Interhospital transfer linked to treatment delays, worse outcomes in stroke patients

January 31, 2019 – Patients who were moved between hospitals before receiving endovascular therapy were more likely to experience adverse clinical outcomes.

Endovascular therapy (EVT) presents a good chance of saving stroke patients’ lives, but because the treatment is not available at every hospital, many patients must transfer hospitals before they can receive this chance. New research published today in Circulation indicates that stroke patients who undergo interhospital transfer experience longer delays before receiving endovascular therapy and have worse outcomes.

Shreyansh ShahThe article, authored by the DCRI’s Shreyansh Shah, MD, (pictured) and Ying Xian, MD, PhD, examined data from the American Heart Association’s Get With the Guidelines-Stroke registry, which includes ischemic stroke patients from more than 2,000 hospitals across the U.S.

The team found that between 2012 and 2017, almost 43 percent of the 37,620 patients who received EVT received the treatment after transferring hospitals. Because EVT, also known as mechanical thrombectomy, requires a trained person to administer the treatment as well as special equipment, not every hospital has the capacity to offer the treatment. However, referral rates for EVT continued to rise throughout the study period, which Xian said is because strong evidence supporting the efficacy of EVT was published in 2015.

The team found that while EVT can be effective, interhospital transfers can have consequences. Patients who transferred hospitals were more likely to develop symptomatic intracranial hemorrhage (7.0 percent versus 5.7 percent). They were also less likely to be able walk independently at discharge (33.1 percent versus 37.1 percent) or to be discharged to home (24.3 percent versus 29.1 percent).

These differences in outcomes could be at least partially attributed to longer wait times that transfer-in patients experience, said Shah, who recently received a “Stroke Care in Emergency Medicine” award from the American Heart Association and the American Stroke Association. The study examined the time from last known well to EVT initiation and found that transfer patients had a significantly longer wait time (median 289 minutes) than patients who arrived at a hospital that offers EVT (median 213 minutes). However, the transfer-in patients were more likely to have a door to EVT initiation time of less than 90 minutes upon arriving at the EVT-offering hospital (65.6 percent versus 23.6 percent).

“Patients who must transfer hospitals experience a longer wait time before receiving treatment,” Shah said. “In stroke patients, time is critical because as time progresses, the brain deteriorates and there is less we can do to salvage the brain and help the patient.”

Shah said the team’s findings will be of assistance as hospitals collaborate to create stroke systems of care.

“The reason this collaboration is needed is because everyone is starting to realize that stroke patients need treatment as soon as possible,” he said. “The only way we can deliver treatment urgently is if we join hands together across institutions.”

To avoid interhospital transfers and combat the risk of worsened outcomes, the authors of the manuscript have several recommendations. Firstly, EMS professionals need to receive more education and training so that they can accurately determine when a patient is having a stroke potentially caused by a large vessel occlusion, meaning that EVT could be beneficial. Regulatory changes would also help because they would allow EMS professionals to take these patients to the nearest hospital that offers EVT rather than requiring patients to be transported to the nearest hospital.

Another potential solution is to increase the number of hospitals that can provide EVT by creating mobile teams of specialists that are not based in a specific location. For example, Shah said, Duke has a team that moves between Duke University Hospital in Durham and Duke Raleigh Hospital, which enables Wake County stroke patients to receive treatment at their local hospital rather than be transferred to Durham.

In addition to policy and organizational changes, Xian said, it is important to continue to educate the public about symptoms of a stroke so patients will know to seek help before they miss the window for treatment. The American Stroke Association uses the acronym FAST—Face (changes in expression), Arm (difficulty moving or grasping), Speech (slurring of words), and Time (Call 911 as soon as possible).