Factors Affecting Door-in-door-out Times Among Patients Transferred From Non-Endovascular Stroke Centers For Endovascular Therapy

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Introduction: In the management of large vessel occlusion (LVO) stroke, patients are frequently evaluated first at a non-endovascular stroke center and later require transfer to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals. The goal of this study is to identify factors affecting DIDO times in patients who are transferred EVT. Methods: The OPUS-REACH consortium is a group of nine health systems in the Northeast United States. The OPUS-REACH registry is comprised of all LVO patients who underwent EVT at these nine health systems from 2015-2020. The database was queried for all patients who were transferred from a non-ESC to for EVT. All patients who were transferred from a non-ESC and received EVT for a LVO stroke were included in this study. Patients were excluded from the study if their DIDO time were not available or their stroke occurred after admission to the hospital. Results: 2139 patients were screened and 511 were included in the final analysis. The mean DIDO times for all patients was 137.8 minutes. When looking at the entire population of patients, we found no single variable associated with increased DIDO times. This included initial National Institutes of Health Stroke Scale, demographics, arrival via personal vehicle, administration of intravenous thrombolysis (IVT), performance of vascular imaging, or the level of transferring hospital. On multivariate analysis, the performance of vascular imaging and being a non-certified stroke center were associated with longer DIDO times. We also performed a subgroup analysis of patients with DIDO times less than 60, 90, and 120 minutes. In the subgroup of patients with DIDO times <60 minutes, <90 and <120 minutes, only performance of vascular imaging was associated with a longer DIDO times. Conclusions: Vascular imaging in the subgroups of patients was the only factors that consistently prolonged DIDO times. Non-ESCs should integrate vascular imaging into their work flow to reduce DIDO times. Further work examining the transfer process such ground or air and distance to ESC could help further illustrate opportunities to improve DIDO times.

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