Principles of safe inter-hospital transfer of critically unwell adults.

The purpose of this article is to explore the key themes and safety considerations connected to the inter-hospital transfer of critically unwell adults. First, the evidence base surrounding the subject is critically explored and clinical guidelines and national policy are discussed. Second, safety considerations are explored that highlight the risks and challenges associated with the inter-hospital transfer of critically unwell people.

Collaboration, coordination and communication as facilitators of transitions for patients with advanced cancer: a scoping review linked to the Pal-Cycles project.

BACKGROUND: Person-centred care is becoming increasingly recognised as an important element of palliative care. The current review syntheses evidence in relation to transitions in advanced cancer patients with palliative care needs. The review focuses on specific elements which will inform the Pal-Cycles programme, for patients with advanced cancer transitioning from hospital care to community care. Elements of transitional models for cancer patients may include, identification of palliative care needs, compassionate communication with the patient and family members, collaborative effort to establish a multi-dimensional treatment plan, review and evaluation of the treatment plan and identification of the end of life phase. METHODS: A scoping review of four databases (MEDLINE, EMBASE, CINAHL, PsycINFO) was conducted to identify peer-reviewed studies published from January 2013 to October, 2022. A further hand-search of references to locate additional relevant studies was also undertaken. Inclusion criteria involved cancer patients transitions of care with a minimum of two of components from those listed above. Studies were excluded if they were literature reviews, if transition of care was related to cancer survivors, involved non-cancer patients, had paediatric population, if the transition implied a change of therapy and or a lack of physical transit to a non-hospital place of care. This review was guided by Arksey and O'Malley's framework and narrative synthesis was used. RESULTS: Out of 5695 records found, 14 records were selected. Transition models identified: increases in palliative care consultations, hospice referrals, reduction in readmission rates and the ability to provide end of life care at home. Transition models highlight emotional and spiritual support for patients and families. No uniform model of transition was apparent, this depends on the healthcare system where it is implemented. CONCLUSIONS: The findings highlight the importance of collaboration, coordination and communication as central mechanisms for transitional model for patients with advanced cancer. This may require careful planning and will need to be tailored to the contexts of each healthcare system.

Patients near death receiving specialized palliative home care being transferred to inpatient care - a registry study.

BACKGROUND: The majority of palliative care patients express a preference for remaining at home for as long as possible. Despite progression of disease there is a strong desire to die at home. Nonetheless, there are transfers between care settings, demonstrating a discrepancy between desired and actual place of death. AIM: To map the prevalence of patients near death undergoing specialized palliative home care and being transferred to inpatient care in Sweden. METHODS: A national retrospective cross-sectional study based on data from the Swedish Register of Palliative Care. Patients ≥ 18 years of age enrolled in specialized palliative home care with dates of death between 1 November 2015 and 31 October 2022 were included (n = 39,698). Descriptive statistics were used. RESULTS: Seven thousand three hundred eighty-three patients (18.6%), approximately 1,000 per year, were transferred to inpatient care and died within seven days of arrival. A considerable proportion of these patients died within two days after admission. The majority (73.6%) were admitted to specialized palliative inpatient care units, 22.9% to non-specialized palliative inpatient care units and 3.5% to additional care units. Transferred patients had more frequent dyspnoea (30.9% vs. 23.2%, p < 0.001), anxiety (60.2% vs. 56.5%, p < 0.001) and presence of several simultaneous symptoms was significantly more common (27.0% vs. 24.8%, p 0.001). CONCLUSION: The results show that patients admitted to specialized palliative home care in Sweden are being transferred to inpatient care near death. A notable proportion of these patients dies within two days of admission. Common features, such as symptoms and symptom burden, can be observed in the patients transferred. The study highlights a phenomenon that may be experienced by patients, relatives and healthcare personnel as a significant event in a vulnerable situation. A deeper understanding of the underlying causes of these transfers is required to ascertain whether they are compatible with good palliative care and a dignified death.

Efficacy of a Standardized Process in Optimizing Appropriate Use of Progressive Care Unit Beds in a Tertiary Care Facility.

