Related Experiment Video
Updated: Oct 18, 2025
Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide
Published on: January 15, 2017
Door-In-Door-Out Process Times at Primary Stroke Centers in Chicago
Shyam Prabhakaran1, Rebeca Khorzad2, Zahra Parnianpour3
1Department of Neurology, The University of Chicago, Chicago, IL.
Insights
Reducing door-in-door-out times for acute stroke patients is crucial. Key modifiable factors include optimizing CT angiography, alteplase administration, and ambulance request processes to improve patient transfer efficiency.
Area of Science:
- Neurology
- Emergency Medicine
- Healthcare Quality Improvement
Background:
- Interfacility transfer of acute stroke patients from primary to comprehensive stroke centers is common.
- Time-sensitive endovascular reperfusion necessitates reducing door-in-door-out times at primary stroke centers for quality improvement.
Purpose of the Study:
- To identify modifiable predictors of door-in-door-out times in acute stroke patients transferred from Chicago-region primary stroke centers.
Main Methods:
- Retrospective analysis of 191 acute stroke patients transferred between February 2018 and January 2020.
- Data abstracted by stroke coordinators included transport type, interventions, and time intervals.
- Median regression models evaluated predictors of door-in-door-out time.
Main Results:
- Median door-in-door-out time was 148.5 minutes.
- Significant contributors to delay included CT to CT angiography time and transfer ambulance time at the primary center.
- Factors associated with longer times: CT angiography at primary center, walk-in arrival, intubation.
- Factors associated with shorter times: alteplase administration, ambulance request by primary center.
Conclusions:
- Chicago-area primary stroke centers average nearly 150 minutes for door-in-door-out time.
- Interventions targeting CT angiography, alteplase administration, and ambulance request timing are crucial for reducing transfer delays.
Study Objective:
Acute stroke patients often require interfacility transfer from primary stroke centers to comprehensive stroke centers. Given the time-sensitive benefits of endovascular reperfusion, reducing door-in-door-out time at the primary stroke center is a target for quality improvement. We sought to identify modifiable predictors of door-in-door-out times at 3 Chicago-region primary stroke centers.
Methods:
We performed a retrospective analysis of consecutive patients with acute stroke from February 1, 2018 to January 31, 2020 who required transfer from 1 of 3 primary stroke centers to 1 of 3 affiliated comprehensive stroke centers in the Chicago region. Stroke coordinators at each primary stroke center abstracted data on type of transport, medical interventions and treatments prior to transfer, and relevant time intervals from patient arrival to departure. We evaluated predictors of door-in-door-out time using median regression models.
Results:
Of 191 total patients, 67.9% arrived by emergency medical services and 57.4% during off-hours. Telestroke was performed in 84.2%, 30.5% received alteplase, and 48.4% underwent a computed tomography (CT) angiography at the primary stroke center. The median door-in-door-out time was 148.5 (interquartile range 106 to 207.8) minutes. The largest contributors to door-in-door-out time, in minutes, were CT to CT angiography time (22 [7 to 73.5]), transfer center contact to ambulance request time (20 [8 to 53.3]), ambulance request to arrival time (20.5 [14 to 36]), and transfer ambulance time at primary stroke center (26 [21 to 35]). Factors associated with door-in-door-out time were (adjusted median differences, in minutes [95% confidence intervals]): CT angiography performed at primary stroke center (+39 [12.3 to 65.7]), walk-in arrival mode (+53 [4.1 to 101.9]), administration of intravenous alteplase (-29 [-31.3 to -26.7]), intubation at primary stroke center (+23 [7.3 to 38.7]), and ambulance request by primary stroke center (-20 [-34.3 to -5.7]).
Conclusion:
Door-in-door-out times at Chicago-area primary stroke centers average nearly 150 minutes. Reducing time to CT angiography, receipt of alteplase, and ambulance request are likely important modifiable targets for interventions to decrease door-in-door-out times at primary stroke centers.
