Time Of Interhospital Transfer Research Articles

Predicting Mortality Prior to Interhospital Hospital for "Unseen" General Surgery Patients: Development, Validation and Feasibility Trial of a Mortality Risk Calculator.

Develop and validate a mortality risk calculator that could be utilized at the time of transfer, leveraging routinely collected variables that could be obtained by trained non-clinical transfer personnel. There are no objective tools to predict mortality at the time of inter-hospital transfer for Emergency General Surgery (EGS) patients that are "unseen" by the accepting system. Patients transferred to general or colorectal surgery services from January 2016 through August 2022 were retrospectively identified and randomly divided into training and validation cohorts (3:1 ratio). The primary outcome was admission-related mortality, defined as death during the index admission or within 30 days post-discharge. Multiple predictive models were developed and validated. Among 4,664 transferred patients, 280 (6.0%) experienced mortality. Predictive models were generated utilizing 19 routinely collected variables; the penalized regression model was selected over other models due to excellent performance using only 12 variables. The model performance on the validating set resulted in an area under the receiver operating characteristic curve, sensitivity, specificity, and balanced accuracy of 0.851, 0.90, 0.67, and 0.79, respectively. After bias correction, Brier score was 0.04, indicating a strong association between the assigned risk and the observed frequency of mortality. A risk calculator using twelve variables has excellent predictive ability for mortality at the time of interhospital transfer among "unseen" EGS patients. Quantifying a patient's mortality risk at the time of transfer could improve patient triage, bed and resource allocation, and standardize care.

Inter-hospital transfer for thrombectomy: transfer time is brain.

Patients with acute ischaemic stroke and a large vessel occlusion who present to a non-endovascular-capable centre often require inter-hospital transfer for thrombectomy. Whether the inter-hospital transfer time is associated with 3-month functional outcome is poorly known. Acute stroke patients enrolled between January 2015 and December 2022 in the prospective French multicentre Endovascular Treatment of Ischaemic Stroke registry were retrospectively analysed. Patients with an anterior circulation large vessel occlusion transferred from a non-endovascular to a comprehensive stroke centre for thrombectomy were eligible. Inter-hospital transfer time was defined as the time between imaging in the referring hospital and groin puncture for thrombectomy. The relationship between transfer time and favourable 3-month functional outcome (modified Rankin Scale 0-2) was assessed through a mixed logistic regression model adjusting for centre and symptom-onset-to-referring-hospital imaging time, age, sex, diabetes, referring hospital National Institutes of Health Stroke Scale score, Alberta Stroke Programme Early Computed Tomography Score, occlusion site and intravenous thrombolysis use. Overall, 3769 patients were included (median inter-hospital transfer time 161 min, interquartile range 128-195; 46% with favourable outcome). A longer transfer time was independently associated with lower rates of favourable outcome (p < 0.001). Compared to patients with transfer time below 120 min, there was a 15% reduction in the odds of achieving favourable outcome for transfer times between 120 and 180 min (adjusted odds ratio 0.85; 95% confidence interval 0.67-1.07), and a 36% reduction for transfer times beyond 180 min (adjusted odds ratio 0.64; 95% confidence interval 0.50-0.81). A shorter inter-hospital transfer time is strongly associated with favourable 3-month functional outcome. A speedier inter-hospital transfer is of critical importance to improve outcome.

Safety of helicopter transport in patients with acute coronary syndrome.

ST-elevation myocardial infarction (STEMI) systems of care have reduced inter-hospital transfer times and facilitated timely reperfusion goals. Helicopters may be an option when land transportation is not feasible; however, the safety of air transport in patients with acute coronary syndrome (ACS) is a factor to consider. The aim of this study was to evaluate the safety of helicopter transport for patients with ACS. Prospective, observational, and descriptive study including patients diagnosed with ACS within the STEMI network of a metropolitan city transferred by helicopter to a large cardiovascular center to undergo percutaneous coronary intervention. The primary outcome of the study was the incidence of air-travel-related complications defined as IV dislodgement, hypoxia, arrhythmia, angina, anxiety, bleeding, and hypothermia. Secondary outcomes included the individual components of the primary outcome. A total of 106 patients were included in the study; the mean age was 54 years and 84.9% were male. The most frequent diagnosis was STEMI after successful fibrinolysis (51.8%), followed by STEMI with failed fibrinolysis (23.7%) and non-reperfused STEMI (9.4%). Five patients (4.7%) developed at least one complication: IV dislodgement (1.8%) and hypoxemia (1.8%) in two patients and an episode of angina during flight (0.9%). A flight altitude of > 10,000 ft was not associated with complications. The results of this study suggest that helicopter transportation is safe in patients undergoing acute coronary syndrome, despite the altitude of a metropolitan area.

Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times.

In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times. In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation. Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08). In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.

Effect of a prioritization score on the inter-hospital transfer time management of severe COVID-19 patients: a quasi-experimental intervention study.

BackgroundThe overburdening of the healthcare system during the coronavirus disease 19 (COVID-19) pandemic is driving the need to create new tools to improve the management of inter-hospital transport for patients with a severe COVID-19 infection.ObjectiveThe aim of this study was to analyse the usefulness of the application of a prioritization score (IHTCOVID-19) for inter-hospital transfer of patients with COVID-19 infection.MethodsThe study has a quasi-experimental design and was conducted on the Medical Emergency System, the pre-hospital emergency department of the public company belonging to the Autonomous Government of Catalonia that manages urgent healthcare in the region. Patients with a severe COVID-19 infection requiring inter-hospital transport were consecutively included. The pre-intervention period was from 1 to 31 March 2020, and the intervention period with the IHTCOVID-19 score was from 1 to 30 April 2020 (from 8 am to 8 pm). The prioritization score comprises four priority categories, with Priority 0 being the highest and Priority 3 being the lowest. Inter-hospital transfer (IHT) management times (alert-assignment time, resource management time and total central management time) and their variability were evaluated according to whether or not the IHTCOVID-19 score was applied.ResultsA total of 344 IHTs were included: 189 (54.9%) in the pre-intervention period and 155 (45.1%) in the post-intervention period. The majority of patients were male and the most frequent age range was between 50 and 70 years. According to the IHTCOVID-19 score, 12 (3.5%) transfers were classified as Priority 0, 66 (19.4%) as Priority 1, 247 (71.8%) as Priority 2 and 19 (5.6%) as Priority 3. Overall, with the application of the IHTCOVID-19 score, there was a significant reduction in total central management time [from 112.4 (inter-quartile range (IQR) 281.3) to 89.8 min (IQR 154.9); P = 0.012]. This significant reduction was observed in Priority 0 patients [286.2 (IQR 218.5) to 42.0 min (IQR 58); P = 0.018] and Priority 1 patients [130.3 (IQR 297.3) to 75.4 min (IQR 91.1); P = 0.034]. After applying the IHTCOVID-19 score, the average time of the process decreased by 22.6 min, and variability was reduced from 618.1 to 324.0 min.ConclusionThe application of the IHTCOVID-19 score in patients with a severe COVID-19 infection reduces IHT management times and variability.

Abstract TMP26: Understanding Changes In Thrombectomy Eligibility Among Large Vessel Occlusion Stroke Transfers In A Hub-and-spoke Telestroke System

Introduction: Endovascular thrombectomy (EVT) has revolutionized the care of emergent large vessel occlusion (ELVO) stroke patients. It is, therefore, crucial to optimize its delivery to eligible candidates. Within hub-and-spoke hospital system models, some patients first present to distant spoke hospitals and require transfer to hub hospitals for EVT. We sought to understand changes in EVT eligibility during transfer. Methods: Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CTA-defined ELVO and Alberta Stroke Program Early CT Score ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day functional independence (modified Rankin Scale, mRS ≤2). Results: Among 258 patients, the median age was 70 years (IQR 60-81) and 50% were female. Forty-four percent underwent EVT upon hub arrival, of which 87% achieved Thrombolysis in Cerebral Infarction 2b-3 reperfusion. Compared to EVT-eligible patients, ineligible patients were older (73 vs 68 years, p=0.04), had lower NIH Stroke Scale (NIHSS, 10 vs 16, p&lt;0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p&lt;0.0001), and received less IV alteplase (32% vs 45%, p=0.04). The clinical reasons cited for becoming EVT ineligible upon hub arrival included large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion location (5%), subocclusive lesion (3%), and goals of care (3%). Becoming EVT ineligible independently reduced the odds of 90-day functional independence (aOR=0.26, 95%CI=0.12,0.56; p=0.001), even when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions: These data support that approaches to increase EVT eligibility among ELVO transfers may improve long term outcomes. Infarct growth represents the primary reason for ineligibility. Possible interventions include direct field triage to the hub when feasible, improving inter-hospital transfer times, supporting ischemic penumbra before EVT, and developing novel agents to slow infarct growth.

