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

Abstract

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, >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.

Challenges to Door-In-Door-Out Time Thresholds for Patients With Stroke—Reply

“…In Reply We acknowledge the comments from Dr Hsu and colleagues and thank them for their interest in our study. However, we believe the findings from our study are both important and meaningful despite the concerns regarding prespecified target benchmarks for door-in-door-out time and our approach to cohort assembly.…”

“…Although it is accurate that the door-in-door-out recommendation of less than 120 minutes proposed by the Brain Attack Coalition and the Joint Commission is not currently reflected in formal guidelines, this benchmark nevertheless represents an important quality metric in the management of acute stroke. The aim of our study was not to determine the appropriate cut point for door-in-door-out times, although it is clear from our analysis that the median door-in-door-out time of 174 minutes from Get With the Guidelines (GWTG)–participating hospitals far exceeds this proposed target . Furthermore, our primary analysis and outcome included door-in-door-out as a continuous variable, in which we identified several important factors independently associated with door-in-door-out time, irrespective of a particular dichotomized cut point.…”

Challenges to Door-In-Door-Out Time Thresholds for Patients With Stroke

“…To the Editor We have several concerns about the recent article that reported that median door-in-door-out time was longer than current recommendations for acute stroke transfer in the US.…”

“…The 2-hour rule lacks universal consensus and has not been established as a guideline. Therefore, this study may require sensitivity analyses using various cutoffs to confirm the presence of factors contributing to extended door-in-door-out times. For example, when using a 120-minute threshold as a dichotomous end point, the authors observed an association between conducting magnetic resonance imaging (MRI) and extended door-in-door-out time .…”

“…Therefore, this study may require sensitivity analyses using various cutoffs to confirm the presence of factors contributing to extended door-in-door-out times. For example, when using a 120-minute threshold as a dichotomous end point, the authors observed an association between conducting magnetic resonance imaging (MRI) and extended door-in-door-out time . In clinical practice, however, a noncontrast computed tomographic (CT) scan may not be sufficient for diagnosis because it can appear normal during the very early stages following an acute stroke.…”