Earlier Communication or Admission? Impact of Interhospital Transfer on the Treatment of Acute Ischemic Stroke in a County Hospital in China

Abstract

Background: Interhospital transfer is associated with significant treatment delays and worse clinical outcomes for AIS patients. Obtaining informed consent from patients results in treatment delay. However, there are few studies concerning referral delays and communication time in patients first enrolled in community hospitals and then transferred to county hospitals in China's county-level cities. We included AIS patients who received rt-PA or MT at our stroke center via either interhospital transfer or direct presentation and compared the clinical outcomes and time metrics between the direct presentation and transfer patients to analyze the impact of interhospital transfer delays in county-level cities and the time to obtain informed consent on AIS treatment. Methods: We retrospectively enrolled patients with AIS admitted to our stroke center from March 2014 to February 2018. Patients treated with rt-PA and MT were classified into the transfer and direct groups. We collected their general information and time points. Statistical analyses were conducted to examine differences in the clinical outcomes and time metrics between these groups. Results: A total of 160 patients were enrolled; 119 patients received IV-rt-PA (transfer group, n=28; direct group, n=91), and 44 received MT (transfer group, n=14; direct group, n=14). For the rt-PA, rt-PA (NIHSS scores ≥5) and MT subgroups, the baseline characteristics were mostly similar between the direct and transfer groups. Among patients treated with rt-PA, the direct group had shorter onset-to-door times and higher initial NIHSS scores and NIHSS scores on discharge but longer door-to-stroke unit, stroke unit-to-rt-PA (representing the time to obtain informed consent) and DNT times than did the transfer group. There were no significance differences in onset-to-IV-rt-PA times. Among patients with NIHSS scores ≥5 treated with rt-PA, the direct group had shorter onsetto-door times but longer door-to-stroke unit, stroke unit-to-rt-PA and DNT times. There were no significant differences in onset-to-IV-rt-PA times, initial NIHSS scores or NIHSS scores on discharge. Among patients treated with MT, the direct group had shorter onset-to-door time but longer door-to-stroke unit, stroke unit-to-puncture and door-to-puncture times.There were no significance differences in onset-to-puncture times, initial NIHSS scores and NIHSS scores on discharge. Conclusions Our research confirmed that in a stroke center of a county-level city hospital, the time to obtain informed consent delayed intravenous thrombolysis or endovascular treatment in AIS patients. Interhospital transfers effectively reduced the time to obtain informed consent, and overlapping communication and transit times provided positive significance of the referral. Cooperation should be established with community hospitals and ambulances to allow simultaneous communication and transit to reduce the AIS onset-to-treatment time. Funding: This work was funded by the Guidance plan for social development of Taizhou Municipal Science and Technology (ssf20160141). The funder had no role in the study design, data collection, data analysis, data interpretation, writing of the report, decision to publish, or preparation of the manuscript. Conflict of Interest: None of the authors report a conflict of interest. Ethical Approval Statement: The study was approved by the medical ethics committee of Jingjiang People’s Hospital.