Skip to main content
  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Circulation Doodle
      • Doodle Gallery
      • Circulation Cover Doodle
        • → Blip the Doodle
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
    • Subscribe to AHA Journals
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
      • Recently Published Guidelines
    • Bridging Disciplines
    • Circulation at Major Meetings
    • Special Themed Issues
    • Global Impact of the 2017 ACC/AHA Hypertension Guidelines
    • Circulation Supplements
    • Cardiovascular Case Series
    • ECG Challenge
    • Hospitals of History
      • Brigham and Women's Hospital
      • Hartford Hospital
      • Hospital Santa Maria del Popolo, Naples, Italy
      • Instituto do Coração-INCOR (São Paulo, Brasil)
      • Minneapolis City Hospital
      • Parkland Hospital: Dallas, Texas
      • Pennsylvania Hospital, Philadelphia
      • Pitié-Salpêtrière Hospital
      • Royal Infirmary of Edinburgh, Scotland
      • Tufts Medical Center
      • University of Michigan
      • Uppsala University Hospital
      • Vassar Brothers Medical Center (Poughkeepsie, NY)
      • Wroclaw Medical University
      • Women's College Hospital, Toronto, Canada
      • Henry Ford Hospital, Detroit, Michigan
      • Instituto Nacional de Cardiología Ignacio Chávez – INCICh México City, México
      • Kuang-Tien General Hospital (Taichug, Taiwan)
    • On My Mind
    • Podcast Archive
    • → Subscribe to Circulation on the Run
    • →Circulation FIT Podcast 2018
    • → #FITFAVs
  • Resources
    • Instructions for Authors
      • Accepted Manuscripts
      • Revised Manuscripts
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • Circulation CME
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
  • Facebook
  • Twitter

  • My alerts
  • Sign In
  • Join

  • Advanced search

Header Publisher Menu

  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

Circulation

  • My alerts
  • Sign In
  • Join

  • Facebook
  • Twitter
  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Circulation Doodle
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
    • Subscribe to AHA Journals
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
    • Bridging Disciplines
    • Circulation at Major Meetings
    • Special Themed Issues
    • Global Impact of the 2017 ACC/AHA Hypertension Guidelines
    • Circulation Supplements
    • Cardiovascular Case Series
    • ECG Challenge
    • Hospitals of History
    • On My Mind
    • Podcast Archive
    • → Subscribe to Circulation on the Run
    • →Circulation FIT Podcast 2018
    • → #FITFAVs
  • Resources
    • Instructions for Authors
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • Circulation CME
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
Original Article

“Picture to Puncture”Clinical Perspective

A Novel Time Metric to Enhance Outcomes in Patients Transferred for Endovascular Reperfusion in Acute Ischemic Stroke

Chung-Huan J. Sun, Raul G. Nogueira, Brenda A. Glenn, Kerrin Connelly, Susan Zimmermann, Kim Anda, Deborah Camp, Michael R. Frankel, Samir R. Belagaje, Aaron M. Anderson, Alexander P. Isakov, Rishi Gupta
Download PDF
https://doi.org/10.1161/CIRCULATIONAHA.112.000506
Circulation. 2013;127:1139-1148
Originally published March 11, 2013
Chung-Huan J. Sun
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Raul G. Nogueira
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Brenda A. Glenn
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kerrin Connelly
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Susan Zimmermann
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kim Anda
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Deborah Camp
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael R. Frankel
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Samir R. Belagaje
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Aaron M. Anderson
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alexander P. Isakov
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rishi Gupta
From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (C.J.S., R.G.N., B.A.G., M.R.F., S.R.B., A.M.A., R.G.); Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., B.A.G., K.C., M.R.F., S.R.B., A.M.A., R.G.); Wellstar Kennestone Regional Medical Center, Marietta, GA (S.Z.); Southern Regional Medical Center, Riverdale, GA (K.A.); Atlanta Medical Center, Atlanta, GA (D.C.); and Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA (A.P.I.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters

Jump to

  • Article
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Disclosures
    • Footnotes
    • References
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters
Loading

Abstract

Background—Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome.

Methods and Results—This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P=0.009).

Conclusions—Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

  • cerebral infarction
  • cerebrovascular disease
  • stroke

Introduction

Time is a critical component in the treatment of acute ischemic stroke.1 Delays to treatment not only preclude patients from available therapies but also influence neurological outcomes.2 Despite guidelines advocating the initiation of intravenous tissue plasminogen activator (tPA) within 60 minutes of patient arrival, <26.6% of tPA patients achieve this goal, with <5% of all stroke patients receiving intravenous tPA at all.3,4 The advent of endovascular reperfusion therapies has subsequently broadened the time window for treatment to 8 hours, heralding an opportunity to treat patients with larger clot burdens who do not qualify for tPA treatment or patients in whom intravenous tPA has failed. In 2000, the Brain Attack Coalition developed the comprehensive stroke center (CSC) model as an opportunity to consolidate the care of ischemic stroke patients within specialized centers of excellence, granting wider access to endovascular treatments within the community.5 The challenge to this treatment paradigm, however, is that despite technological advancements in the angiography suite, improved reperfusion rates have yet to be concordant with better neurological outcome.6 Significant delays in transferring patients to centers that provide endovascular therapy may be one of the reasons. A recent single-center retrospective study suggested that for every minute of delay in transfer, there is a 2.5% lower probability that a patient receives endovascular therapy.7 The timing from symptom onset to angiographic reperfusion itself has also been implicated as a predictor of clinical outcomes in intra-arterial treatment (IAT), with no significant benefit beyond 6 hours.8 We sought to determine the amount of delay that currently exists in the interhospital transferring of patients to our center with an emphasis on the time from outside hospital computed tomography (CT) to groin puncture at our facility (“picture-to-puncture” [P2P] time). With the assumption that this metric encompasses the continuum of care from initial imaging to treatment, our goal was to investigate the impact of P2P times on patient outcomes and to develop strategies for streamlining system processes to minimize these delays.

