Miller, Blake

Abstract Background and aims Interfacility transfers in rural areas are challenging due to limited ambulance and bed availability, image sharing issues, and access disparities. Regional transfers to strategically located primary stroke centers can reduce time to care, decrease helicopter use, support local economies, and conserve comprehensive stroke center (CSC) resources. This study established a primary stroke center as a regional transfer center (rSTC) within a telestroke network. Methods Over one year, stakeholders created regionally appropriate transfer workflows defined as patients without large vessel occlusion, low likelihood for neurosurgical decompression or critical illness within a rSTC and 4 surrounding centers. Continuous education and prospective case logs were maintained by the rSTC stroke coordinator and a retrospective chart review was conducted one year following the intervention period. Results Of 99 patients requiring transfer, 73 (73.7%) went to the rSTC, with an average stay of 2.1 days, no deaths, and no secondary CSC transfers. The remaining 26 (26.3%) were sent to the CSC, with longer stays (10.6 days) and higher mortality (23.1%). Transfers to the rSTC were faster (60 min vs. 188 min). Financial analysis showed significant EMS savings ($455,111) and local health system benefits ($730,000) when compared to the pre-intervention period. Conclusions Establishing an effective regional transfer model is possible with broad stakeholder engagement and regular network maintenance. rSTCs provide the right level of care for the right patient, improving efficient allocation of healthcare resources and avoiding futile transfers with costly admissions far from home while opening beds and reducing transfer times to CSCs. Conflict of interest Nothing to disclose

Background: Interfacility transfers, especially in rural settings, present challenges including limited ambulance availability, bed capacity, image sharing and disparities in access. Regional transfer minimizes time to definitive stroke center care, relies less on costly helicopter transport, supports local healthcare economies, and preserves comprehensive stroke center (CSC) resources for those most likely to benefit. Although these advantages are well-established and reflected in the guidelines, transfers within our connected care rural network were not previously accepted at hospitals outside of our central comprehensive stroke center (CSC). Methods: We identified a local primary stroke center to serve as the regional stroke transfer center (rSTC) within our larger telestroke network. Over one year, (2023-2024), stakeholder meetings with representatives from the rSTC, surrounding smaller hospitals and the CSC were conducted to pinpoint potential roadblocks and create workflows that facilitated regional transfer. Regionally appropriate transfers were defined as patients without LVO, low likelihood for any neurosurgical decompression, or critical illness requiring dedicated neuro-intensive care. Education surrounding these criteria occurred quarterly and case logs were maintained and reviewed by the rSTC stroke coordinator. Retrospective chart review one year following the intervention period (2024-2025) was performed. Results: Of the 99 total transferred patients, 73 (73.7%) patients were transferred regionally. Their average LOS was 2.1 days, with 0% mortality rate and 0% requiring a secondary transfer to the CSC. 26 (26.3%) patients went to the CSC; LOS was 10.6 days and mortality 23.1%. Transfer times were shorter for rSTC patients (60 min vs 188 min). Six CSC patients met regional criteria (26.3% overtriage rate). Conclusion: Establishing an effective regional transfer model is possible with broad stakeholder engagement and regular network maintenance. Following our intervention, most eligible patients remained local and were treated appropriately. Although there was a significant reduction of the patients transferred to the CSC, the majority of CSC transfers were also appropriately triaged. This rSTC model facilitates the care of all stroke patients by providing the right level of care for the right patient, avoiding futile transfers with costly admissions far from home while opening beds and reducing transfer times to CSCs.