Door-in-Door-Out Times at Referring Hospitals and Outcomes from Hemorrhagic Stroke
Authors: Royan Regina , Ayodele Iyanuoluwa , Stamm Brian , Alhanti Brooke , Sheth Kevin N. , Pruitt Peter , Mac Grory Brian , Meurer William J. , Prabhakaran Shyam 
Published: April 2024

ABSTRACTBackgroundGuidelines recommend DIDO (Door-In-Door-Out) time<120 minutes at the transferring emergency department (ED); however, it is unknown whether inter-hospital transfer times are related to clinical outcomes.MethodsRetrospective, observational cohort study using US registry data from GWTG-Stroke participating hospitals. Patients age ≥18 years with intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) from January 1, 2019 to July 31, 2022 who were transferred from the ED to a GWTG-participating receiving hospital. Outcomes included discharge modified Rankin Score (mRS) 0-3 vs 4-6; ability to ambulate independently at discharge; and in-hospital mortality at the receiving hospital.ResultsIn total, 19,708 ICH patients were included, with median age 68.0 years (IQR 57.0-78.0), 46.2% female, 65.2% White, 16.8% Black, and 8.5% Hispanic. 7,757 SAH patients were included, with median age 59.0 years (IQR 49.0-69.0), 62.7% female, 62.0% White, 14.6% Black, and 11.9% Hispanic. For ICH patients, increasing DIDO time was associated with greater odds of mRS 0-3 vs 4-6 at discharge in the unadjusted analyses (DIDO 91-180 mins, OR 1.15 [1.04-1.27]; 181-270 mins, OR 1.51 [1.33, 1.71]; >270 mins, OR 1.83 [1.58, 2.11]; vs DIDO<90 mins as reference; P<.0001), but these associations became statistically non-significant in the adjusted analyses. Similar results were seen for mRS at discharge in SAH patients. In both ICH and SAH patients, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of in-hospital mortality.ConclusionDIDO times were inversely related to in-hospital mortality, ability to ambulate independently at discharge, but not discharge mRS for patients with ICH and SAH. These findings may suggest that a longer period of stabilization in the initial ED may be associated with better outcomes from hemorrhagic stroke and that current interhospital transfer protocols currently expedite transfer of the sickest patients. Prospective studies are needed to balance ED stabilization with arrival at a definitive destination in patients with hemorrhagic stroke.KEY POINTSQuestionIs Door-In-Door Out time at a transferring hospital associated with global disability at hospital discharge (modified Rankin Score (mRS))for patients with intracranial hemorrhage?FindingsIn this cohort study using a large nationwide quality improvement database, increasing DIDO time was associated with greater odds of mRS 0-3 vs 4-6 at discharge in the unadjusted analyses for both ICH and SAH patients, but these associations became statistically non-significant in the adjusted analyses. In both ICH and SAH patients, longer DIDO times were associated with greater odds of independent ambulation at discharge and lower odds of in-hospital mortality in both the unadjusted and adjusted analyses.MeaningThese findings may suggest that a longer period of stabilization in the initial emergency department (ED) may be associated with better outcomes from hemorrhagic stroke and that current interhospital transfer protocols tend to expedite transfer of the sickest patients. Prospective studies are needed to determine whether early or delayed transport with ED stabilization is optimal for care of patients with hemorrhagic stroke.