Clinical Perspective on p 1148

Methods

Approval for the study was granted by the institutional review board of our institution. A retrospective review of a prospectively maintained database was performed on consecutive patients with IAT for large-vessel occlusive disease between November 1, 2010, and July 10, 2012. These were patients in whom intravenous tPA within 4.5 hours of presentation had failed (<4-point improvement in National Institutes of Health Stroke Scale [NIHSS] score on arrival to our institution), or they were not candidates for intravenous tPA. All large-vessel occlusion patients who were transferred but did not receive IAT were also documented over the same time frame. Patients in this cohort were excluded from IAT because of having an Alberta Stroke Program Early CT Score (ASPECTS) of <5 on follow-up imaging at our institution.9

Among the patients who received IAT, data were collected on demographics, past medical history, baseline laboratory values, clinical assessments, radiographic findings, and angiographic data along with 90-day modified Rankin Scale scores that were performed by a certified examiner blinded to the procedure results. We considered the following time intervals for analysis: last known normal (LKN) to arrival at the outside hospital, arrival at outside hospital to initial CT, initial CT to first CSC telephone call, CSC telephone call to arrival of emergency medical services (EMS), arrival of EMS to CT at our institution, CT at our institution to groin puncture, and groin puncture to reperfusion. Patients who were treated from our emergency department had data collected on LKN to arrival, arrival to initial CT, initial CT to groin puncture, and groin puncture to reperfusion. We also considered patients who underwent multimodal imaging with CT angiography and/or CT perfusion either at our institution or at an outside facility to determine its impact on time. The frequency and timing of neurology consultations at the referring facilities were documented for all transferred patients. CT images obtained at our facility were reviewed for ASPECTS, with favorable ASPECTS defined as >7 for purposes of analysis. Our protocol was to transfer patients with a NIHSS score ≥10 and an ASPECTS >7 at the outside facility. A repeat CT image was performed on arrival if the patient received intravenous tPA and/or presented >60 minutes from the initial CT scan at the outside hospital. The Totaled Health Risks in Vascular Events (THRIVE) score was tabulated to compare the neurological prognosis of patients treated from our emergency department with that of outside hospital transfers.10 All images were reviewed for angiographic reperfusion and graded with the use of the Thrombolysis in Cerebral Infarction scale, in which Thrombolysis in Cerebral Infarction category 2B was denoted as reperfusion of more than two thirds of the vascular territory.11 Successful reperfusion was defined as Thrombolysis in Cerebral Infarction category 2B or 3. Symptomatic hemorrhage was defined as a development of parenchymal hematoma type 1 or type 2 bleeds within 36 hours of the procedure according to the European Cooperative Acute Stroke Study definition.12 Data pertaining to modes of transportation and total distances traveled were collected for all outside hospital transfers.

Statistical Analysis

An analysis was performed comparing the baseline characteristics between patients arriving from outside hospitals and those admitted directly to our local emergency department. All continuous variables including transfer times and internal processing times were analyzed with the use of Student t tests and Mann-Whitney U tests, as determined by the equality of variances and distribution. Mann-Whitney U, Fisher exact, and χ2 tests were calculated for all categorical and ordinal variables, as appropriate. A univariable analysis was subsequently performed to identify potential factors associated with good clinical outcome after endovascular reperfusion. All variables with P<0.20 on univariable modeling were included for multivariable analysis. Entry of factors into the model was verified by multicollinearity testing. A likelihood ratio test was also performed to compare the current model with an alternative model with P2P excluded to determine whether P2P enhanced the model. Correlations between distance traveled and transfer times were determined by Spearman rank correlation testing. A separate logistic regression model was also generated to identify predictors of emergent angiography among transferred patients, including those with large-vessel occlusions who failed to qualify for IAT.

Results

We reviewed 250 consecutive patients who received IAT at our institution over a 21-month period. A total of 183 anterior large-vessel occlusion transfers occurred during this time, of which 152 (83%) were treated with IAT and 31 (17%) failed to receive endovascular intervention. A total of 57 IAT patients were excluded from the study, as described in Figure 1. Of the 193 patients with IAT analyzed, 132 (68.4%) were outside hospital transfers, and 61 (31.6%) were local emergency department admissions.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Flow chart description of patient selection and exclusion for all analyses and subanalyses. ED indicates emergency department; GP, groin puncture; IAT, intra-arterial treatment; LKN, last known normal; and LVO, large-vessel occlusion.

The mean age and median NIHSS score for the cohort were 65.8±14.5 years and 19 (interquartile range [IQR], 15–23), respectively, with an overall good outcome rate of 35.7%. Table 1 summarizes the baseline differences between patients arriving from outside facilities and those who were admitted directly to our local emergency department. Of note, patients from outside hospitals had a lower probability of favorable ASPECTS (50% versus 76%; P<0.001) before treatment at our CSC as well as longer time intervals from LKN to groin puncture (301 minutes [IQR, 252–362] versus 177 minutes [IQR,145–268]; P<0.001) compared with the local cohort. Additionally, the time from P2P was significantly prolonged among transferred patients by >2-fold (205 minutes [IQR, 162–274] versus 89 minutes [IQR, 70–119]; P<0.001). The combination of fewer patients with favorable ASPECTS and lengthy P2P times was associated with a substantially lower rate of good clinical outcomes in the transferred cohort (29% versus 51%; P=0.003). There was also a decreased prevalence of hypertension among the outside hospital patients (69% versus 84%; P=0.03), with a trend toward higher rates of symptomatic hemorrhage (9% versus 2%; P=0.07). The 2 groups were otherwise comparable with regard to age, past medical history, rates of intravenous tPA delivery, and reperfusion success. No differences in baseline NIHSS, THRIVE, or Acute Physiology and Chronic Health Evaluation II scores were observed on first hospital admission.

