Gurmeen Kaur, MBBS
The current decade has seen a revolution in stroke care with the advent of endovascular therapy (EVT) and extended timelines for stroke intervention. With the expansion of stroke care, there is a tremendous increase in the need for angiographic suites and providers. Most smaller, non thrombectomy capable centers have set up contracts with academic or bigger centers nearby to transfer their stroke patients for emergent large vessel occlusions.
However, given that the number of treatable strokes far exceeds the number of thrombectomy capable centers, it is the right time to review our nationwide policies on transfers for improved patient care and quality improvement. In this paper, authors Shah et al. have done a great job elucidating the temporal trends in transfer of patients for EVT and how those transfer trends are influencing the final outcome, using the Get with the Guidelines database.
The authors found that transfer-in patients had significantly longer last known well to EVT initiation time (median 289 min vs 213 min, absolute standardized difference 67.33), but were more likely to have door to EVT initiation time of ≤ 90 minutes (65.6% vs 23.6%, absolute standardized difference 93.18). This is explained by the fact that the endovascular teams are mostly pre-notified and ready to receive a transfer patient for endovascular therapy versus it takes longer to activate the necessary resources in case of a direct walk-in stroke.
The authors also found that even when adjustment was made for age, sex, race, NIHSS, IV tPA use, the transfer group had worse outcomes with respect to symptomatic intracranial hemorrhage, discharge destination and ambulation at discharge. The in-hospital mortality was also higher in the transfer group in unadjusted models, but this difference disappeared in the adjusted models.
These findings raise significant concerns regarding our current practice of transfer from primary to comprehensive stroke centers. According to the authors, expanding EVT capability to more centers can improve access, but will have to be balanced with the need for maintaining sufficient case volume and competence of EVT providers at these new centers. Additionally, the EMS bypass strategy of direct transfer to thrombectomy capable center if pre-hospital stroke scale is high may be a viable solution in years to come. Future studies should look closely at outcomes of implementing bypass strategies, as well as more efficient means of transfer via on site transport teams and better network between the hub and the spoke hospital.