Abstract TP45: Promoting High Value Care For Stroke Patients Within A Stroke System Of Care: Reducing Unnecessary Hospital Transfers For Patients Not Taken For Thrombectomy

Abstract

Introduction: High value care aims to provide the best patient outcomes while avoiding defects and waste. Our previous work determined that 39% of patients transferred for possible thrombectomy based on clinical criteria and CT only did not have a large vessel occlusion (LVO) which led to a health system-wide guideline to improve transfer selection by adding criteria for emergent CT angiography. This study aims to describe the impact of that guideline and reanalyze the reasons why patients transferred for consideration of thrombectomy do not receive the procedure. Methods: All patients transferred from within and outside of the health system as a potential thrombectomy candidate between 1/1/19- 6/30/21 were reviewed for reasons why thrombectomy was not pursued. Results: Over 30 months, 316 patients transferred for possible thrombectomy were not taken to the angio suite primarily due to absence of LVO on vessel imaging (26.3%), lack of suspicion of LVO on assessment (18%) and significant improvement in clinical symptoms (12%). Other reasons included too large of core infarct (13.3%), CT head ASPECT score (8.2%), lack of perfusion imaging mismatch (6.3%), poor baseline functional status (4.7%), lesion too distal (3.8%), ICH (3.2%), time since last known well (1.9%), chronic ICA occlusion preventing access to acute lesion (1.9%), and medically unstable (0.3%). Conclusions: Despite the institution of a system-wide protocol for acute CTA imaging to guide patient selection, the major reason for not proceeding to thrombectomy was still absence of LVO, some of which was related to out-of-system hospital transfers. Drawbacks of unnecessary patient transfer include increased cost of care, moving patients farther away from their home and family, and non-essential use of tertiary hospital bed space, particularly in the setting of a pandemic. Given the prevalence of potentially preventable unnecessary transfers, protocols that support in-the-field triage and transport based on clinical criteria alone, without CT or CTA, are destined to worsen health system efficiency and decrease the value of care for patients with major acuteischemic stroke.