View this table:
  • View inline
  • View popup
Table 1.

Baseline Patient Characteristics Between Local ED Admissions and Outside Hospital Transfers

All variables associated with patient outcome were identified on univariable testing (Table I in the online-only Data Supplement). In a binary logistic regression model adjusted for age, gender, reperfusion success, NIHSS scores, hypertension, symptomatic hemorrhage, and endovascular procedure time (Table 2), the P2P time was an independent predictor of patient outcome (odds ratio [OR], 0.994; 95% confidence interval [CI], 0.990–0.999; P=0.009). A likelihood ratio test comparing the current model with an alternative model without P2P yielded a critical value of 7.7 with 1 degree of freedom (P<0.01). This confirmed that the addition of P2P enhanced the model. ASPECTS and transfer status were withheld from the model because of significant collinearity with P2P times. When a P2P reference of <90 minutes was used, patients treated at subsequent intervals of 91 to 180 minutes, 181 to 270 minutes, and >270 minutes had adjusted ORs of 0.30 (95% CI, 0.11–0.81; P=0.018), 0.32 (95% CI, 0.11–0.93; P=0.036), and 0.18 (95% CI, 0.05–0.64; P=0.008) in association with good outcomes, respectively (Figure 2A). The ORs of patients with favorable ASPECTS similarly declined to 0.22 (95% CI, 0.07–0.70), 0.19 (95% CI, 0.06–0.62), and 0.16 (95% CI, 0.04–0.57) across the same time intervals (Figure 2B).

View this table:
  • View inline
  • View popup
Table 2.

Binary Logistic Regression Model Identifying Factors Associated With Good Outcome After Endovascular Treatment for Acute Ischemic Stroke

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

A, Depiction of good outcome rates at differing time intervals of picture to puncture (P2P). Unadjusted good outcome rates and adjusted odds ratios (ORs) are shown. B, Depiction of favorable Alberta Stroke Program Early CT Score (ASPECTS) at differing time intervals of P2P. Unadjusted favorable ASPECTS percentages and adjusted ORs are shown. CI indicates confidence interval.

When ASPECTS was forced into the binary logistic regression model, favorable ASPECTS on preprocedural imaging revealed the strongest association with good outcome (OR, 9.04; 95% CI, 3.34–24.52; P<0.001), whereas P2P was no longer significant (OR, 0.996; 95% CI, 0.991–1.001; P=0.098).

Table 3 summarizes the time delays that occur at every step of the stroke-systems work flow from P2P at both the local and outside hospital levels. Decision-making time, as defined by initial CT to CSC notification, contributed to 37% of the entire P2P continuum among transferred patients (Figure 3A). This process was significantly prolonged when a neurologist was consulted to make the referral as opposed to when an emergency physician directly called the CSC without consultation (76 minutes [IQR, 46–116] versus 47 minutes [IQR, 23–70]; P<0.001). In addition, patients who received multimodal imaging at outside hospital facilities had nearly a 1-hour delay in decision making compared with patients who obtained noncontrast head CTs alone (111 minutes [IQR, 73–179] versus 54 minutes [IQR, 32–76]; P<0.001) (Figure 3B). There were no differences in baseline characteristics between the patient cohorts in these comparisons.

View this table:
  • View inline
  • View popup
Table 3.

Description of Work-Flow Metrics Between Local ED Admissions and Outside Hospital Transfers

Figure 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3.

A, Time continuum from last known normal (LKN) to reperfusion. Comparison is made between outside hospital transfers (OSH) and local emergency department (ED) admissions at the comprehensive stroke center (CSC). All time metrics are reported as mean values. P<0.001, Student t test. Times of CSC notification and emergency medical services (EMS) contact were not available for 4 patients. B, Areas of potential delays occurring at outside facilities before patient arrival at the CSC. Referring physician data were not available for 13 patients. Only 2 patients at outside hospitals received computed tomographic perfusion (CTP). CT indicates computed tomography; CTA, computed tomographic angiography; and Non-Con, noncontrast.

The ensuing transfer time, as defined by initial CSC contact to CSC imaging, encompassed 47% of the P2P continuum and had a positive correlation with interhospital distance, irrespective of transportation modality (Spearman ρ=0.58; P<0.001). Patients arriving from centers located >60 miles away had far greater delays in transfer time (>60 miles: 138 minutes [IQR, 116–168] versus <60 miles: 86 minutes [IQR, 72–106]; P<0.001) as well as fewer good outcomes (12% versus 33%; P=0.037). In a secondary analysis, delays in transfer time were also associated with reductions in patient selection for IAT after interhospital transfers (OR, 0.990; 95% CI, 0.983–0.997; P=0.008) (Tables II and III in the online-only Data Supplement). Patients who failed to qualify for IAT had longer transfer times (130 minutes [IQR, 98–159] versus 91 minutes [IQR, 75–121]; P<0.001) and lower pretreatment ASPECTS (4 [IQR, 3–4.5] versus 7 [IQR, 6–9]; P<0.001) than patients who received IAT. Delays from outside hospital CT to CSC CT were also observed among the non-IAT cohort (224 minutes [IQR, 166–293] versus 175 minutes [IQR, 134–232]; P=0.006).

On arrival at our facility, CSC processing was the final component of the P2P continuum, encompassing the interval between CSC imaging to groin puncture in the angiography suite. This time frame was substantially less for patients arriving from outside facilities (outside hospital transfer: 30 minutes [IQR, 20–43] versus local emergency department: 89 minutes [IQR, 70–119]), although the overall P2P time was still much greater among transfers. The overall P2P times were strongly correlated with the number of patients transferred by each respective hospital (r=−0.55, P=0.036), in which P2P times declined as transfer volumes increased (Figure 4).

Figure 4.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 4.