BACKGROUND: Poor patient progression from the progressive care unit (PCU) beds has been recognized as a bottleneck, limiting the hospital's ability to optimize capacity for the sickest patients. Improving nurse management on PCU admission and discharge criteria could avoid PCU bottlenecks. LOCAL PROBLEM: Our institution lacked a standard process to identify clinically appropriate patients ready for transfer out of the PCU, causing delays in vacating PCU beds. OBJECTIVES: The aim of this study was to determine if creating a standard process to empower bedside nurses and unit nursing leaders to push readiness information to the provider team improves the appropriateness of PCU stay and transfers patients out of the PCU earlier. METHODS: The most common causes of delayed transfer out of the PCU were discussed among stakeholders. A process was designed to empower the bedside nurses to partner with a physician leader to send information to the provider team requesting evaluation of the patient's readiness to leave the unit. The improvement of meeting the criteria for PCU was evaluated by comparing 60 patients prior to the intervention phase with 139 patients during the intervention. RESULTS: The primary outcome, percentage of patients meeting PCU criteria, was 53% during the audit phase and 68% during the intervention phase (P = .05). The PCU transfer time was pushed 1 hour earlier in the day. CONCLUSIONS: The standard process of empowering bedside nurses to partner with physician leaders to push readiness for transferring patients out of the PCU resulted in a significant improvement in the percentage of patients meeting PCU criteria and earlier discharge of appropriate patients.

Development and psychometric testing of a scale to measure effective rural emergency transfer (RET).

BACKGROUND: The process of transferring patients from small rural primary care facilities to referral facilities impacts the quality of care and effectiveness of the referral healthcare system. The study aimed to develop and evaluate the psychometric properties of a scale measuring requirements for effective rural emergency transfer. METHODS: An exploratory sequential design was utilized to develop a scale designed to measure requirements for effective emergency transport. Phase one included a qualitative, interview study with 26 nursing transport providers. These transcripts were coded, and items developed for the proposed scale. Phase two included a content validity review by these 16 transport providers of the domains and items developed. Phase three included development and evaluation of psychometric properties of a scale designed to measure requirements for effective emergency transport. This scale was then tested initially with 84 items and later reduced to a final set of 58 items after completion by 302 transport nurses. The final scale demonstrated three factors (technology & tools; knowledge & skills; and organization). Each factor and the total score reported excellent scale reliability. RESULTS: The initial item pool consisted of 84 items, generated, and synthesized from an extensive literature review and the qualitative descriptive study exploring nurses' experiences in rural emergency patient transportation. A two-round modified Delphi method with experts generated a scale consisting of 58 items. A cross-sectional study design was used with 302 nurses in rural clinics and health in four rural health districts. A categorical principal components analysis identified three components explaining 63.35% of the total variance. The three factors, technology, tools, personal knowledge and skills, and organization, accounted for 27.32%, 18.15 and 17.88% of the total variance, respectively. The reliability of the three factors, as determined by the Categorical Principal Component Analysis (CATPCA)'s default calculation of the Cronbach Alpha, was 0.960, 0.946, and 0.956, respectively. The RET Cronbach alpha was 0.980. CONCLUSIONS: The study offers a three-factor scale to measure the effectiveness of emergency patient transport in rural facilities to better understand and improve care during emergency patient transport.

Use of computer simulation to identify effects on hospital census with reduction of transfers for non-procedural patients in community hospitals.

OBJECTIVE: In-person healthcare delivery is rapidly changing with a shifting employment landscape and technological advances. Opportunities to care for patients in more efficient ways include leveraging technology and focusing on caring for patients in the right place at the right time. We aim to use computer modelling to understand the impact of interventions, such as virtual consultation, on hospital census for referring and referral centres if non-procedural patients are cared for locally rather than transferred. PATIENTS AND METHODS: We created computer modelling based on 25 138 hospital transfers between June 2019 and June 2022 with patients originating at one of 17 community-based hospitals and a regional or academic referral centre receiving them. We identified patients that likely could have been cared for at a community facility, with attention to hospital internal medicine and cardiology patients. The model was run for 33 500 days. RESULTS: Approximately 121 beds/day were occupied by transferred patients at the academic centre, and on average, approximately 17 beds/day were used for hospital internal medicine and nine beds/day for non-procedural cardiology patients. Typical census for all internal medicine beds is approximately 175 and for cardiology is approximately 70. CONCLUSION: Deferring transfers for patients in favour of local hospitalisation would increase the availability of beds for complex care at the referral centre. Potential downstream effects also include increased patient satisfaction due to proximity to home and viability of the local hospital system/economy, and decreased resource utilisation for transfer systems.

