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. 2023 Jan 17;5(1):e000376.
doi: 10.1136/bmjno-2022-000376. eCollection 2023.

Door-in-door-out times for patients with large vessel occlusion ischaemic stroke being transferred for endovascular thrombectomy: a Victorian state-wide study

Joseph Zhi Wen Wong  1   2 , Helen M Dewey  1   3 , Bruce C V Campbell  2 , Peter J Mitchell  4 , Mark Parsons  2 , Thanh Phan  5   6 , Ronil V Chandra  6   7 , Henry Ma  5   6 , Alexandra Warwick  8 , Mark Brooks  9 , Vincent Thijs  8 , Essie Low  2 , Tissa Wijeratne  10 , Sharon Jones  11 , Ben Clissold  11 , Mei Yan Ngun  12 , Douglas Crompton  12 , Rumes Kanna Sriamareswaran  13 , Jayantha Rupasinghe  13 , Karen Smith  14 , Chris Bladin  15   16 , Philip M C Choi  1   3
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Door-in-door-out times for patients with large vessel occlusion ischaemic stroke being transferred for endovascular thrombectomy: a Victorian state-wide study

Joseph Zhi Wen Wong et al. BMJ Neurol Open. .

Abstract

Background: Time to reperfusion is an important predictor of outcome in ischaemic stroke from large vessel occlusion (LVO). For patients requiring endovascular thrombectomy (EVT), the transfer times from peripheral hospitals in metropolitan and regional Victoria, Australia to comprehensive stroke centres (CSCs) have not been studied.

Aims: To determine transfer and journey times for patients with LVO stroke being transferred for consideration of EVT.

Methods: All patients transferred for consideration of EVT to three Victorian CSCs from January 2017 to December 2018 were included. Travel times were obtained from records matched to Ambulance Victoria and the referring centre via Victorian Stroke Telemedicine or hospital medical records. Metrics of interest included door-in-door-out time (DIDO), inbound journey time and outbound journey time.

Results: Data for 455 transferred patients were obtained, of which 395 (86.8%) underwent EVT. The median DIDO was 107 min (IQR 84-145) for metropolitan sites and 132 min (IQR 108-167) for regional sites. At metropolitan referring hospitals, faster DIDO was associated with use of the same ambulance crew to transport between hospitals (75 (63-90) vs 124 (99-156) min, p<0.001) and the administration of thrombolysis prior to transfer (101 (79-133) vs 115 (91-155) min, p<0.001). At regional centres, DIDO was consistently longer when patients were transported by air (160 (127-195) vs 116 (100-144) min, p<0.001). The overall door-to-door time by air was shorter than by road for sites located more than 250 km away from the CSC.

Conclusion: Transfer times differ significantly for regional and metropolitan patients. A state-wide database to prospectively collect data on all interhospital transfers for EVT would be helpful for future study of optimal transport mode at regional sites and benchmarking of DIDO across the state.

Keywords: cerebrovascular disease; interventional; stroke.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Map showing geographic distribution of all stroke centres included in this study. CSC, comprehensive stroke centre; metro, metropolitan sites; VST, Victorian Stroke Telemedicine sites.
Figure 2
Figure 2
Flow chart summarising the inclusion and exclusion of patients for the study. CSC, comprehensive stroke centre; EVT, endovascular thrombectomy.
Figure 3
Figure 3
Boxplots comparing DIDO and use of the same outbound crew, stratified by regional and metropolitan sites. The difference was found to be statistically significant at metropolitan sites in univariate and multivariate analyses. DIDO, door-in-door-out time.
Figure 4
Figure 4
Graph comparing road and air transport at regional sites which used both modes of transport. Not all transfers occurred to the closest CSC for that site and these data were excluded from the graph. University Hospital Geelong is considered a metropolitan primary stroke centre within the Victorian system. It is the only metropolitan site which used air and road transport. CSC, comprehensive stroke centre; DIDO, door-in-door-out time.
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