Scatterplot of median picture to puncture times (initial computed tomography to groin puncture) for each primary stroke center, stratified by the total number of patients transferred during the 21-month study period.

Twenty-seven patients were excluded from the primary study because of a time from LKN to groin puncture of >9 hours. In a secondary analysis, no significant differences were observed in baseline characteristics or outcomes between patients treated beyond 9 hours versus those treated within 9 hours, with the exception of lower rates of intravenous tPA delivery and longer P2P times in the group with time from LKN to groin puncture of >9 hours (Table IV in the online-only Data Supplement). The association of P2P time with good patient outcome, however, remained statistically significant in a binary logistic model, despite the inclusion of all patients regardless of LKN times (OR, 0.997; 95% CI, 0.993–0.999; P=0.043) (Table V in the online-only Data Supplement).

Discussion

Our present analysis points to a unique opportunity to improve efficiencies when patients are transferred for endovascular reperfusion therapy. We have shown that as P2P time elapses, fewer patients have favorable imaging characteristics and good clinical outcomes. The importance of understanding time delays and opportunities to improve transfer processes cannot be understated given the current push toward CSC certification. When this issue is addressed, many similarities and lessons should be drawn from the cardiac literature.

Time delays to primary angioplasty (percutaneous transluminal coronary angioplasty) in the treatment of ST-segment elevation myocardial infarctions have been well characterized in association with increased mortality.13 This relationship subsequently spearheaded nationwide efforts to reduce delays to percutaneous transluminal coronary angioplasty through adjustments in institutional practice.14 In 1999, the American Heart Association published its first performance guidelines, advocating “door-to-balloon” times of <90 minutes.15 Although ensuing studies substantiated the merits of this metric in reducing patient mortality,16 a collaborative registry showed that this metric was achieved in 52% of nontransferred patients in 2005.17 The CathPCI group was able to improve door-to-balloon times to <90 minutes in 76% of patients by 2008 through a concerted effort of education and dissemination of best practices.

Transferred patients represented a challenging group for whom time metrics had not been well established. To improve outcome measures among this unique cohort, the American Heart Association designated a new “door-in door-out” metric in 2008 that captured the time interval from outside hospital admission to EMS departure.18 Studies since have shown that door-in door-out times of <30 minutes are associated with not only faster times to treatment but also reductions in patient mortality. Fewer than 10% of patients achieved this metric in practice, thus highlighting the importance of streamlining interfacility networks to minimize transfer delays and improve patient outcomes.19 We believe that these concepts also hold true for the treatment of ischemic strokes with IAT.

As more CSCs become certified, the “hub-and-spoke” model of interfacility transfers from primary stroke centers to CSCs will eventually constitute a large proportion of patients treated with IAT. At our institution alone, 68% of the patients treated during a 21-month period arrived from referring primary stroke centers. Substantial delays existed within this transferring process, during which P2P times were prolonged by 2 hours compared with the times of the local cohort. Such delays were associated with a 22% absolute lower probability of a good outcome. The severity of stroke, as defined by baseline NIHSS and pretreatment THRIVE scores, was analogous in both cohorts and thus did not render the poorer outcomes observed among the transferred patients.

Timely delivery of IAT has been shown previously in the Interventional Management of Stroke I/II trials to increase the probability of good outcomes in patients with acute ischemic stroke.8 Our multivariable analysis similarly reveals that every 10-minute delay in P2P times correlates to a 6% relative lower probability of achieving a good outcome. This translates into 1 fewer good outcome per every 5 ischemic stroke patients transferred from outside facilities.

Currently, there are limited data in regard to the time metrics surrounding IAT. As recently as 2011, recommendations were made toward targeting an “arrival-to-treatment” time of <2 hours, although there is still debate in regard to whether successful reperfusion or start of procedure time should be defined as the proper end point. A recent study highlighted the possibility of using procedure time as an appropriate metric for predicting patient outcomes, with target goals of <60 minutes.20 Although the time to successful reperfusion may hold more physiological relevance than puncture time in determining treatment efficacy, difficulty remains in quantifying this end point because of the presence of partial recanalization that occurs before complete revascularization.21 Despite advances in device technology to enhance reperfusion rates and reduce procedure times, outcomes have not yet improved,6,22 which may reflect our current systems of care in transferring patients.

Door-in door-out times have been designated previously as the most appropriate metric for evaluating interfacility transfers in cardiology. However, <50% of the continuum of care from patient presentation to reperfusion is accounted for within this metric. In our study, the P2P time heralds a greater opportunity to minimize delays and enhance outcomes, spanning 74% of the entire continuum of care. Therefore, we propose the utilization of P2P time as a metric for determining the efficiency of work-flow processes in interhospital transfers for strokes, with a target time of 90 minutes. At this threshold, patients would have the greatest opportunity for a positive outcome and an estimated 2-fold increment in the number of patients that qualify for IAT. To achieve this goal, we have identified several opportunities for improvement (Table 4).

View this table:
  • View inline
  • View popup
Table 4.

Strategies to Reduce P2P Times Among Interhospital Transfers

The time between initial CT at the outside hospital to CSC notification (decision making) is substantial. This is due to multiple factors including delays in neurological assessments, interpretation of imaging, utilization of advanced modality imaging, and determination of tPA effectiveness. In our study, obtainment of advanced imaging contributed to a 57-minute delay in decision making without substantial benefits in patient outcome. To produce more efficient systems of care, processes such as these must be streamlined with a minimalist approach similar to the ECG for myocardial infarction. Noncontrast head CT imaging can be used as a tool to discern whether a hemorrhage is present but can additionally be used to assess for a thrombus with thin-cut reconstructions23 as well as for core infarct with the use of the ASPECTS method.9 We acknowledge that these tools are not as precise as magnetic resonance imaging or CT perfusion, but time delays diminish the likelihood of benefit from IAT, particularly in transferred patients. A previous study has also demonstrated that obtaining multimodal imaging not only contributes to delays in treatment but fails to reduce hemorrhage rates or improve clinical outcomes.24

