Abstract TP255: Tackling Door in-Door Out Through a Statewide Initiative

Abstract

Background: The AHA/ASA has determined thrombectomy is standard-of-care up to 24 hours after last seen normal (LSN) for ischemic stroke patients with anterior circulation large vessel occlusion (LVO), provided the perfusion imaging profile meets criteria. Many patients require secondary transfer to access thrombectomy centers. The door in-door out (DIDO) is a target for process improvement. Methods: The Louisiana Emergency Response Network (LERN)’s stroke system of care was initiated in 2010. Submission of quarterly emergency department stroke data to LERN was voluntary as of Q1 2014 and was mandated as of Q1 2018 for hospitals attesting to Acute Stroke Ready Hospital (ASRH) capability. Sites across the state were invited to pilot expanded variable in order to assess LVO screening and baseline DIDO for patients with LVO. Results: Of 56 ASRHs, 34 sites submitted one or more quarters of data during the pilot phase contributing a total of 1808 cases. LVO screening was performed in 992 (54.9%) cases; 172 (17.3%) were LVO screened positive. VAN was used in 75.6% of LVO positive patients and CTA was used in 20.3%. Most patients (71.3%) arrived via ambulance. The median NIHSS in LVO positive patients was 12 (IQR 5-20). Transfer time was available in 114 (66%) LVO positive patients; median DIDO was 146 minutes (IQR 89-243 minutes). Transfer request time was available in 30 (17.4%) of LVO positive patients; median interval from transfer request to departure was 47 minutes (IQR 31-65 minutes). Discussion: Given that most patients with ischemic stroke caused by LVO will not present initially to a thrombectomy center, DIDO must be minimized to preserve penumbra and maximize likelihood of eligibility for thrombectomy when the thrombectomy center is accessed. LERN’s pilot LVO screening study established a baseline from which DIDO is a necessary target for intervention. Only 25% of LVO positive patients were transferred with DIDO less than 90 minutes. LERN’s initial goal is to shift the median DIDO to 90 minutes. Participation in the expanded variables targeting LVO screening and DIDO was mandated by LERN effective Q3 2018.