Transition of Intensive Care Unit Patients and Their Families to Home After Acute Hospital Care.

Patients in the intensive care unit (ICU) increasingly are expected to eventually return home after acute hospital care. Yet transitional care for ICU patients and their families is often delayed until the patient is about to be transferred to another location or level of care. Transitions theory is a middle-range nursing theory that aims to provide guidance for safe and effective nursing care and research while an individual experiences a transition. Intensive care unit nurses are well positioned to provide ICU transitional care planning early. This article applies the transitions theory as a theoretical model to guide the study of the transition to home after acute hospital care for ICU patients and their families. This theory application can help ICU nurses provide holistic patient- and family-centered transitional care to achieve optimal outcomes by addressing the predischarge and postdischarge needs of patients and families.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Improving First Case Operating Room Efficiency.

INTRODUCTION: Improving transition to the operating room (OR) can enhance healthcare efficiency. Our aim was to determine whether adopting a communication board (CB) for first case surgical patients reduced delays to OR. METHODS: A retrospective observational study was conducted from April to October 2021. We calculated differences in surgical daycare (SDC) departure time before and after implementation of the CB, differences in departure whether the CB was used or not, delay in variability between surgical specialties, and overall adoption of the CB. RESULTS: After CB adoption, 13% of first cases left SDC by predefined target times. The mean delay in transfer was 18:51 minutes. When the CB was used, cases were on average 10:43 late, compared with 26:00 when it was not used. Otolaryngology had the shortest delays while plastic surgery had the longest. Reasons for delays included staffing delays, holds, and pending laboratory results. CONCLUSIONS: Introducing a CB significantly reduced delays in transferring first case surgical patients from SDC to the OR.

Parents' experience of children's transitions from intensive care unit after liver transplantation: A qualitative study.

OBJECTIVE: The aim of this study was to understand parents' perspectives on caring for children who underwent liver transplantation in the intensive care unit transition period and to provide a reference for the development of targeted intervention strategies. METHODS: Thirteen parents of children who underwent liver transplantation at a tertiary hospital in Hangzhou, Zhejiang Province were chosen for in-depth semi-structured interviews via purposive sampling. The interview data were analyzed and summarized via content analysis. FINDINGS: Three themes were extracted, including a period of separation and suffering (being apart from child is tough, chilling atmosphere, and limited family access); being an overwhelming caregiver (hope coupled with worry, conflict of roles, and existential care dilemmas); and facing a new normal: searching for information and support (information on medical conditions, post-discharge care assistance, educational support, and peer support). CONCLUSION: For parents whose child underwent liver transplantation, the transition period from the intensive care unit to the general ward is challenging. Parents are burdened with several caregiving responsibilities and require a variety of information and support. It is advised that nurses should offer sufficient information and suitable educational approaches to enhance these parents' capacity to care for their children and assist children and their parents in making a smooth transition. IMPLICATIONS FOR CLINICAL PRACTICE: This study highlights parents' perspectives on caring for children with liver transplants transferred from the intensive care unit to a general ward. Transitional care is strenuous, evoking different feelings before and after transfer. The health care professionals should focus on the needs and challenges faced by parents who are caring for children with liver transplants during the intensive care unit transition period. To achieve this, it is critical to establish a supportive environment and provide suitable information and education for parents to enhance their caregiving abilities.

Supporting rural families during interhospital patient transfers for critical illness events: An exploration of an acceptable communication process.

