Department of Neurology, University of Michigan, Ann Arbor.
Department of Neurology, Northwestern University, Chicago, Illinois.
JAMA. 2023 Aug 15;330(7):636-649. doi: 10.1001/jama.2023.12739.
Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED).
To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.
DESIGN, SETTING, AND PARTICIPANTS: US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.
Patient- and hospital-level characteristics.
The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.
Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.
In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.
并非每家医院都能提供治疗急性中风的时间敏感型治疗，往往需要医院间转移。目前的指南建议，在转诊急诊室（ED），门到门的时间不超过 120 分钟。
评估美国心脏协会 Get With The Guidelines-Stroke 注册中心急性中风转院的门到门时间，并确定与门到门时间相关的患者和医院因素。
设计、地点和参与者：这是一项基于美国注册中心的回顾性研究，研究对象为 2019 年 1 月至 2021 年 12 月期间从注册中心附属医院转至其他急性护理医院的缺血性或出血性中风患者。
患者和医院水平的特征。
主要结果是门到门时间（转移出时间减去到达转诊 ED 的时间）作为连续变量和分类变量（≤120 分钟，＞120 分钟）。使用广义估计方程（GEE）回归模型来确定患者和医院水平的特征与门到门时间之间的总体关系以及出血性中风、急性缺血性中风适合血管内治疗和急性缺血性中风因血管内治疗以外的其他原因转院的亚组之间的关系。
在从 1925 家医院转来的 108913 名患者（平均[SD]年龄，66.7[15.2]岁；71.7%非西班牙裔白人；50.6%男性）中，67235 名患者患有急性缺血性中风，41678 名患者患有出血性中风。总体而言，中位数门到门时间为 174 分钟（IQR，116-276 分钟）：29741 名患者（27.3%）门到门时间为 120 分钟或更短。与中位数时间较长显著相关的因素包括年龄 80 岁或以上（与 18-59 岁相比；14.9 分钟，95%CI，12.3 至 17.5 分钟）、女性（5.2 分钟；95%CI，3.6 至 6.9 分钟）、非西班牙裔黑人与非西班牙裔白人（8.2 分钟，95%CI，5.7 至 10.8 分钟）和西班牙裔与非西班牙裔白人（5.4 分钟，95%CI，1.8 至 9.0 分钟）。与中位数门到门时间较短显著相关的因素包括：急诊医疗服务预先通知（-20.1 分钟；95%CI，-22.1 至-18.1 分钟）、国家卫生研究院中风量表（NIHSS）评分超过 12 分与评分 0 至 1 分（-66.7 分钟；95%CI，-68.7 至-64.7 分钟）和急性缺血性中风适合血管内治疗的患者与出血性中风亚组（-16.8 分钟；95%CI，-21.0 至-12.7 分钟）。在适合血管内治疗的急性缺血性中风患者中，女性、黑人种族和西班牙裔与门到门时间显著延长相关，而急诊医疗服务预先通知、静脉溶栓和更高的 NIHSS 评分与门到门时间显著缩短相关。
在这项基于美国注册中心的急性中风医院间转移研究中，中位数门到门时间为 174 分钟，长于急性中风转移的当前推荐。与较长门到门时间相关的差异和可改变的卫生系统因素是质量改进计划的合适目标。
