Patients arriving at a primary stroke center with acute ischemic stroke due to large vessel occlusion and eligible for endovascular stroke therapy (EVT) require rapid transfer to a hospital equipped to perform EVT. The Door-In-Door-Out (DIDO) metric measures the time from patient arrival to transfer out of the initial facility.
The “Get with the Guidelines” (GWTG) program recommends that 50% of DIDOs should occur within 90 minutes. However, GWTG data from 2023 showed that only 20% of DIDOs met this timeframe.
At Kaiser Permanente Roseville Emergency Department (ED), a multi-disciplinary team has been working to improve care for this patient population through bundled interventions. In collaboration with regional leadership, the Roseville ED set a more stringent DIDO goal of 75 minutes or less for 50% of cases. Despite using 911 services, the ED only met this target 33% of the time in 2021.
Throughout 2022, the ED conducted improvement events, which included placing a registered nurse (RN) as the first point of contact to initiate the BEFAST protocol for quick stroke alert activation, standardizing documentation, refining communication within the integrated stroke response team, providing robust stroke education, and ensuring the Stroke RN responded regardless of patient ED placement. In 2023, ED Assistant Nurse Managers coordinated 911 calls and completed debriefs for timely follow-up.
Benchmarked against national performance metrics, these improvements resulted in the ED ranking in the top third percentile for the Joint Commission DIDO metric in the first quarter of 2024. Their success continued, and by the end of 2024, the Roseville ED achieved 76% compliance.