Acquisition of Prehospital Stroke Severity Scale is associated with shorter door-to-puncture times in patients with prehospital notifications transported directly to a thrombectomy center

Abstract

Background We sought to identify systemic factors influencing door-to-puncture times (DTP) among patients with pre-arrival notifications presenting directly to a comprehensive stroke center (CSC) and undergoing emergent mechanical thrombectomy (MT). Methods In this retrospective analysis of a prospectively maintained registry of acute ischemic stroke (AIS) patients undergoing MT at two CSCs between January 2021 and October 2023, we included consecutive AIS patients presenting directly to the CSC with pre-arrival notifications via emergency medical services (EMS) and who underwent emergent MT. We excluded patients with known confounders to DTP and divided this cohort into two groups: DTP ≤75 min and >75 min. We used variables with P value <0.2 in the univariate analysis to build a binary logistic regression model to identify their association with DTP >75 min, adjusting for door-to-CT time. Results Of 900 patients, 605 were inter-facility transfers, 89 were excluded due to known confounders/missing prehospital notifications, leaving 206 qualifying patients. On multivariable analysis, not meeting American Heart Association (AHA) level 1 criteria (adjusted OR (aOR) 3.04, 95% CI 1.62 to 5.82, P<0.001), lack of Prehospital Stroke Severity Scale (PSSS) acquisition (aOR 2.2, 95% CI 1.19 to 4.11, P=0.01), and presentation after-hours (aOR 2.27, 95% CI 1.23 to 4.28, P=0.01) were associated with >75 min DTP times. Most patients (62.3%) had no clearly documented reasons for delay in MT, whereas 25.8% of delays were attributed to prolonged medical decision-making. Conclusion Arrival outside business hours, not meeting AHA level 1 criteria, and lack of PSSS acquisition by EMS were associated with prolonged DTP. Impacting modifiable factors such as prehospital assessment of stroke severity is an optimal target for quality improvement. Data are available upon reasonable request. Data supporting the findings of this study will be made available upon reasonable request.