, and rely on a timely transfer to a comprehensive stroke center (CSC) where such treatments can be given. Stroke teams at 2 Chicago area PSCs and 4 CSCs, collectively, developed solutions (Graph) targeting both reported and perceived failures/delays/weakness in the current PSC door-in-door-out (DIDO) process for transferring patients to a CSC. The study simulates the potential impact of the solutions on DIDO. Methods: Current state (baseline) times were calculated from time stamps in the electronic health record (EHR) (e.g., door to CT), estimated by the stroke teams (e.g., hand-off time) or retrieved (e.g., DIDO, door to stroke activation) from a prospectively maintained REDCap data registry (2/2018-1/2020). Proportions (e.g., % with ischemic stroke, % transferred) were estimated from hospital data. Changes in times after implementation of a solution were obtained from peer reviewed literature, when available, or by consensus expert opinion. Simio (version 11.197.19514) was used to simulate the current and future states with implementation of the solutions, with 500 replications, to estimate changes in DIDO. Results: Implementation of all solutions would achieve a decrease in DIDO of 33 minutes (19%) from current state. The largest driver of this change was direct to CT/CTA protocol implementation (21 minutes) followed by using a handoff tool for paramedics prior to transfer (13 minutes). Conclusion: The proposed solutions can achieve nearly a 20% reduction in DIDO times. The “Direct to CT/CTA Protocol” solution is the major driver of the improvement. Data simulation is helpful by assessing the potential impact of many solutions and the relative impact of each solution to inform implementation decisions.