Delays in decision making are further compounded by inefficiencies in consultation practices. When referring neurologists were consulted to evaluate an acute stroke patient, the time to CSC notification was delayed by 30 minutes. A number of factors contributed to this delay, including discussions with the emergency department physician, time spent reevaluating the patient, delivery of intravenous tPA, and, in many instances, awaiting the arrival of an off-site neurologist for bedside assessment. Although we recognize the importance of specialty consultations in the setting of difficult clinical presentations, we recommend that emergency department physicians directly upload CT images through regional Picture Archiving and Communication Systems that allow for images to be read directly by CSC physicians. This would potentially reduce the need for unnecessary consultations and expedite the CSC acceptance process. Similar strategies have been described in the cardiology literature, in which emergency physician activation of the catheterization laboratory team reduces door-to-balloon times significantly.25 Given that referring facilities have different thresholds for initiating patient transfers, we are currently working to implement a “rapid-transfer protocol” within our own community that standardizes the minimal requirements needed to contact a CSC for interhospital transfer.

Transfer time itself was also identified as an opportunity for improvement. The time from CSC notification to EMS arrival at the referring facility spanned >30 minutes, with an additional hour to CSC imaging. Simultaneous activation of the EMS team at the time of CSC contact would reduce delays to EMS mobilization, including expedited personnel contact and earlier weather reports. Current practices at many outside facilities have inefficiencies between EMS arrival and hospital departure, including the following: deactivation of the helicopter; transportation of the EMS team to the patient’s room; reevaluation of the patient at bedside; time for awaiting copies of hospital records to be printed; transportation of the patient back to the helipad; and finally, reinitiation of the helicopter engine while loading the patient. In an effort to better streamline this process, direct delivery of patients to the helipad without deactivation of the helicopter engine would substantially mitigate these delays. Electronic or facsimile transmission of records directly to the CSC would reduce the time that EMS is on site. Furthermore, our study reveals that patients transferred from outside facilities beyond 60 miles from the CSC experience delays of up to an hour in transfer time, which was associated with poorer patient outcomes. The development of distance thresholds may eventually be warranted to identify patients who will not benefit from endovascular therapy because of delays in transfer.

Finally, CSC processing time (CSC CT to groin puncture) was noted to be less for outside hospital transfers than for local admissions. This is unique to our institution because the angiography suite is located in the neuro–intensive care unit and next to the CT scanner. We note a reduced time for processing of outside hospital transfers because the entire team awaits the patient, including the anesthesiologist. We suspect that there is an additional time delay in this component in many institutions, and this offers an additional opportunity to implement early activation of the interventional team.

We recognize that there may be additional steps to reduce treatment times for acute stroke patients that fall outside the P2P continuum. For instance, we are currently in the process of training EMS to recognize stroke symptoms earlier using the Los Angeles Motor Score,26 as well as having patients transferred directly to our CSC when located equidistant to referring primary stroke centers at the time of onset. These measures would not only reduce the time from LKN to arrival but also eliminate the delays associated with outside hospital transfers.

In a recent retrospective analysis, higher-volume endovascular stroke centers were correlated with faster treatment times, better reperfusion rates, and improved clinical outcomes.27 We found a similar relationship with interfacility transfers in which centers that transferred more patients had faster P2P times. This demonstrates the importance of hospital experience and the need for streamlined protocols when it comes to achieving lower P2P times.

An ancillary result from our study is the interplay between ASPECTS and time, in which delays to treatment correlate with less favorable imaging. Although we recognize that there is variability in patient collateral status, we believe that transfer delays lead to larger preprocedural core infarcts, which translate into lower ASPECTS over time. Future studies will be needed to better understand the rate of ASPECTS decay as a function of time and collateral status and to further discern the relationship between imaging deterioration and patient outcome.

Our protocol was to accept patients with an ASPECTS >7 and NIHSS score ≥10 from referring facilities. On repeat imaging at our CSC, patients with ASPECTS that deteriorated to 5 to 7 were still considered for treatment as long as their CT images revealed a frank hypodensity that was less than one third of the middle cerebral artery territory. Given that only 13% of patients with ASPECTS ≤7 had good outcomes at 90 days, our CSC has since adopted an ASPECTS threshold of >7 for selection of IAT. By implementing the aforementioned “action items,” our goal is to eventually include P2P times as part of the selection parameter for IAT, with a target goal of <90 minutes for all outside hospital transfers.

We acknowledge there are limitations to our analysis given that this is a consecutive case series from a single CSC. Additionally, the angiographic images were not adjudicated by a central core laboratory. Our limited sample size also risks overfitting of the model, although repeat modeling with increased stringency and likelihood ratio testing confirmed the impact of P2P on outcomes. Third, we had to exclude one fifth of the patients because of a large proportion with posterior infarcts or treatment beyond 9 hours. Patients with posterior infarcts were removed to better homogenize the data set and reflect an anterior stroke population with similarities in disease physiology. We believed that patients with LKN to groin puncture times >9 hours would bias the results of the analysis because they represent a unique cohort with favorable imaging characteristics who are not traditionally studied in standard clinical trials. When analyzed separately, these patients had no significant differences in imaging or outcomes compared with patients treated in <9 hours (Table IV in the online-only Data Supplement), reiterating the notion of their superior collateral systems. Indeed, the significance of time may not be as profound among these patients, whose physiology allows them to overcome the perils of long transfer delays. Nevertheless, inclusion of these patients in our model did not eliminate the overall significance of P2P times in terms of patient outcome because the odds of a good outcome declined by 3% for every 10-minute delay in P2P, regardless of LKN (Table V in the online-only Data Supplement). Moreover, among the patients treated beyond 9 hours, those with good outcomes had shorter times from LKN to groin puncture than those with poor outcomes, although this was not statistically significant because of our small sample size.

