Abstract WMP36: Quality Improvement for Improved Ischemic Stroke Large Vessel Occlusion Door-In-Door-Out Times at an Urban Primary Stroke Center Integrated Health System

Abstract

Background: Stroke patients who present to an Emergency Department (ED) with an acute ischemic stroke (AIS) due to a large vessel occlusion (LVO) and are eligible for endovascular stroke therapy (EST) require rapid transfer to a facility capable of EST. Nationwide data for 2022 suggest that 19% of LVO patients are transferred for EST within 90 minutes. Our practice center is a large urban community-based Primary Stroke Center, part of a spoke and hub integrated system. In 2022, we had a median door-in-door-out (DIDO) time of 98 min with 33% percent of cases under 90 min (n = 12). Purpose: Knowing the importance of early reperfusion, we implemented a quality improvement project using a pre-post design to improve our DIDO times for patients with AIS due to LVO, with a goal of achieving a median DIDO time of 75 min or less. Methods: Our approach was multidisciplinary. We completed comprehensive chart reviews focusing on critical time points and reviewed recent literature (2022 - 2023) for best practices. We created an ED interdisciplinary DIDO workgroup which developed and implemented a DIDO checklist after education and socialization. In March 2023, we created a dedicated regional neuro transfer hub to address changes with EMS notification and response to expedite LVO transfers. Other DIDO literature recommendations were already in place, including the use of a regionalized telestroke program. Best practices identified but not implemented focused on Emergency Medical Services (EMS), such as holding a rig while completing imaging, providing enroute reports, and conducting joint drills post-COVID. Results: After the implementation of the DIDO checklist, DIDO times decreased to 82 minutes from August 2022 to July 2023 (a decrease of 16 min), with 44% of cases under 75 mins (n = 9). Our median time for 2023 (January - July) is 68 min (n = 2). Conclusion: Transfer of LVO patients is a low-volume, high-risk event, but one where every minute matters for optimal patient outcomes. The DIDO checklist was a helpful aid for staff to ensure key steps were completed timely, leading to a decrease in DIDO times.