Abstract 135: Door in Door Out Time at Primary Stroke Centers Predicts Outcome for Patients With Large Vessel Occlusion Stroke

Abstract

Introduction: We have previously shown that a transfer protocol for patients with suspected large vessel occlusion (LVO) stroke which includes early vessel imaging at the Primary Stroke Center (PSC) is associated with decreased onset to recanalization times driven entirely by improved initial hospital processes at the PSC and reflected in the PSC Door-in Door-out (DIDO) time. In this study, we examined the association between DIDO and outcomes. Methods: We collected prospective data on 195 patients transferred to our Comprehensive Stroke Center (CSC) with PSC-confirmed LVO between July 1, 2015 and June 30, 2017. The patients were accepted from 2 states and 16 different PSCs (only 2 of which were part of our hospital system) and the furthest PSC being 56 miles away. We included all patients with LVO stroke (ICA, M1, Basilar) with an NIHSS of 6 or higher. We examined PSC workflow factors associated with shorter DIDO times. Outcomes were examined by DIDO using generalized mix modeling assuming a binomial distribution with SAS 9.4. Results: The median [IQR] age and NIHSS of the 195 ELVO transfers was 75 [62-84] and 17 [12-22]. IV tpA was administered to 64% of patients. Regarding specific workflow metrics, Median [IQR] times (in minutes) for PSC door to CT was 12 [9-20], PSC door to CTA 26 [19-50], PSC door to tPA 58 [46-78], DIDO 87 [68-113], PSC door to CSC groin puncture 140 [115-179], and PSC door to CSC recanalization of 169 [136-216]. As can be seen in the Figure, longer DIDO were associated with more deleterious scores on discharge NIHSS (p=0.04), discharge mRS (p=0.009) and 90d mRS (p=0.002). Full execution of the PSC LVO protocol and “hold, drip and go” strategy for EMS transport were associated with shorter DIDO times. Conclusion: For patients diagnosed with LVO at a PSC, longer DIDO time appears to have a deleterious effect on outcome at discharge from the CSC and at 90 days. All PSCs should take measures to decrease DIDO and use it as a quality metric.