Finally, we had 31 patients who were transferred but did not receive IAT because of unfavorable imaging characteristics. It is possible that a subset of these patients would have had shorter P2P times yet would have had poor clinical outcomes, thereby creating a bias in the patients selected for analysis. We believe this to be unlikely, however, given that the time from outside hospital CT to CSC CT was significantly prolonged among patients who were not treated with IAT. As such, their P2P times would also have been substantially greater than those of the patients included in our study. Our data demonstrate that every minute of delay in transfer time correlates with a 1% lower probability that a patient qualifies for IAT, which is comparable to the results of previous studies.7

In conclusion, our study defines a unique metric (P2P) that captures systems processes associated with transferring patients to a CSC. Delays in P2P result in lower ASPECTS on preprocedural imaging and worse patient outcomes at 90 days. We have subsequently identified opportunities to minimize these delays and to streamline the transfer process between primary stroke centers and CSCs. We believe that such changes will expand the number of candidates for reperfusion, facilitate higher transfer volumes within the hub-and-spoke network, and ultimately improve patient outcomes.

Disclosures

Dr Nogueira serves on scientific advisory boards for Stryker Neurovascular, Covidien, and CoAxia. He also serves on the Data Safety Monitoring Board for Rapid Medical. Dr Belagaje serves as a consultant for Neural Stem. Dr Gupta serves on scientific advisory boards for Stryker Neurovascular, Covidien, and CoAxia. He is also a member of the Data Safety Monitoring Board for Reverse Medical and Rapid Medical. He is an Associate Editor for the Journal of Neuroimaging. Dr Frankel provides legal consultation services as an expert witness. The other authors report no conflicts.

Footnotes

  • The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.000506/-/DC1.

  • Received October 28, 2012.
  • Accepted January 29, 2013.
  • © 2013 American Heart Association, Inc.

