We sought to characterize transfer workflow from regional facilities to comprehensive stroke center (CSC) in a rural hub and spoke stroke network.

The inter-facility transfer process is a critical component in the treatment of large vessel occlusion stroke in the era of mechanical thrombectomy. Delays in transfer can lead to poor outcomes in these patients despite successful recanalization.

Consecutive patients transferred from 17 facilities to a single comprehensive stroke center between September 2017 and May 2018 were included in a retrospective study. Demographics, originating hospital status (rural vs. urban; rural defined as population <50, 000 people), thrombolysis frequency and inter-facility key time metrics were collected.

Sixty-four patients were identified. Median age was 70.9 years (interquartile range [IQR], 62.5–84.5), 53.1% were female, 35.9% received thrombolysis and 82.1% originated from a rural facility. Median transfer time measured by regional facility door-to-CSC door (D2D) was 140 minutes of which 67.8% was spent at the regional facility (door-in-door-out [DIDO]; 95 minutes; IQR, 65.0-149). The longest component of DIDO was the door-first contact with CSC team (median 58 minutes; IQR, 39–86). 82.8% patients had DIDO exceeding 60 minutes benchmark of our network. Median transport time was 45 minutes (IQR 31-60) and constituted 32% of D2D.

In a large rural hub-and-spoke stroke network, D2D and DIDO times are long. Major delays were observed in first contact with CSC team and transport time. Improving network workflow through parallel processing and early call for interventional plan represents a major opportunity to expedite thrombectomy.