Background: Potential performance measures to assess care of acute ischemic stroke patients transferred from initial hospitals to interventional centers for thrombectomy include: 1) door-in to door-out (DIDO) time (time from arrival to discharge at first hospital, and 2) first imaging at referral hospital to first arterial access at endovascular hospital (FIFA) (time from qualifying CT/MR imaging at initial hospital to arterial puncture at endovascular hospital).
Methods: In a prospectively maintained registry, we analyzed consecutive patients transferred from regional referral hospitals to receive thrombectomy at an academic medical center, January 2015 to March 2016.
Results: Among 35 patients, transferred from 10 referral hospitals, with documented time intervals, mean age was 52.8 (±12.2), 37% female, mean NIHSS 12.3 (±8.3). Initial hospital imaging was NCCT alone in 49%, and NCCT with CTA or MRA in 51%. Overall, 20 (57%) received IV tPA at the initial hospital, and 14 (40%) thrombectomy at the interventional hospital. Door-in door-out times were median 153 min (IQR 99-220). For candidate target DIDO performance metric intervals: <60m was achieved in 6%; <90m in 20%. Interfacility travel was by air in 34% (median distance 65, IQR 50-65, miles] and ground in 66% (median 16, IQR 12-16, miles), and travel times were similar for air v ground, 58 min (IQR 37-87) v 51 min (IQR 40-70), p=0.52. First (outside) imaging to first arterial access times were median 261 min (IQR 190-315). For candidate target FIFA performance metric intervals: <90m (SNIS “ideal”) was achieved in 3%; <120m in 6%. Additional intervals were: onset to first door, 52 min (IQR 33-156); onset to second door, 304 min (IQR 240-434); onset to puncture, 355 min (IQR 312-447); and onset to substantial reperfusion, 412 min (IQR 342-529).
Conclusion: Substantial opportunities exist to expedite thrombectomy for patients presenting to referral hospitals and transferred to interventional centers. National programs to improve achievement of DIDO and FIFA performance measure targets would benefit acute stroke patients in developing regional acute stroke care networks