Transfer Delays Tied to Worse Acute Stroke Intervention Results

For patients with acute ischemic stroke who require transfer to another hospital for endovascular therapy, spending more time in the initial emergency department is associated poorer short-term outcomes, an analysis of the Get With The Guidelines-Stroke registry shows.

Patients who had door-in-door-out (DIDO) times that exceeded the guideline-recommended target of 90 minutes or less at the receiving hospital were less likely to undergo endovascular therapy at the thrombectomy-capable hospital, were more likely to have complications from the procedure, and had worse functional outcomes at discharge, researchers led by Regina Royan, MD, and Brian Stamm, MD (both from University of Michigan, Ann Arbor), report in a study published in the February 2026 issue of the Lancet Neurology.

“We know that ‘time is brain’ for acute stroke treatment, so we hypothesized that longer DIDO delays would be associated with worse outcomes. Yet, there were several prior, small studies with conflicting results regarding the association between DIDO time and stroke outcomes,” Stamm told TCTMD via email. “Our comprehensive, national study now provides compelling evidence that DIDO time is strongly associated with outcomes from stroke.”

More than 40% of patients with acute ischemic stroke will need to be transferred between hospitals to receive endovascular therapy, and a prior study by these investigators showed that DIDO time at the first center often exceeded the goal of 90 minutes or less recommended in guidelines from the American Heart Association/American Stroke Association (AHA/ASA).

Commenting for TCTMD, Michael Mullen, MD (Temple University Hospital, Philadelphia, PA), a member of the stroke systems of care advisory group of the AHA/ASA, said this new study, “by quantifying not just the overall benefits of moving faster, but the benefits of a shorter door-in-door-out time, really helps to underscore the importance of DIDO and provides a very actionable target for future quality-improvement initiatives.”

DIDO Has Greater Impact in Patients Treated With Thrombectomy

The study included data on 22,410 patients (median age 70 years; 50.1% women) from the Get With The Guidelines-Stroke registry who were transferred from an acute care hospital to one of 489 thrombectomy-capable centers for endovascular therapy evaluation between 2019 and 2023.

The median DIDO time at the initial emergency department was 121 minutes, with only 26.3% of patients having a time of 90 minutes or less. Roughly three-quarters of patients received endovascular thrombectomy after transfer.

The primary outcome was the ordinal modified Rankin Scale (mRS) score at hospital discharge. After adjustment for potential confounders, having a DIDO time longer than 90 minutes, across multiple thresholds, was associated with greater odds of having a 1-point increase in mRS score at discharge:

• 91-180 minutes (adjusted OR 1.29; 95% CI 1.20-1.37)
• 181-270 minutes (adjusted OR 1.49; 95% CI 1.36-1.64)
• > 270 minutes (OR 1.70; 95% CI 1.53-1.89)

Moreover, patients with a longer DIDO time were less likely to undergo endovascular therapy:

• 91-180 minutes (adjusted OR 0.71; 95% CI 0.65-0.79)
• 181-270 minutes (adjusted OR 0.50; 95% CI 0.44-0.57)
• > 270 minutes (adjusted OR 0.35; 95% CI 0.30-0.40)

The link between longer DIDO times and worse functional outcomes was stronger in patients who ultimately received endovascular therapy than in those who didn’t. DIDO times greater than 90 minutes also were associated with lower odds of independent ambulation at discharge and of complication-free reperfusion therapy.

Altogether, Stamm said, “these findings underscore the importance of optimizing DIDO times to improve stroke outcomes.”

Targeting Speedier Transfers

Although the study was not designed to identify what factors played into longer DIDO times, Stamm said that prior research has identified multiple variables that are important when thinking about shortening delays, including rapid identification of stroke symptoms at the initial center, use of workflows that bundle required brain imaging, and optimization of ambulance availability for patient transport.

The ongoing HI-SPEED trial, which is led by the senior author of the current study, Shyam Prabhakaran, MD (University of Chicago Medicine, IL), “seeks to further understand the major barriers and test interventions to improve DIDO times,” Stamm noted.

There are two major components to improving the speed at which patients are transferred from one center to another for endovascular therapy, Mullen said. First, “there’s going to need to be a push to move as efficiently as possible at the primary stroke centers, at the acute stroke ready hospitals, and that will include getting advanced imaging whenever possible,” he said.

Second, there will have to be a focus on transport, with considerations dictated by system- and region-specific variables, Mullen said, noting, for example, that some centers use their own transport companies and others use outside services. “Every health system or different region is going to probably have slightly different pressures or barriers to getting an appropriate transport at the initial hospital as quickly as possible.”

Exact solutions are beyond the scope of the paper, but the study is helpful for setting DIDO time goals that hospitals can work toward, Mullen said.

“If these data are used to create quality targets, I think we’ll be surprised at how well we’ll be able to drive that time down if it’s appropriately incentivized,” he said. “We see that all over the place, whether it’s door-to-needle times for IV thrombolysis for stroke or door-to-balloon times for the cardiac space.”