A new study led by researchers from the University of Chicago Medicine (Chicago, USA) has revealed that nearly 75% of acute stroke patients wait more than two hours to be transferred to a comprehensive stroke centre (CSC)—a treatment delay that creates an increased risk of long-term disability.
“In neurology, we often say that ‘time is brain’,” said Shyam Prabhakaran (University of Chicago, Chicago, USA), senior author on the study, which has been published in the Journal of the American Medical Association (JAMA). “For every 15 minutes that pass without treatment, prior research shows there is a steady decrease in the chances of good outcomes for stroke patients. Getting to the right hospital quickly can be lifesaving.”
Analysing recent data from over 100,000 patients at 1,925 hospitals across the USA, the researchers found that the median time between initial arrival and departure for transfer—known as door-in-door-out (DIDO) time—was 174 minutes, with almost three in four patients waiting longer than the recommended maximum of 120 minutes.
The researchers also note that these intervals do not include the subsequent transport time between hospitals, meaning that it can be three hours or more before a patient receives critical interventions to treat their stroke, such as a mechanical thrombectomy procedure.
Furthermore, the data revealed that patients who were elderly, Hispanic, Black or female were more likely to have high DIDO times than their respective counterparts. Although many factors, such as variations in disease presentation, could contribute to these differences, Prabhakaran stated that the results should nevertheless prompt greater focus on health equity when it comes to stroke care.
“Our findings expose disparities that should not exist,” he said. “If you are having a stroke, it does not matter if you are a man or a woman, or Black or white—you should be able to get the same care.”
In addition, Prabhakaran urged healthcare providers and policymakers alike to be vigilant against and combat systemic biases that exist in healthcare.
However, he also emphasised that DIDO times are too high across the board, and that healthcare systems and patients should work together to bring them down. The data published recently by him and his colleagues uncovered multiple factors that lowered DIDO times. When emergency medical services (EMS) called ahead to notify medical centres that stroke patients were en route via ambulance, for example, median DIDO times were reduced by roughly 20 minutes.
“If you are a patient, one of the lessons from this is that calling 911 has immediate benefits, not only for stabilising you but for the downstream effects that it carries,” said Prabhakaran.
To follow up on this research, Prabhakaran et al are leading a National Institutes of Health (NIH)-funded study entitled, “Hospital implementation of a stroke protocol for emergency evaluation and disposition”—a multicentre, cluster randomised clinical trial to test interventions aimed at reducing DIDO times and improving functional outcomes in acute stroke patients requiring inter-hospital transfer. Such studies are intended to identify best practices and determine the benefits of improving stroke systems of care in diverse geographic regions of the USA.
“We have to think about ways to help smaller hospitals redesign the clinical pathways they use to evaluate and consider patients for transfer, and then expedite the procedures to make those transfers faster,” Prabhakaran added.
