title: Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding.
abstract: OBJECTIVE
  National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT.
  
  
  METHODS
  We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal.
  
  
  RESULTS
  A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm's prediction of DIT.
  
  
  CONCLUSIONS
  ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.
authors.affiliation: From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.). mreznek@hotmail.com.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Reznek
authors.affiliation: From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.).
authors.forename: Evangelia
authors.initials: E
authors.lastname: Murray
authors.affiliation: From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.).
authors.forename: Marguerite N
authors.initials: MN
authors.lastname: Youngren
authors.affiliation: From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.).
authors.forename: Natassia T
authors.initials: NT
authors.lastname: Durham
authors.affiliation: From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA (M.A.R, E.M., S.S.M., M.N.Y); and CVS Health, Woonsocket, RI (N.T.D.).
authors.forename: Sean S
authors.initials: SS
authors.lastname: Michael
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003441:Crowding; D057286:Electronic Health Records / Q000592:standards; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging* / Q000628:therapy*; D061665:Time-to-Treatment / Q000592:standards*
keywords: crowding; emergency service, hospital; stroke; time-to-treatment