Expediting Stroke Transfers: Improving Door-In Door-Out Times in a Community Hospital Emergency Department

Background: Patients with acute ischemic stroke are at high risk for death and disability without rapid treatment. Thrombectomy is a time-sensitive procedure that can restore blood flow to the brain. Local Problem: Hospitals unable to perform thrombectomies transfer patients to tertiary care facilities. A community hospital in Pennsylvania transferred patients to one of two facilities, both at an average distance of 90 miles. The average transfer time was 143 minutes with the facility goal set for 90 minutes. Methods: Quality improvement methods including the Plan Do Study Act cycle, a fishbone diagram, and a process map were used to develop and implement an emergency department (ED) protocol. The door-in door-out (DIDO) time was used to measure time of ED arrival to departure. Physician adherence was measured using two time parameters in the transfer process. Interventions: An ischemic stroke transfer protocol was developed and education was provided to ED staff. Protocol implementation and measurements occurred over 3 months. Results: During the study period, two patients were transferred for thrombectomy with an average DIDO time of 82 minutes. Door-to-computed tomography angiogram (CTA) average was 11 minutes and door-to-decision to transfer average was 44 minutes. Retrospective analysis of patients revealed an 87-minute decrease in DIDO, a 19-minute decrease in door-to-CTA and a 74-minute decrease in transfer decision time. Conclusions: A transfer protocol can be successfully implemented in a community hospital ED using quality improvement methodologies. The DIDO time decreased with the protocol; however, the sample size was too small for generalizability.