Written by Darin Vercillo, MD, Chief Medical Officer, Central Logic
LinkedIn Hard Cases— May, 2019 — A 64-year-old female patient presents to the emergency department of our suburban community hospital with acute confusion, aphasia, and right sided facial droop. Code stroke called. Labs drawn. Telestroke initiated. Imaging shows large vessel occlusion (LVO).
Though the diagnosis is not difficult to make, the dilemma we face—and that many hospitals face at this point—is how to optimize management. In this case, three hospitals downtown can perform endovascular thrombectomy. It is time to transfer. However, this patient’s transfer takes much longer than it should, when every minute matters.
Nearly every clinician has a horror story about a transfer such as this one that took too long, regardless of which end we were on. We get bounced around between providers and are forced to repeat information multiple times. Transports or records are delayed. When the patient arrives, nothing is arranged and further delays occur. There was one such case that kept me from calling a particular hospital’s transfer center back for years. Though delays and mismanagement are inconvenient—or even distressing—for us as providers, ultimately it is the patient that is harmed in these situations.
Clinical cases that hit home the hardest do not always stand out because they are particularly rare, puzzling or complex. Some cases that grab your attention, such as this one, are fairly routine issues—but they burn brightly in your mind because you know that modifications to the clinical approach or streamlining operational efficiencies could improve outcomes.
I was reminded of this while reviewing a recent study published in the American Heart Association’s (AHA’s) peer-reviewed journal Circulation. The study identified a concerning trend: When patients diagnosed with a stroke need to be transferred from a smaller hospital to a specialty center for endovascular therapy (“EVT”—mechanical removal of a blood clot that caused the stroke), treatment is often delayed.
Researchers found, as one would expect, that delays cause worse outcomes in these patients, and the authors’ findings included a deeply concerning correlation: Increasingly common interhospital transfers (>500 percent growth over five years) for endovascular therapy are associated with an average 63.7-minute delay in initiating EVT.
It is natural to wonder if this problem could be solved by avoiding transferring these patients in the first place, since the transfer process may be associated with delays in treatment. However, that’s simply not possible: Not every patient who presents with “stroke-like” symptoms can be routed directly to an EVT-capable, comprehensive stroke center. This would overload the system with every atypical migraine, transient ischemic attack (TIA), medication reaction and many other presenting issues. Diagnosis must be made first, and routing decisions after.
There is also the simple reality of access—statistically speaking, the vast majority who have a stroke will arrive at a hospital not equipped to perform EVT; so, if medical therapy is not successful, it’s likely they will need to be transferred—emergently.
Why the need for patient transfers is exploding
Transfers are likely to grow in the future, for these patients and many others, due to a number of reasons. They include: health system consolidation with a trend towards specialty centers, access to care barriers in rural areas and other healthcare “deserts,” and community hospitals not equipped to perform EVT or other specialized interventions.
The solution lies in optimizing the process to reduce the time from intake to diagnosis to transfer to treatment, so that these patients receive the right level of specialized care without unnecessary delay. For example, techniques such as VAN assessments can help triage patients to CT angiography versus conventional. In combination with a widening window of allowable tissue plasminogen activator (tPA—or “clot buster”) administration, improved information-sharing, and other advancements, even more valuable time can be saved and improvements in outcomes realized.
We should also examine and address delays inherent in the unoptimized transfer process for patients who have had strokes. These issues can be addressed with programs that utilize technology, workflow design and other best practices, including:
- Establishing formal agreements with transport providers and using available technology to mobilize ground, flight and clinical teams earlier, and more quickly.
- Implementing protocols to pre-admit patients and leveraging technology and quality improvement programs that focus on reducing the time to treatment. For example, a waiting “arrival zone” stroke team will bypass the ED and ICU, routing the patient straight to the neurovascular lab, with the interventionalist ready. Such an improvement could reduce time-to-treatment by up to 45 minutes.
- Improving image-sharing capabilities so neurointerventionalists can better prepare, and so studies will not be repeated prior to puncture (a recurring delay noted in an earlier study published in Circulation, the 2017 Froehler study of STRATIS data).
- Effectively employing telestroke to shorten evaluation and diagnostic times at smaller hospitals.
For stroke patients, and many other patients who need specialty care, minutes matter. The March 2019 Circulation study demonstrates that fact clearly.
Optimizing transfers for optimal outcomes
When taken as a whole, these and other similar studies underscore the need to optimize the transfer process across healthcare. If we do not, every case involving a transfer will only become more challenging for care teams, more resource-intensive for healthcare organizations, more stressful for patients and their families, and less likely to result in optimal outcomes.
When we look at patient transfers holistically—for all patients, in all care settings—it is clear that the fundamental way to improve outcomes is to shave off minutes at every point possible. As providers, we will be able to approach these situations more confidently and systematically.
More importantly, as in the case of our 64-year-old female patient discussed earlier, this may make the difference between achieving an outcome of normalcy, as opposed to suffering a lifetime of terrible debility.
We cannot change the fact that patients will continue to need inter-facility transfers. We can however, ensure that accurate decisions are made promptly, their journey is as efficient as possible, that they arrive at their destination fully prepped, and that the receiving care team has all the information needed to deliver the right care without delay.