Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding

Abstract

Background and Purpose-National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT. Methods-We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal. Results-A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm's prediction of DIT. Conclusions-ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.

Emergency department crowding: A systematic review of causes, consequences and solutions

“…Effects on patients included delays in being assessed and receiving required care [ 29 , 30 , 76 – 79 , 81 , 83 , 84 , 87 , 90 , 91 , 93 , 94 , 97 , 98 , 103 , 104 ], increased frequency of exposure to error [ 18 ], including medication errors [ 17 ], reduced patient satisfaction [ 102 ], increased inpatient length of stay (IPLOS) [ 82 , 88 , 95 , 99 , 101 ] and poorer outcomes [ 29 , 30 , 75 , 92 , 107 ]; the latter included increased inpatient mortality [ 3 , 80 , 85 , 96 , 99 – 101 ].…”

Overcrowding in the Emergency Department and Patient Safety

“…In patients with acute cerebrovascular accidents, ED overcrowding is associated with delay to CT scanning, and boarding of these patients is associated with increased mortality, complications, and poorer recovery [26,27]. Overcrowding increases delays to antibiotics in patients with pneumonia as well as febrile neonates [28,29].…”

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy

“…A recent study at an academic medical center revealed that emergency room occupancy can adversely influence door-toimaging times in acute stroke patients. 24 With increasing awareness of acute stroke symptoms and available treatments, there is a growing volume of patients requiring triage in the ED. Directly admitting the LVO population to the neuroangiography suite partitions this group to a different portion of the hospital and allows for better utilization of ED resources.…”