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Original research
Intrinsic hospital factors: overlooked cause for variations in delay to transfer for endovascular thrombectomy
  1. Ron Danziger1,
  2. Christina Tan1,
  3. Leonid Churilov1,2,
  4. Peter Mitchell3,
  5. Richard Dowling3,
  6. Steven Bush3,
  7. Bernard Yan1
  1. 1Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
  2. 2Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
  3. 3Radiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Ron Danziger, Neurology, The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia; ronjdanziger{at}


Background Intrinsic hospital factors leading to time delay to inter-hospital transfer for endovascular thrombectomy (EVT) have not been adequately investigated, leading to uncertainty in generalizability of hub and spoke EVT services. We investigated the contribution of intrinsic hospital factors to variations in time delay in a multicenter, retrospective study.

Methods The setting was a hub and spoke EVT state-wide system for a population of 6.3 million and 34 spoke hospitals. We collected data on acute large vessel occlusion strokes transferred from spoke to hub for consideration of EVT between January 2016 and December 2018. The primary endpoint was the proportion of variability in delay-time in transfer cases contributed to by intrinsic hospital factors estimated through variance component analysis implemented as a mixed-effect linear regression model with hospitals as random effects.

Results We included 434 patients. The median age was 72 years (IQR 62–79), 44% were female, and the median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 11–20). The median onset to CT time was 100 mins (IQR 69–157) at the spoke hospitals and CT acquisition at the spoke hospital to time of transfer was 93 min (IQR 70–132). 53% of the observed variability in time from CT acquisition at the spoke hospital to transfer to the EVT center was explained by intrinsic hospital factors, as opposed to patient-related factors.

Conclusions Intrinsic hospital factors explained more than half of the observed variability in time from CT acquisition at the spoke hospital to departure for transfer. We recommend that the design of hub and spoke EVT services should account for intrinsic hospital factors to minimize hospital transfer delay.

  • angiography
  • standards
  • statistics
  • stroke
  • thrombectomy

Statistics from


  • Contributors Authors R Danziger and CT contributed equally to data collection and writing of the manuscript. LC contributed to statistical analysis. PM, R Dowling, SB and BY performed EVT procedures at our institution and contributed to reviewing the manuscript. BY supervised research project.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. Data are de-identified patient information and are not available in a repository.

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