References

  1. 1.↵
    1. Saver JL
    . Time is brain–quantified. Stroke. 2006;37:263–266.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    1. Hacke W,
    2. Donnan G,
    3. Fieschi C,
    4. Kaste M,
    5. von Kummer R,
    6. Broderick JP,
    7. Brott T,
    8. Frankel M,
    9. Grotta JC,
    10. Haley EC Jr.,
    11. Kwiatkowski T,
    12. Levine SR,
    13. Lewandowski C,
    14. Lu M,
    15. Lyden P,
    16. Marler JR,
    17. Patel S,
    18. Tilley BC,
    19. Albers G,
    20. Bluhmki E,
    21. Wilhelm M,
    22. Hamilton S
    ; ATLANTIS Trials Investigators; ECASS Trials Investigators; NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–774.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Fonarow GC,
    2. Smith EE,
    3. Saver JL,
    4. Reeves MJ,
    5. Bhatt DL,
    6. Grau-Sepulveda MV,
    7. Olson DM,
    8. Hernandez AF,
    9. Peterson ED,
    10. Schwamm LH
    . Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123:750–758.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Reeves MJ,
    2. Arora S,
    3. Broderick JP,
    4. Frankel M,
    5. Heinrich JP,
    6. Hickenbottom S,
    7. Karp H,
    8. LaBresh KA,
    9. Malarcher A,
    10. Mensah G,
    11. Moomaw CJ,
    12. Schwamm L,
    13. Weiss P
    ; Paul Coverdell Prototype Registries Writing Group. Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke. 2005;36:1232–1240.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Alberts MJ,
    2. Latchaw RE,
    3. Selman WR,
    4. Shephard T,
    5. Hadley MN,
    6. Brass LM,
    7. Koroshetz W,
    8. Marler JR,
    9. Booss J,
    10. Zorowitz RD,
    11. Croft JB,
    12. Magnis E,
    13. Mulligan D,
    14. Jagoda A,
    15. O’Connor R,
    16. Cawley CM,
    17. Connors JJ,
    18. Rose-DeRenzy JA,
    19. Emr M,
    20. Warren M,
    21. Walker MD
    ; Brain Attack Coalition. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36:1597–1616.
    OpenUrlAbstract/FREE Full Text
  6. 6.↵
    The Penumbra Pivotal Stroke Trial Investigators. The Penumbra Pivotal Stroke Trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial larger vessel occlusive disease. Stroke. 2009;40:2761–2768.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Prabhakaran S,
    2. Ward E,
    3. John S,
    4. Lopes DK,
    5. Chen M,
    6. Temes RE,
    7. Mohammad Y,
    8. Lee VH,
    9. Bleck TP
    . Transfer delay is a major factor limiting the use of intra-arterial treatment in acute ischemic stroke. Stroke. 2011;42:1626–1630.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. Khatri P,
    2. Abruzzo T,
    3. Yeatts SD,
    4. Nichols C,
    5. Broderick JP,
    6. Tomsick TA
    ; IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009;73:1066–1072.
    OpenUrlCrossRef
  9. 9.↵
    1. Barber PA,
    2. Demchuk AM,
    3. Zhang J,
    4. Buchan AM
    . Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy; ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355:1670–1674.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Flint AC,
    2. Cullen SP,
    3. Faigeles BS,
    4. Rao VA
    . Predicting long-term outcome after endovascular stroke treatment: the Totaled Health Risks in Vascular Events Score. AJNR Am J Neuroradiol. 2010;31:1192–1196.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Higashida RT,
    2. Furlan AJ,
    3. Roberts H,
    4. Tomsick T,
    5. Connors B,
    6. Barr J,
    7. Dillon W,
    8. Warach S,
    9. Broderick J,
    10. Tilley B,
    11. Sacks D
    . Trial design and reporting standards for intraarterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003;34:109–137.
    OpenUrlCrossRef
  12. 12.↵
    1. Berger C,
    2. Fiorelli M,
    3. Steiner T,
    4. Schäbitz WR,
    5. Bozzao L,
    6. Bluhmki E,
    7. Hacke W,
    8. von Kummer R
    . Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke. 2001;32:1330–1335.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Berger PB,
    2. Ellis SG,
    3. Holmes DR Jr.,
    4. Granger CB,
    5. Criger DA,
    6. Betriu A,
    7. Topol EJ,
    8. Califf RM
    . Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: result from the GUSTO-IIb trial. Circulation. 1999;100:14–20.
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Bradley EH,
    2. Herrin J,
    3. Wang Y,
    4. Barton BA,
    5. Webster TR,
    6. Mattera JA,
    7. Roumanis SA,
    8. Curtis JP,
    9. Nallamothu BK,
    10. Magid DJ,
    11. McNamara RL,
    12. Parkosewich J,
    13. Loeb JM,
    14. Krumholz HM
    . Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355:2308–2320.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Ryan T,
    2. Antman E,
    3. Brooks N,
    4. Califf R,
    5. Hillis L,
    6. Hiratzka LF,
    7. Rapaport E,
    8. Riegel B,
    9. Russell RO,
    10. Smith EE,
    11. Weaver WD,
    12. Gibbons RJ,
    13. Alpert JS,
    14. Eagle KA,
    15. Gardner TJ,
    16. Garson A Jr.,
    17. Gregoratos G,
    18. Ryan TJ,
    19. Smith SC Jr.
    . 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 1999;34:890–911.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Cannon CP,
    2. Gibson CM,
    3. Lambrew CT,
    4. Shoultz DA,
    5. Levy D,
    6. French WJ,
    7. Gore JM,
    8. Weaver WD,
    9. Rogers WJ,
    10. Tiefenbrunn AJ
    . Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA. 2000;283:2941–2947.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Bradley EH,
    2. Nallamothu BK,
    3. Herrin J,
    4. Ting HH,
    5. Stern AF,
    6. Nembhard IM,
    7. Yuan CT,
    8. Green JC,
    9. Kline-Rogers E,
    10. Wang Y,
    11. Curtis JP,
    12. Webster TR,
    13. Masoudi FA,
    14. Fonarow GC,
    15. Brush JE Jr.,
    16. Krumholz HM
    . National efforts to improve door-to-balloon time: results from the Door-to-Balloon Alliance. J Am Coll Cardiol. 2009;54:2423–2429.
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Krumholz HM,
    2. Anderson JL,
    3. Bachelder BL,
    4. Fesmire FM,
    5. Fihn SD,
    6. Foody JM,
    7. Ho PM,
    8. Kosiborod MN,
    9. Masoudi FA,
    10. Nallamothu BK
    . ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction. J Am Coll Cardiol. 2008;52:2046–2099.
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Wang TY,
    2. Nallamothu BK,
    3. Krumholz HM,
    4. Li S,
    5. Roe MT,
    6. Jollis JG,
    7. Jacobs AK,
    8. Holmes DR,
    9. Peterson ED,
    10. Ting HH
    . Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011;305:2540–2547.
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Hassan AE,
    2. Chaudry SA,
    3. Miley JT,
    4. Khatri R,
    5. Hassan SA,
    6. Suri MF,
    7. Qureshi AI
    . Microcatheter to recanalization (procedure time) predicts outcomes in endovascular treatment in patients with acute ischemic stroke: when do we stop [published online ahead of print July 19, 2012]? Am J Neuroradiol.
  21. 21.↵
    1. Leifer D,
    2. Bravata D,
    3. Connors III JJ,
    4. Hinchey JA,
    5. Jauch EC,
    6. Johnston SC,
    7. Latchaw R,
    8. Likosky W,
    9. Ogilvy C,
    10. Qureshi AI,
    11. Summers D,
    12. Sung GY,
    13. Williams LS,
    14. Zorowitz R
    . Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations. Stroke. 2011;42:849–77.
    OpenUrlAbstract/FREE Full Text
  22. 22.↵
    1. Smith WS,
    2. Sung G,
    3. Starkman S,
    4. Saver JL,
    5. Kidwell CS,
    6. Gobin YP,
    7. Lutsep HL,
    8. Nesbit GM,
    9. Grobelny T,
    10. Rymer MM,
    11. Silverman IE,
    12. Higashida RT,
    13. Budzik RF,
    14. Marks MP
    ; MERCI Trial Investigators. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36:1432–1438.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Riedel CH,
    2. Zimmermann P,
    3. Jensen-Kondering U,
    4. Stingele R,
    5. Deuschl G,
    6. Jansen O
    . The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42:1775–1777.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. Sheth KN,
    2. Terry JB,
    3. Nogueira RG,
    4. Horev A,
    5. Nguyen TN,
    6. Fong AK,
    7. Gandhi D,
    8. Prabhakaran S,
    9. Wisco D,
    10. Glenn BA,
    11. Tayal AH,
    12. Ludwig B,
    13. Hussain MS,
    14. Jovin TG,
    15. Clemmons PF,
    16. Cronin C,
    17. Liebeskind DS,
    18. Tian M,
    19. Gupta R
    . Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes [published online ahead of print October 16, 2012]. J Neurointerv Surg.
  25. 25.↵
    1. Kontos MC,
    2. Kurz MC,
    3. Roberts C
    . Emergency physician–initiated cath lab activation reduces door to balloon times in ST-segment elevation myocardial infarction patients. Am J Emerg Med. 2011;29:868.
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Llanes JN,
    2. Kidwell CS,
    3. Starkman S,
    4. Leary MC,
    5. Eckstein M,
    6. Saver JL
    . The Los Angeles Motor Scale (LAMS): a new measure to characterize stroke severity in the field. Prehosp Emerg Care. 2004;8:46–50.
    OpenUrlPubMed
  27. 27.↵
    1. Gupta R,
    2. Horev A,
    3. Nguyen T,
    4. Gandhi D,
    5. Wisco D,
    6. Glenn BA,
    7. Tayal AH,
    8. Ludwig B,
    9. Terry JB,
    10. Gershon RY,
    11. Jovin T,
    12. Clemmons PF,
    13. Frankel MR,
    14. Cronin CA,
    15. Anderson AM,
    16. Hussain MS,
    17. Sheth KN,
    18. Belagaje SR,
    19. Tian M,
    20. Nogueira RG
    . Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates, and higher rates of good clinical outcomes [published online ahead of print July 25, 2012]. J Neurointerv Surg.

