title: "Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke.
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.
  
  
  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.
authors: Department of Neurology, Emory University School of Medicine, Atlanta, GA 30303, USA.
authors: Chung-Huan J
authors: CH
authors: Sun
authors: Raul G
authors: RG
authors: Nogueira
authors: Brenda A
authors: BA
authors: Glenn
authors: Kerrin
authors: K
authors: Connelly
authors: Susan
authors: S
authors: Zimmermann
authors: Kim
authors: K
authors: Anda
authors: Deborah
authors: D
authors: Camp
authors: Michael R
authors: MR
authors: Frankel
authors: Samir R
authors: SR
authors: Belagaje
authors: Aaron M
authors: AM
authors: Anderson
authors: Alexander P
authors: AP
authors: Isakov
authors: Rishi
authors: R
authors: Gupta
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000628:therapy*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006119:Groin / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D007261:Infusions, Intra-Arterial / Q000379:methods; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000379:methods*; D011856:Radiographic Image Enhancement / Q000379:methods*; D015424:Reperfusion / Q000379:methods*; D012189:Retrospective Studies; D020521:Stroke / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome