Door in-Door out Time for Stroke Thrombectomy Transfers in a Large Hub-and-Spoke Network
Robert Regenhardt1, Rashid Ahmed1, Thabele Leslie-Mazwi2, Alvin Das3, Adam Dmytriw1, James Rabinov1, Christopher Stapleton1, Aman Patel1, Aneesh Singhal1, Natalia Rost1
1Massachusetts General Hospital, 2University of Washington, 3Beth Israel Deaconess Medical Center
Objective:
To analyze real-world data of the impact and determinants of door-in-door out (DIDO) times in a large, hub-and-spoke network.
Background:
The mantra ‘time is brain’ cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVO) requiring transfer to an endovascular thrombectomy (EVT) capable center.
Design/Methods:
Individuals were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 min based in the American Heart Association goal for DIDO ≤90 min for 50% of transfers. Multivariable regression analyses were performed for determinants of 90-day ordinal modified Ranking Scale (mRS) and DIDO.
Results:
We identified 194 patients transferred for EVT with available DIDO. The median age was 67 (IQR 57-80), and 46% were female. The median NIHSS was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 min (97-149), with DIDO ≤90 min achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS (B=0.007, 95%CI=0.001-0.012, p=0.013), even when accounting for last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B=0.918, 95%CI=0.010-1.826, p=0.048), atrial fibrillation or heart failure (B=0.793, 95%CI=0.257-1.329, p=0.004), and basilar LVO location (B=2.528, 95%CI=1.154-3.901, p<0.001).
Conclusions:
Spoke DIDO was the most important period of time for long term outcomes of LVO stroke patients treated with EVT. Further investigation of the determinants of DIDO is needed to improve systems of care and improve patient outcomes.