Abstract 114: Spoke-administered Thrombolysis Improves Large Vessel Occlusion Early Reperfusion And Inter-hospital Transfer Time For Mechanical Thrombectomy In A Hub-and-spoke Telestroke Network.

Introduction: The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is controversial. Low early recanalization (ER) rates and potential delays to MT may support bypassing IVT before MT. Recent trials suggest MT alone is reasonable for LVO patients presenting directly to MT-capable centers. However, bypassing IVT has not been evaluated for patients first presenting to “spoke” hospitals capable of administering IVT but requiring transfer to a “hub” hospital for MT. Here we examined how spoke IVT influences LVO ER and spoke-to-hub transfer time (TT) within our hub-and-spoke network. Methods: Patients presenting to 25 spoke hospitals before hub transfer from 2018 to 2020 who were considered possible EVT candidates with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. ER was determined by chart review of vessel imaging on hub arrival. TT was prospectively recorded. Statistics were performed using permutation resampling and linear regression in R. Results: Of 177 patients included, 76 received IVT. Baseline characteristics, NIHSS, and intracerebral hemorrhage were similar between groups. Spoke IVT improved ER frequency [12/76 (15.8%) vs. 3/101 (3.0%), P&lt;0.0001]. Further, spoke IVT was associated with improved ER (aOR=5.9, 95% CI=1.3,33.7, p=0.02), independent of last known well. Patients receiving IVT had decreased mean TT by 25 minutes (139±59 min vs. 164±71 min, p=0.01). Patients with ER had NIHSS interval improvement from spoke to hub [median -2 (IQR 0.0, -3.5) vs. 0 (1.0, -0.4), p=0.02]. IVT was associated with improved 90d mRS ≤2 independent of age, NIHSS, and MT treatment (OR=2.5, 95% CI=1.1, 6.1, p=0.04). Conclusion: Within our network, IVT significantly increases ER and decreases TT, which may contribute to improved 90-day outcomes. This retrospective study supports following current recommendations that IVT be given to all eligible patients at spoke hospitals prior to transfer for MT consideration.

The Value of Health Information Technology Interoperability: Evidence from Interhospital Transfer of Heart Attack Patients

Problem definition: Health information technology (HIT) interoperability refers to the ability of different electronic health record systems and software applications to communicate, exchange data, and use the information that has been exchanged. The U.S. Government has invested heavily to promote HIT interoperability in recent years in an attempt to improve patient outcomes and control healthcare expenditure. This study empirically assesses the value of HIT interoperability in the interhospital transfer process of heart attack patients. Academic/practical relevance: HIT interoperability is supposed to enable health information exchange between disparate providers. However, there exists little evidence about how it affects care delivery processes across providers. Methodology: Using transfer records of heart attack patients and HIT interoperability adoption records of hospitals in New York State between 2013 and 2015, we estimate the effect of HIT interoperability on care delivery process measures and patient outcome measures. We demonstrate the robustness of the results with alternative samples and model specifications, including the instrumental variable method, the propensity score matching method, the difference-in-differences method, and a falsification test. Results: We show that HIT interoperability shortens the throughput time of interhospital transfer by 45.6 minutes on average or 12.0%. Surprisingly, we find that HIT interoperability has little effect in reducing duplicate electrocardiogram (EKG) testing for transferred patients at receiving hospitals. When HIT interoperability is enabled through a common software vendor, it yields 15.6% more reduction in the throughput time than when it is enabled through different vendors, but it still has no significant effect on duplicate EKG testing. Furthermore, we find that HIT interoperability leads to a 3.0-percentage point decrease in the 30-day readmission rate of transferred patients, which can be explained by the reduction in the throughput time. Managerial implications: Our findings demonstrate the value of incentivizing HIT adoption and promoting widespread exchange of health information because HIT interoperability indeed improves the efficiency of healthcare delivery across providers, which ultimately translates to improved patient outcomes. Given the lack of reduction in duplicate testing in our study, we call for more provider effort toward realizing the full potential of HIT interoperability by minimizing the gap between technology adoption and utilization.

Use of a Smartphone Application to Speed Up Interhospital Transfer of Acute Ischemic Stroke Patients for Thrombectomy.

