Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago

Khorzad, Rebeca; Parnianpour, Zahra; Romo, Elida; Richards, Christopher T; Meurer, William J; Lee, Jung Hwa; Mendelson, Scott; Holl, Jane L.

doi:10.1016/j.annemergmed.2021.06.018

Cited by 6 publications

(12 citation statements)

References 33 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A possible explanation for why the hemorrhagic stroke subgroup had faster door-in-door-out times than the acute ischemic stroke-other subgroup is that guidelines recommend emergency transfer of patients with hemorrhagic stroke from community hospitals to centers with dedicated stroke expertise, 31,32 significantly streamlining the transfer algorithm for such patients. It is also likely that additional workup and treatment of acute ischemic stroke, including computed tomographic (CT) angiogram as well as IV thrombolysis, adds substantial time 7 or impedes transfer. From a systems and quality improvement standpoint, EMS prenotification, not merely EMS mode of arrival, was significantly associated with shorter door-in-door-out times in the overall cohort and in the subgroup with acute ischemic stroke eligible for endovascular therapy.…”

Section: Discussionmentioning

confidence: 99%

“…Because stroke treatments are exquisitely time-sensitive, the Joint Commission and Brain Attack Coalition recommend that the time from “arrival to discharge” for transfer from an emergency department (ED)–door-in-door-out time be less than 120 minutes for stroke transfers. However, for patients with acute ischemic stroke who are eligible for endovascular therapy, door-in-door-out times are often prolonged, leading to worse clinical outcomes …”

Section: Introductionmentioning

confidence: 99%

“…Data are limited on door-in-door-out times in clinical practice with incomplete knowledge about factors associated with interhospital transfer . Understanding existing disparities, as well as potentially modifiable factors associated with door-in-door-out times, could help hospitals redesign interhospital transfer processes to reduce delays . Additionally, establishing a national baseline for door-in-door-out times could help inform targets for future interhospital transfer interventions in acute stroke.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Stamm

Royan

Giurcanu

et al. 2023

JAMA

Self Cite

View full text Add to dashboard Cite

ImportanceTreatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED).ObjectiveTo evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.Design, Setting, and ParticipantsUS registry–based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.ExposurePatient- and hospital-level characteristics.Main Outcomes and MeasuresThe primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, &gt;120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.ResultsAmong 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (−20.1 minutes; 95% CI, −22.1 to −18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (−66.7 minutes; 95% CI, −68.7 to −64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (−16.8 minutes; 95% CI, −21.0 to −12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.Conclusions and RelevanceIn this US registry–based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Stamm

Royan

Giurcanu

et al. 2023

JAMA

Self Cite

View full text Add to dashboard Cite

show abstract

“… 21 For patients requiring transfer to higher levels of stroke care for acute therapy, time is a premium, and current processes for reducing door‐in‐door‐out times of interfacility transfers are typically prolonged. 22 , 23 These delays can be minimized through collaborative processes within networks with established transfer protocols. 24 Future innovations in times of high inpatient census at CSCs may even look to models where patients receive advanced hyperacute therapies, such as EVT, but complete the remainder of their inpatient hospitalization at a PSC in the patient's local community.…”

mentioning

confidence: 99%

“…Leveraging hospital networks of care, or “hub‐and‐spoke” collaborative care models between institutions, can lead to efficient regionalization of resources, facilitating patients being treated at the level of stroke center that is most appropriate for their type of stroke 21 . For patients requiring transfer to higher levels of stroke care for acute therapy, time is a premium, and current processes for reducing door‐in‐door‐out times of interfacility transfers are typically prolonged 22,23 . These delays can be minimized through collaborative processes within networks with established transfer protocols 24 .…”

