Stroke teams in Victoria have shown that streamlining can halve the transfer times for patients in a primary stroke centre (PSC) to a comprehensive stroke centre (CSC) with mechanical thrombectomy services.
By identifying and eliminating delays in management of patients presenting with acute ischaemic stroke from emergent large vessel occlusion (ELVO), stroke specialists at Box Hill Hospital were able to reduce the median Door-In, Door Out (DIDO) time from 111 minutes to 67 minutes over a four year period.
(Door-In time defined as when the patient arrived for triage at the ED and Door-Out time defined as when outbound ambulance leaves the ED.)
In a review of records for 133 patients who were transferred to the to the Royal Melbourne Hospital they found that ongoing review and streamlining of treatment processes such as imaging and transfer protocols led to reduction of 14% per year in DIDO times.
The quality improvement program sought input from key staff including the stroke neurologists, acute stroke nurse, MIT, ED nurse, ED doctor, radiologist, PACS manager, MIT, and CT application specialist. Regular quarterly meetings were held to discuss treatment delays encountered and barriers to improving DIDO times.
Changes made to facilitate faster transfers included sending only select CT images from the primary stroke centre and transferring them directly to the thrombectomy-capable centre, bypassing a centralised hub, a change that saved 25 minutes.
ED and ambulance protocols were streamlined, and direct specialist level communication was established between the onsite stroke registrar and neurointerventionalist at the centre for thrombectomy.
The greatest improvement in transfer times were seen during working hours, with a median DIDO time of 59 minutes achieved in 2018.
Overall, 65 patients had no documented delays (49%) with a median DIDO time of 75 minutes, compared to 103 minutes in those with at least one delay factor documented.
The study authors led by Dr Philip Choi of the Department of Neurosciences, Box Hill Hospital, said the findings could be used to set DIDO benchmarks, particularly for stroke centres in cities where the typical transport time to a referral centre would be 30 minutes or less.
“In our setting, patients with acute stroke are assessed by neurology registrars, they wrote in Stroke.
“As outlined earlier, hyper-acute management of patients with ELVO is first discussed with the on-call PSC neurologist (who may or may not be a stroke neurologist), with appropriate cases referred to the CSC neurointerventionalist.
“An alternative and more streamlined process, such as direct discussion between frontline PSC nonstroke specialists (eg, ED resident/registrar/specialist) with a stroke neurologist or CSC neurointerventionalist is possible, but would require radical changes to the existing service organisation.”