Background: In most countries, large cerebral artery occlusion is identified as the leading cause of disability. In 2015, five large-scale clinical trials confirmed the benefit of intra-arterial thrombectomy. However, thrombectomy is a highly technical and facility-dependent procedure. Primary stroke centers need to transfer patients to comprehensive stroke centers to perform thrombectomy. The time-lapse during interhospital transfer would decrease the chance of the patient's proper recovery. Communication barriers also contribute to this delay.Aims: We used a smartphone application to overcome communication barriers between hospitals. We aimed to shorten the door-to-puncture time of interhospital transfer patients.Methods: We began using a smartphone application, “LINE,” to facilitate interhospital communication on May 01, 2018. We carried out retrospective data analyses for all the transfer patients (n = 351), with the primary outcome being the door-to-puncture time in our comprehensive stroke center (China Medical University Hospital). We compared the three periods: May 01 to Dec 31, 2017 (before the use of the smartphone application); May 01 to Dec 31, 2018 (the 1st year of using the smartphone application); and May 01 to Dec 31, 2019 (the 2nd year of using the smartphone application). We also compared the transfer data with non-transfer thrombectomies in the same period.Results: We compared 2017, 2018, and 2019 data. The total number of transfer patients increased over the years: 63, 113, 175, respectively. The mean door-to-puncture time decreased significantly, going from 109, through 102, to 92 min. Meanwhile, the mean door-to-puncture time in non-transfer patients were 140.3, 122.1, and 129.3 min. The main reason of time saving was the change of the way of communication, from point-to-point interhospital communication to hub-to-spoke interhospital communication.Conclusions: We used this smartphone application to enhance interhospital communication, changed from the point-to-point to hub-to-spoke method. It made us overcome the communication barrier and build up interhospital connection, thus shortening the door-to-puncture time. Our experience demonstrated the importance of close communication and teamwork in hyperacute stroke care, especially in interhospital transfer for thrombectomy.

Total Transfer Time for Ground vs. Air Transport for Interhospital and Scene Transfers of Acute Stroke Patients

ObjectivesStroke patients are frequently transported to a comprehensive stroke center for treatment, either from a regional hospital via interhospital transfer or from the field via direct-from-scene transfer, by air or ground transportation. We sought to determine whether air or ground transport was faster in both transfer circumstances. Materials and methodsA retrospective study of patients transferred to a single comprehensive stroke center for stroke treatment was conducted. EMS and medical records were used to evaluate the time and distance of transfer and functional outcome. ResultsOf the 205 transfers, 47 were interhospital transfers by air (22.9%), 68 were interhospital transfers by ground (33.2%), 40 were scene transfers by air (19.5%), and 50 were scene transfers by ground (24.4%). Ground transfers had shorter alarm to EMS departure times (30 min. vs 40 min.; p<0.0001). Air transfers had shorter EMS departure to arrival times when normalized by transfer distance indicating a faster travel velocity. Interhospital transfers by air were predicted to be faster than ground over 40 miles, and scene transfers by air were predicted to be faster than ground over 28 miles. Transfer mode had no significant effect on functional outcome when controlling for tPA, thrombectomy, and NIH Stroke Scale in this small study. ConclusionsTransfer efficiency for stroke patients depends on logistics prior to EMS arrival as well as the speed of travel. While air transport clearly results in faster travel velocity, total interhospital transfer times are faster for air transportation only when traveling more than 40 miles.

Presentation delay, misdiagnosis, inter-hospital transfer times and surgical outcomes in testicular torsion: analysis of statewide case series from central Brazil.

ABSTRACTPurpose To estimate statewide presentation delay, misdiagnosis rate, inter-hospital transfer times and testicular salvage for testicular torsion patients treated in our state’s public health system.Patients and Methods Case series of consecutive testicular torsion patients treated in our state’s public health system between 2012-2018. Predictors included presentation delay (time from symptoms to first medical assessment), facilitie’s level-of-care (primary, secondary, tertiary), first diagnosis (torsion, epididymitis, other), Doppler-enhanced ultrasound request (Doppler-US) and inter-hospital transfer times, with surgical organ salvage as the main response. We used Bayesian regression to estimate the effect of first examining facilitie’s level-of-care, first diagnosis, and Doppler-US on transfer time.Results 505 patients were included, most (298, 59%) with presentation delay >6 hours. Misdiagnosis at first examining facility raised transfer time from median 2.8 to 23.4 (epididymitis) and 37.9 hours (other) and lowered testicular salvage rates from 60.3% (torsion) to 10.7% (epididymitis) and 18.3% (other). Doppler-US had negligible effects on transfer time once controlling for misdiagnosis in the regression model. Although organ salvage in patients presenting before 6 hours at the tertiary facility was high (94.6%, and about 20% lower for those presenting at lower levels-of-care), the overall salvage rate was more modest (46%).Conclusion Our low overall testicular salvage rates originated from a large proportion of late presentations combined with long transfer times caused by frequent misdiagnoses. Our results indicate that efforts to improve salvage rates should aim at enhancing population-wide disease awareness and continuously updating physicians working at primary and secondary levels-of-care about scrotal emergencies.

