To identify systematic delays in large vessel occlusion (LVO) evaluation workflow  to optimize door-to-device (DTD) times.

Earlier onset to endovascular treatment (EVT) for LVO patients is critical for decreasing mortality and improving functional outcomes. In 2015, Target: Stroke Phase III established new targets for EVT in direct arriving (ED) patients including DTD within 90 minutes in at least 50% of patients.

A retrospective review was conducted of all stroke codes in a suburban teaching hospital ED involving LVO patients from January 2019 to December 2020. Timestamps of acute care management were obtained from stroke code documentation, radiology scan timestamps, and interventional radiology (IR) operative notes. T-test statistics were conducted comparing timestamps against hospital and clinical factors including off-hours, hospital pre-notification, tPA administration, or need for intubation.

77 LVO patients were identified with a mean age of 77 (IQR: 67, 89), with 18/77 (23.4%) cases occurring during weekends and 40/77 (51.9%) occurring during off-hours. A total of 46 (59.7%) underwent EVT with 30/77 (39.0%) receiving tPA and 46/77 (14.3%) requiring intubation. The median DTD time was 112.5 minutes (IQR: 83.3, 132) with 14/46 (30.4%) within the 90 minute window. Sequentially, median time to first CT image was 9 minutes (IQR: 5, 20), LVO detection to IR activation was 15 minutes (IQR: 12, 25), IR activation to device deployment was 65 minutes (IQR: 47, 75). Identified delays include delay in arrival to angiosuite during off-hours, with median time of 74 minutes compared to 50 minutes during on-hours (p = 0.013).

This review of ED stroke codes identified multiple targeted inventions to optimize DTD including faster notification of IR team after LVO detection and improving off-hour evaluation of LVO patients. An ongoing quality improvement initiative is currently underway to target these delays.