Critically ill patients in rural areas at times require an interhospital transfer from their local hospital to an urban tertiary care centre for advanced critical care services not available locally. Family members have described this transfer window as a communication blackout and one of the most stressful times of their relative's critical illness event. OBJECTIVE: To explore what communication process would be most acceptable between family members and transfer team members (consisting of critical care nurses, paramedics, and physicians) during interhospital transfers of critically ill patients. RESEARCH METHODOLOGY: Using a qualitative descriptive approach of critical thematic analysis, data were collected in September and November 2022, from focus groups of five family members and four transfer team members who experienced this phenomenon. SETTING: Rural Canada where speciality services such as interventional cardiology and neurosurgery are unavailable, and a tertiary care hospital is more than 160 km away. FINDINGS: Within themes of unequal power relations and status-based hierarchies, family members described how communication during interhospital transfers supports connection and coping, challenges experienced in accessing information, an overwhelming unknown, and practical challenges of the transfer. Transfer team members described a context of power relations and status-based hierarchies in which themes of transfer team burden, role confusion or connection, protection and management of family members, and complexities of information sharing during interhospital transfers were identified. CONCLUSION: In critical illness, communication linkages are created between healthcare providers and family members but are broken during an interhospital transfer resulting in increased stress for family members. Acceptable communication elements described by transfer team members and family members may maintain these linkages during the transfer window. IMPLICATIONS FOR CLINICAL PRACTICE: These findings provide the foundation for critical care nurses and their professional colleagues to take family care to the next level with an explicit communication strategy during interhospital transfers.

Supporting equitable care of patients transferred from police watch-houses to the emergency department: A qualitative study of the perspectives of emergency doctors.

OBJECTIVE: People detained in short-term police custody often have complex health conditions that may necessitate emergency care, yet little is known about their management in EDs. The present study aimed to understand ED doctors' experiences and perceptions regarding the appropriateness and management of detainee transfers from police watch-houses to the EDs. METHODS: A qualitative descriptive study, using semi-structured interviews undertaken with ED doctors working in five purposively sampled EDs across Queensland, Australia. Data were analysed using inductive content analysis. RESULTS: Fifteen ED specialists and trainees participated. Participants reported that their overarching approach was to provide equitable care for watch-house detainees, as they would for any patient. This equitable approach needed to be responsive to complicating factors common to this population, including presence of police guards; restraints; complexity (physical/mental/social) of presentation; reliance on police to transport; ED doctors' often limited understanding of the watch-house environment; justice processes and uncertain legal disposition; communication with the watch-house; and detainees misreporting symptoms. Thresholds for assessment and treatment of detainees were contextualised to the needs of the patient, ED environment, and imperatives of other relevant agencies (e.g. police). Participants often relied on existing strategies to deliver quality care despite challenges, but also identified a need for additional strategies, including education for ED staff; improved communication with watch-houses; standardised paperwork; extended models of watch-house healthcare; and integrated medical records. CONCLUSIONS: Providing equitable healthcare to patients transported from watch-houses to the EDs is challenging but essential. Numerous opportunities exist to enhance the delivery of optimal care for this underserved population.

Strategies to Improve Emergency Transitions From Long-Term Care Facilities: A Scoping Review.

BACKGROUND AND OBJECTIVES: Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs. RESEARCH DESIGN AND METHODS: In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success. RESULTS: Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes. DISCUSSION AND IMPLICATIONS: Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.

Navigating Transitions in Oncology Care: From Emergency Department to Outpatient Clinic.