The Value of Health IT Interoperability: Evidence from Interhospital Transfer of Heart Attack Patients

Problem definition: Health IT (HIT) interoperability refers to the ability of different electronic health record systems and software applications to communicate, exchange data, and use the information that has been exchanged. U.S. government has invested heavily to promote HIT interoperability in recent years in an attempt to improve patient outcomes and control healthcare expenditure. This study empirically assesses the value of HIT interoperability in the interhospital transfer process of heart attack patients. Academic/practical relevance: HIT interoperability is supposed to enable health information exchange between disparate providers. However, there exists little evidence about how it affects care delivery processes across providers. Methodology: Using transfer records of heart attack patients and HIT interoperability adoption records of hospitals in the New York State between 2013 to 2015, we estimate the effect of HIT interoperability on care delivery process measures and patient outcome measures. We demonstrate the robustness of the results using the instrumental variable method, the propensity score matching method, the difference-in-differences method, and a falsification test. Results: We show that HIT interoperability shortens the throughput time of interhospital transfer by 45.6 minutes on average, or 12.0%. Surprisingly, we find that HIT interoperability has little effect in reducing duplicate EKG testing for transferred patients at receiving hospitals. When HIT interoperability is enabled through a common software vendor, it yields 15.6% more reduction in the throughput time than when it is enabled through different vendors, but it still has no significant effect on duplicate EKG testing. Furthermore, we find that HIT interoperability leads to 3.0 percentage points decrease in the 30-day readmission rate of transferred patients, which can be explained by the reduction of the throughput time. Managerial Implications: Our findings demonstrate the value of incentivizing HIT adoption and promoting widespread exchange of health information because HIT interoperability indeed improves the efficiency of healthcare delivery across providers, which ultimately translates to improved patient outcomes. Given the lack of reduction in duplicate testing in our study, we call for more provider effort toward realizing the full potential of HIT interoperability by minimizing the gap between technology adoption and utilization.

CRT-100.34 Importance of Organized STEMI Network for the Improvement of Contact-to-Wire Time and 30-Day Mortality Rate in STEMI Patients

Medical evidence has shown that PPCI is the preferred method of reperfusion in STEMI if it can be performed in a timely manner. Prehospital delay and interhospital transfer time of STEMI patients requiring primary PPCI can be shortened and mortality decreased by improving quality of service within

Abstract TMP10: Real-World Analysis of Endovascular Stroke Therapy Outcomes for Patients With Large Vessel Occlusions After Inter-Hospital Transfer

Introduction: Prior studies suggest that patients with large vessel occlusion (LVO) who undergo endovascular stroke therapy (EST) after inter-hospital transfer (IHT) have worse outcomes than those who present directly to EST centers. However, these studies were largely derived from clinical trials or registries and may not be representative of real-world clinical practice. Methods: We performed a multicenter, observational cohort study on acute ischemic stroke (AIS) patients with LVO that presented to EST-capable centers directly (LVO-D) or after IHT (LVO-T) between 1/1/2018 to 2/1/2019. The study included 11 hospitals in the Houston area, of which 4 are EST-capable. Clinical data were collected using our cerebrovascular data registry. All transfers were from non-EST capable hospitals to EST-capable hospitals. Logistic regression adjusted for age, NIHSS, occlusion location and direct vs transfer arrival was used to assess the likelihood of good outcome, defined as discharge to home or rehabilitation. Results are given as median [IQR] and OR [95% CI]. Results: Among 4,313 patients with AIS, 772 (18%) patients had LVO. Among LVO patients, median age was 68 [59-79], 47% were female, 51% were white, 378 (49%) were LVO-D and 394 (51%) were LVO-T. Median IHT time was 152 min [114-198]. LVO-D patients arrived at EST-treating hospitals with superior ASPECTS compared to LVO-T (9 [7-10] vs 7 [6-9], p&lt;0.0001), but comparable CTP RAPID infarct cores (5 mL [0-31] vs 7 mL [0-38], p=0.59). LVO-D and LVO-T patients were just as likely to have ICA occlusions (13% vs 12%; p=.64) and proceeded to have equivalent rates of EST (43% vs 47%, p=0.95). Among LVO patients who did not receive EST, good discharge outcomes were comparable (34% vs. 35%, p=0.66, LVO-D vs. LVO-T). Good discharge outcomes were also similar for those receiving EST (34% vs. 37%, p=0.57, LVO-D vs. LVO-T). In logistic regression adjusted for age, NIHSS, and occlusion location, likelihood of good discharge outcome was comparable between the two groups (OR 0.98 [0.71-1.36]). Conclusion: In this real-world cohort of a multi-center stroke network, IHT was not associated with worse outcomes for patients with LVO, for both patients who did receive EST and those that did not.

