118 Emergency Department Crowding is Not Associated With Delays in Acute Stroke Care

Delays in identification and treatment of acute stroke contribute to significant morbidity and mortality. Multiple clinical factors have been associated with delays in acute stroke care. We aimed to determine the relationship between emergency department (ED) crowding and the delivery of timely emergency stroke care. We used prospectively collected data from our institutional Get with the Guidelines-Stroke registry to identify consecutive acute ischemic stroke patients presenting to our large, urban academic ED from July 2016 to August 2018. Patients included in analysis were those who presented within six hours of last known well time. We used ED capacity logs to determine the degree of ED crowding at the time of patients’ presentation (normal, high, and severe capacity constraints). Outcomes of interest were door-to-imaging time (DIT), door-to-needle time (DTN), and door-to-groin puncture times (DGPT). Bivariate comparisons were made using t-tests, chi-square, and non-parametric testing as appropriate. We used wilcoxon rank sum testing to examine the bivariate relationship between ED capacity and our outcomes of interest, and regression models to examine the relationship after accounting for patient demographics, arrival mode, whether the patient was transferred from another hospital, and stroke severity. Of the 1,378 patients who presented with ischemic strokes during the study period, 1,080 (78%) presented during times of normal ED utilization, 203 (15%) during high ED utilization, and 94 (6.8%) during severe capacity constraints. Among patients presenting acutely, median DIT was 51.5 minutes (interquartile range [IQR] 23-130), median DTN time was 43 minutes (IQR 31-59), and median DGPT was 72 mins (IQR 57-117.5). Overall DIT for patients who received alteplase was 18 mins (IQR 14-26). Treatment times were not significantly different during periods of higher ED utilization in bivariate or in multivariable testing. In our single institution analysis, we found no significant delays in stroke care delivery associated with increased ED crowding. This finding suggests that robust processes of care may enable continued high-quality acute care delivery, even during times with an increased capacity burden.