OBJECTIVE: This quality improvement project was a collaborative effort with Penn Medicine's emergency department (ED) and oncology nurse navigators (ONNs). The goal of the project was to streamline patient transitions from the ED to the outpatient oncology clinic by developing a standardized referral process. The main objectives were to simplify and automate the referral process using the electronic medical record, improve multidisciplinary communication across the care continuum, ensure timely follow-up, and address barriers to oncology care. METHODS: The ED providers placed a consult to ONNs. The ONNs reached out to the patient within 48 hours of the consult. They maintained a database of patient referrals and collected information such as patient demographics, reason for referral, insurance, and patient outcomes. RESULTS: The ED providers referred 204 patients to the ONNs from April 2022 to September 2023. The development of a standardized referral process from the ED to the outpatient oncology clinic proved successful. Of the patients referred, the ONNs facilitated 98 cancer diagnoses and 80 of those patients are receiving oncology care at Penn Medicine. The median time to the patient's first appointments was seven days, diagnosis was 15 days, and treatment initiation occurred within 32 days. CONCLUSION: The project team achieved their goal of facilitating timely access to oncology care, ensuring continuity, and addressing patient-specific barriers. IMPLICATIONS FOR NURSING PRACTICE: This quality improvement initiative highlights the ONNs' role in enhancing access and equity in cancer care delivery. The success of the project underscores the ONN's expertise and leadership in addressing healthcare disparities in oncology care. Collaboratively, the teams created a new referral workflow improving care transitions from the ED to the outpatient oncology clinic. The project sets a precedent for optimizing patient care transitions, demonstrating the positive impact of ONNs as key members of the multidisciplinary healthcare team.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU.

BACKGROUND: Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers. METHODS: I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians. RESULTS: Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use. CONCLUSION: I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Handoffs and transitions of care: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: The Joint Commission reports that at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within acute care surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes. METHODS: Clinically relevant questions regarding handoffs and transitions of care with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes were determined. These centered around specific transitions of care within the setting of ACS, specifically perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and intensive care unit (ICU) interactions. A systematic literature review and meta-analysis were conducted using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: A total of 10 studies were identified for analysis. These included 5,113 patients in the standardized handoff group and 5,293 in the current process group. Standardized handoffs reduced handover errors for perioperative interactions and preventable adverse events for intra/interfloor and ICU interactions. There were insufficient data to evaluate outcomes of clinical complications and medical errors. CONCLUSION: We conditionally recommend a standardized handoff in the field of ACS, including perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and ICU interactions. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level III.

A pediatric teletrauma program pilot project: Improves access to pediatric trauma care and timely assessment of pediatric traumas.

BACKGROUND: Geographic location is a barrier to providing specialized care to pediatric traumas. In 2019, we instituted a pediatric teletrauma program in collaboration with the Statewide Pediatric Trauma Network at our level 1 pediatric trauma center (PTC). Triage guidelines were provided to partnering hospitals (PHs) to aid in evaluation of pediatric traumas. Our pediatric trauma team was available for phone/video trauma consultation to provide recommendations on disposition and management. We hypothesized that this program would improve access and timely assessment of pediatric traumas while limiting patient transfers to our PTC. METHODS: A retrospective cohort study was conducted at the PTC between January 2019 and May 2023. All pediatric trauma patients younger than 18 years who had teletrauma consults were included. We also evaluated all avoidable transfers without teletrauma consults defined as admission for less than 36 hours without an intervention or imaging as a comparison group. RESULTS: A total of 151 teletrauma consults were identified: 62% male and median age of 8 years (interquartile range [IQR], 4-12 years). Teletrauma consults increased from 12 in 2019 to 100 in 2022 to 2023, and the number of PHs increased from 2 to 32. Partnering hospitals were 15 to 554 miles from the PTC, with a median distance of 34 miles (IQR, 28-119 miles). Following consultation, we recommended discharge (34%), admission (29%), or transfer to PTC (35%). Of those who were not transferred, 3% (3 of 97) required subsequent treatment at the PTC. Nontransferred teletrauma consults had a higher percentage of TBI (61% vs. 31%, p < 0.001) and were from farther distances (40 miles [IQR, 28-150 miles] vs. 30 miles [IQR, 28-50 miles], p < 0.001) compared with avoidable transferred patients without a teletrauma consult. CONCLUSION: Teletrauma consult is a safe and viable addition to a pediatric trauma program faced with providing care to a large geographical catchment area. The pediatric teletrauma program provided management recommendations to 32 PHs and avoided transfer in approximately 63% of cases. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke.

Importance: Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). Objective: To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. Design, Setting, and Participants: US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Exposure: Patient- and hospital-level characteristics. Main Outcomes and Measures: The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Results: Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. Conclusions and Relevance: In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.