Discrepancy in core infarct between CT aspects and CT perfusion when selecting for mechanical thrombectomy

Mechanical thrombectomy (MT) is now an established treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO) within 6 hours. Since 2018, MT is also recommended from 6–24 hours after selecting with additional multimodal imaging including perfusion imaging. We sought to investigate patients with significant discrepancy in core infarct between CT and CT perfusion (CTP). From February-2018, RAPID Imaging Software (iSchemaView) was used at our institution to analyze CTP data for patients with LVO being selected for MT from 6-24hours of symptom onset. CTP was also done <6hours if significant early ischemic changes or hypodensity was seen on non-contrast CT. All cases utilizing RAPID CTP data for MT selection from February2018–February2019 were collected. Cases with discrepancy between APSECTS on head CT and core volume (CBF <30%) on CTP were analyzed. Evaluation of all RAPID cases performed for MT selection revealed 4patients with significant discrepancy in core infarct between CT and CTP. Please see Table 1. All 4-patients did not have a LVO in the ICA/M1 or M2 segments. This likely occurred due to interval recanalization of a proximal LVO. Recanalization of a LVO can lead to erroneously normal or gross underestimation of core infarct on software analysis of CTP images. This has implications for triage of AIS for MT. CTP images should always be evaluated alongside plain CT images. If inter-hospital transfer times are prolonged, patients transferred from another institution after demonstration of LVO should have CT head repeated if CTP is being considered.

Hot Loading Reduces Time to Intervention for ST-segment Elevation Myocardial Infarction Patients Being Transferred by Helicopter

ObjectiveThe aim of this study was to quantify the effect of helicopter hot loading on the time to percutaneous intervention (time-to-PCI) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing interhospital transfer. MethodsWe performed a retrospective cohort study using data from 2009 to 2014, looking at all patients who had an STEMI, were transferred from a single non-PCI hospital by helicopter emergency medical services, and who received PCI intervention at the PCI-capable hospital. Differences in loading method, flight details, and patient demographics were analyzed to measure the effectiveness of the intervention. ResultsDuring the 5-year study period, 134 STEMI patients were transferred. Sixty-four were hot loaded (47.7%), and 70 were cold loaded. Patients who were hot loaded had a median reduction in interhospital transfer and time-to-PCI of 22.3 minutes from 91.0 minutes (interquartile range, 65-117 minutes) by cold load to 69.5 minutes (interquartile range, 47.5-91.5 minutes) by hot load. There was no increase in reported safety-related events during the hot load process. The median length of hospital stay was equivalent for both groups at 3 days. ConclusionsThis protocol of helicopter hot loading STEMI patients presenting to a non-PCI hospital significantly reduced the median time of interhospital transfer and time-to-PCI without an increase in reported safety events.

Futile inter-hospital transfer for mechanical thrombectomy in a semi-rural context: analysis of a 6-year prospective registry

Background and purposeInter-hospital transfer for mechanical thrombectomy (MT) might result in the transfer of patients who finally will not undergo MT (ie, futile transfers [FT]). This study evaluated FT frequency...