mentioning

confidence: 99%

Strengthening the stroke chain of survival in community emergency departments

Richards

2022

JACEP Open

Self Cite

View full text Add to dashboard Cite

Strengthening the stroke chain of survival in community emergency departmentsIn this issue of JACEP Open, Zachrison et al 1 of the American College of Emergency Physicians Emergency Quality Network, an educational and quality improvement collaborative of emergency departments (EDs) across the United States, describe the diagnostic and treatment capabilities of community EDs for acute stroke. The study population in Zachrison et al primarily consisted of community EDs without a stroke center certification, and care processes varied widely at the study sites. Most, but not all, had reliable access to computed tomography (CT) imaging and real-time stroke specialist consultation, but only two-thirds of EDs surveyed had written protocols for the care of patients with acute stroke. Most were able to administer thrombolytics, and patients requiring endovascular therapy (EVT) were typically transferred, commonly to the first accepting comprehensive stroke center (CSC) or thrombectomy-capable stroke center (TSC) rather than through an established network of care. Although derived from a selfselected convenience sample, their data are an important contribution to a limited existing evidence base about community hospital ED stroke capabilities.Community hospital EDs are essential to providing high-quality acute stroke care for much of the US population, and their role in acute stroke care cannot be understated. 2,3 Particularly, when a community acute stroke ready hospital (ASRH) or primary stroke center (PSC) is the only hospital capable of facilitating a stroke diagnosis and subsequent thrombolysis in a given geographic area, ensuring efficient high-quality stroke care is of utmost importance. However, Zachrison et al identified important gaps in acute stroke care processes that exist in community hospital EDs. In addition, because survey participants were self-selected and likely highly motivated and engaged community hospital EDs, the reported data may actually represent a high-water mark of how community hospitals approach acute stroke care. Therefore, what does this study reveal about the opportunities to improve acute stroke care in community EDs?Particularly in geographic areas with limited access to stroke centers, the community ED can be conceptualized as the anchor of the larger community's stroke chain of survival. The stroke chain of survival conceptual model has helped frame systems of care improvements in EDs and recently in the prehospital setting to facilitate timely reperfusion. 4 To easily conceptualize the critical action steps that occur

show abstract

Transferring Patients From a Primary Stroke Center to Higher Levels of Care: A Qualitative Study of Stroke Coordinators’ Experiences

Patterson

Dusenbury

Stanfill

et al. 2023

SVIN

View full text Add to dashboard Cite

BACKGROUND Transfer times from primary stroke centers and acute stroke–ready hospitals to higher levels of care are often excessive, prompting some to suggest ambulance bypass regulations. Since barriers to rapid transfer have never been fully explored, we sought to understand stroke coordinators’ experiences with transfer of patients with hyperacute stroke from lower to higher levels of stroke centers. METHODS We conducted a national focus group study with primary stroke center stroke coordinators who had recent experience overseeing transfer of a patient with hyperacute stroke to a higher‐level stroke center. Interviews were conducted using prescripted open‐ended questions; information was recorded and data were transcribed for theme identification. RESULTS A total of 23 stroke coordinators participated representing the Northeast, Mid‐Atlantic, Southeast, Midwest, and Western United States. Findings were grouped into 3 main categories: Internal Primary Stroke Center Factors, Transport Factors, and External Comprehensive Stroke Center Factors. Within the primary stroke center group, themes slowing transfer were exclusively physician based, whereas themes emerging from the transport category were associated with poor transport company processes. Within the comprehensive stroke center category, themes were all associated with complex hospital processes and communication. CONCLUSION Important contributors to efficient transfer of patients with hyperacute stroke are beyond the control of stroke coordinators, requiring cross‐system collaboration and improved administrative management to resolve. Quantification of these factors is warranted to support transfer system redesign for rapid access to care for patients with stroke.

show abstract

Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago

Cited by 6 publications

References 33 publications

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Strengthening the stroke chain of survival in community emergency departments

Transferring Patients From a Primary Stroke Center to Higher Levels of Care: A Qualitative Study of Stroke Coordinators’ Experiences

Contact Info

Product

Resources

About