Abstract TP189: Improving Door-In-Door-Out Metrics in Acute Stroke: A Statewide Quality Journey

Background: Timely access to mechanical thrombectomy remains a challenge, with many patients requiring secondary transfer. The Louisiana Emergency Response Network (LERN) collects quarterly data from stroke centers, including large vessel occlusion (LVO) screening and interfacility transfer metrics. Hospitals with median door in-door out (DIDO) time exceeding 180 minutes or falling in the highest quartile are subject to remediation, including Action Plans and monthly mock stroke codes, and on-site reviews. Phase I targets a median DIDO time of < 90 minutes. Methods: We analyzed aggregate data from primary stroke centers (PSCs) without 24/7 thrombectomy access, and separately from Acute Stroke Ready Hospitals (ASRHs), submitting expanded datasets. Metrics included NIHSS scores, door-to-transfer-request (DTTRT) times, and DIDO times. LVO screening practices (clinical tool vs. imaging) were tracked in ASRHs over time. Results: Among PSCs, the majority arrived by EMS. From Q1/Q2 2021 to Q1 2025, DTTRT improved from 52 to 37 minutes. DIDO decreased from 124 to 94 minutes in Q1 2025, with 44.9% of cases meeting the < 90-minute target. In ASRHs, LVO screening rates increased from 89% to 95%, though the screening positive rates (7.6%-18.1%) declined as imaging-based screening replaced clinical tools. DTTRT dropped from 58 to 46 minutes and DIDO improved from 133 to 104 minutes, with 31.6% meeting the target. Key contributors to delay include ambulance availability, transfer acceptance delays, and diagnosis lag due to imaging. Conclusions: Transfer efficiency has improved statewide, with measurable reductions in DTTRT and DIDO and increased compliance with Phase I goals. Eight PSCs and five ASRHs now qualify for advancement to Phase II DIDO, targeting a median < 75 minutes. Further efforts should prioritize DTTRT reductions.