Improved Survival of Patients with ST-Segment Elevation Myocardial Infarction 3–6 Hours After Symptom Onset Is Associated with Inter-Hospital Transfer for Primary Percutaneous Coronary Intervention (PCI) at a Large Regional ST-Segment Elevation Myocardial Infarction (STEMI) Program vs. In-Hospital Thrombolysis in a Community Hospital

BackgroundThis study sought to compare the 30-day and 1-year survival of patients diagnosed with ST-segment elevation myocardial infarction (STEMI), whose symptom onset to in-hospital first medical contact (IHFMC) was 3–6 h, who received either in-hospital thrombolysis (IHT) in the nearest county hospital or direct transfer to a larger hospital in Henan province, China for primary percutaneous coronary intervention (PPCI).Material/MethodsPatients were allocated into 2 groups: one group received IHT in the local county hospital, whereas the other group were transferred to the PCI centers to receive PPCI. Patient demographic data, baseline characteristics, and time between different stages of patient contact to the initiation of treatment for IHT or PPCI were recorded for analysis.ResultsNo significant difference was identified between the 2 groups with the baseline characteristics and demographic data. The all-cause mortality was not significantly different between the IHT and PPCI group at 30 days (13.0% vs. 9.9%, p=0.386). However, a significant difference in mortality between the IHT and PPCI group was observed at 1 year (23.4% vs. 14.1%, p=0.035). Inter-hospital transfer time for PPCI tended to be the independent predictor for survival (OR: 4.4 CI 95%: 1.9–14.5, p 0.001). Overall, the patients undergoing PPCI in inter-hospital transfer had a higher survival rates for 1 year compared with patients receiving IHT.ConclusionsDespite the delay associated with inter-hospital transfer for PPCI, patients with STEMI 3–6 h after symptom onset have improved survival with PPCI over patients treated locally with IHT.

Abstract WMP69: Access to Endovascular Treatment in Remote Areas: Analysis of the Reperfusion Treatment Registry of Catalonia

Background: Benefit of endovascular treatment (EVT) for acute stroke has been demonstrated recently in several randomized clinical trials. This benefit is time-dependent and revascularization achieved at later times is associated with a poor risk-benefit ratio. Hypothesis: Stroke Code systems based on a drip-and-ship model have been implemented worldwide to accelerate iv-tPA treatment. However, access to EVT in remote areas is hampered due to long distances and delays related to inter-hospital transfers. Methods: We studied patients treated with EVT from a prospective multicenter population-based registry of acute stroke patients treated with reperfusion therapies (SONIIA) initiated in January 2011. Three groups were defined: (1) patients directly evaluated in comprehensive stroke centers (CSC) (n=895), (2) patients transferred from a remote hospital located less than 1 hour away from a CSC (n=191) and (3) patients transferred from a remote hospital located more than 1 hour away from a CSC (n=153). We compared population EVT rates (number of EVT/100000 inhabitants/year) and time from stroke onset to groin puncture between groups. The benefit of helicopter over ground transfer was evaluated in group 3. Results: We found no differences between the three groups in baseline characteristics (age, vascular risk factors and stroke severity). 48% of patients in group 1, 60% in group 2 and 62% in group 3 received iv-tPA previously to EVT, with time from symptom onset to iv-tPA of 120 min, 110 min and 137 min respectively. Population EVT rates were 4-fold higher in group 1 (6.69 in group 1, 2.07 in group 2 and 1.68 in group 3). Time from symptom onset to EVT was longer in group 2 (322 min [255-445]) and group 3 (365 min [312-450]) compared to group 1 (243 min [175-404]) (p&lt;0.001). Helicopter transfer was used in 24% of patients in group 3 and reduced the time to groin puncture in 35 minutes. Conclusions: Accessibility to EVT in remote areas is hampered in comparison to areas depending directly on CSC. Time from symptom onset to EVT is 90-120 minutes longer in patients transferred from remote hospitals compared to patients directly evaluated in CSC. Based on these results, strategies to shorten inter-hospital transfer time or alternative mother-ship models should be considered.

Fibrinolysis Use Among Patients Requiring Interhospital Transfer for St-Segment Elevation Myocardial Infarction Care: A Report from The US National Cardiovascular Data Registry: Vora AN, Holmes DN, Rokos I, et al. JAMA Intern Med 2014. doi: 10.1001/jamainternmed.2014.6573. Published online December 8, 2014.

This study used the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With the Guidelines, to examine ST-segment elevation myocardial infarction (STEMI) treatments and outcomes. The objectives of the study were to 1) determine how drive times between referring and receiving centers determined choice of fibrinolysis vs. primary percutaneous coronary intervention (pPCI) and 2) evaluate outcomes for those patients eligible for either fibrinolysis or pPCI based on inter-hospital transfer times.