Background: The emergency department (ED) plays a pivotal role in the care of patients with acute ischemic stroke, particularly when transferred to another facility for definitive treatment. Our objective was to identify potential factors that influence the timeliness of interfacility transfer for ED patients with an acute ischemic stroke.
Methods: We conducted semi-structured interviews with 39 staff at three EDs that routinely transfer acute ischemic stroke patients. A structured interview guide was developed and piloted prior to use. It included the following topics: staff roles, admission and transfer processes, communication, and facilitators/barriers to timely care. Interviews were recorded, transcribed, and analyzed using an iterative inductive-deductive approach to build a list of subthemes, and supporting quotes using prespecified themes: 1) resources, 2) processes and protocols, and 3) organizational behavior (e.g., communication and coordination).
Results: Timely care of acute stroke patients requires a highly coordinated effort within the ED and between facilities (Table). We found that existing ED-based protocols were viewed as facilitating timely tPA treatment but might ignore more severe, potential thrombectomy candidates. Lack of protocolized guidance on imaging (i.e., angiographic) selection and eligibility for treatment options creates uncertainty for emergency physicians forcing reliance on neurology consultation for decision-making. Further, enhanced coordination between organizations such as autoaccept policies and teleneurology services were seen as facilitators to timeliness of care and transfers.
Conclusions: Lack of ED-based protocols to guide angiographic imaging in suspected stroke patients may hinder identification and treatment of acute large vessel ischemic strokes and may be a source of intervention. Further, enhancing organizational coordination is a novel direction to enhance timeliness of transfers.