Clinical Perspective

The evolution of time metrics in the field of percutaneous coronary angioplasty has been the cornerstone for much of the past decade in the establishment of institutional guidelines and expectations for the treatment of patients with ST-segment elevation myocardial infarctions. From the introduction of “door-to-balloon” to the development of “door-in door-out” times, interventional cardiology has transformed the way in which we capture system processes and maintain standards of care for our patients. The field of neurointerventional surgery, however, has been slower to develop time metrics and expectations of system processes for intra-arterial therapies for stroke. Increasing numbers of trials surrounding endovascular reperfusion therapy along with the development of regional stroke centers will bring the issue of efficient systems to the forefront. We are concerned that clinical trials may continue to fail to show the benefit of endovascular reperfusion treatment because system processes have not been optimized, particularly surrounding interfacility transfers. In this article, we present a novel metric, “picture-to-puncture,” that captures the continuum of care from initial computed tomography to groin puncture and is associated with patient outcomes after endovascular reperfusion for ischemic strokes. This novel metric will allow for universal comparison of institutional practices and promote new ways of streamlining interfacility transfers among this patient population. We believe that this timely report will bring attention to a crucial topic surrounding endovascular treatments for stroke and will help to encourage further efficiencies in endovascular stroke therapies in the future.

View Abstract
Back to top
Previous ArticleNext Article

This Issue

Circulation
March 12, 2013, Volume 127, Issue 10
  • Table of Contents
Previous ArticleNext Article

Jump to

  • Article
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Disclosures
    • Footnotes
    • References
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters

Article Tools

  • Print
  • Citation Tools
    “Picture to Puncture”Clinical Perspective
    Chung-Huan J. Sun, Raul G. Nogueira, Brenda A. Glenn, Kerrin Connelly, Susan Zimmermann, Kim Anda, Deborah Camp, Michael R. Frankel, Samir R. Belagaje, Aaron M. Anderson, Alexander P. Isakov and Rishi Gupta
    Circulation. 2013;127:1139-1148, originally published March 11, 2013
    https://doi.org/10.1161/CIRCULATIONAHA.112.000506

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
  •  Download Powerpoint
  • Article Alerts
    Log in to Email Alerts with your email address.
  • Save to my folders

Share this Article

  • Email

    Thank you for your interest in spreading the word on Circulation.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    “Picture to Puncture”Clinical Perspective
    (Your Name) has sent you a message from Circulation
    (Your Name) thought you would like to see the Circulation web site.
  • Share on Social Media
    “Picture to Puncture”Clinical Perspective
    Chung-Huan J. Sun, Raul G. Nogueira, Brenda A. Glenn, Kerrin Connelly, Susan Zimmermann, Kim Anda, Deborah Camp, Michael R. Frankel, Samir R. Belagaje, Aaron M. Anderson, Alexander P. Isakov and Rishi Gupta
    Circulation. 2013;127:1139-1148, originally published March 11, 2013
    https://doi.org/10.1161/CIRCULATIONAHA.112.000506
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo

Related Articles

Cited By...

Subjects

  • Critical Care and Resuscitation
    • Cardiopulmonary Resuscitation and Emergency Cardiac Care
  • Stroke
    • Ischemic Stroke

Circulation

  • About Circulation
  • Instructions for Authors
  • Circulation CME
  • Statements and Guidelines
  • Meeting Abstracts
  • Permissions
  • Journal Policies
  • Email Alerts
  • Open Access Information
  • AHA Journals RSS
  • AHA Newsroom

Editorial Office Address:
200 Fifth Avenue, Suite 1020
Waltham, MA 02451
email: circ@circulationjournal.org
 

Information for:
  • Advertisers
  • Subscribers
  • Subscriber Help
  • Institutions / Librarians
  • Institutional Subscriptions FAQ
  • International Users
American Heart Association Learn and Live
National Center
7272 Greenville Ave.
Dallas, TX 75231

Customer Service

  • 1-800-AHA-USA-1
  • 1-800-242-8721
  • Local Info
  • Contact Us

About Us

Our mission is to build healthier lives, free of cardiovascular diseases and stroke. That single purpose drives all we do. The need for our work is beyond question. Find Out More about the American Heart Association

  • Careers
  • SHOP
  • Latest Heart and Stroke News
  • AHA/ASA Media Newsroom

Our Sites

  • American Heart Association
  • American Stroke Association
  • For Professionals
  • More Sites

Take Action

  • Advocate
  • Donate
  • Planned Giving
  • Volunteer

Online Communities

  • AFib Support
  • Garden Community
  • Patient Support Network
  • Professional Online Network

Follow Us:

  • Follow Circulation on Twitter
  • Visit Circulation on Facebook
  • Follow Circulation on Google Plus
  • Follow Circulation on Instagram
  • Follow Circulation on Pinterest
  • Follow Circulation on YouTube
  • Rss Feeds
  • Privacy Policy
  • Copyright
  • Ethics Policy
  • Conflict of Interest Policy
  • Linking Policy
  • Diversity
  • Careers

©2018 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. The American Heart Association is a qualified 501(c)(3) tax-exempt organization.
*Red Dress™ DHHS, Go Red™ AHA; National Wear Red Day ® is a registered trademark.

  • PUTTING PATIENTS FIRST National Health Council Standards of Excellence Certification Program
  • BBB Accredited Charity
  • Comodo Secured