Background: Administration of alteplase is the standard of care for eligible patients presenting with symptoms of acute ischemic stroke (AIS). Telemedicine is increasingly being used to deliver acute stroke care to patients without in-person access to stroke expertise. This study reviews the thrombolysis experience of the largest known teleneurology network spanning 39 states and distributed across a heterogeneous multihospital population throughout the nation. Methods: Data was abstracted from internal medical records systems and relevant medical records obtained from partner hospitals. A retrospective analysis on the prospectively maintained database of patients who have received alteplase was performed. Data was collected from December 1, 2015 to May 31, 2019. Outcome analysis was restricted to those patients with available complete discharge data. Results: The analysis revealed 8,399 patients as having received alteplase during the study period. Of these, 56.7% had discharge information available. The mean patient age was 68.5 years, with a mean age of 70.5 years for females and 66.5 years for males. The median initial NIHSS score was 7, with 31.2% of patients presenting with an initial NIHSS score ≤4, and 8.7% presenting with an initial NIHSS score ≥21. The transfer rate to another facility was 31.0%. There were 2,417 home discharges (48.2%), 1,057 acute rehabilitation discharges (21.1%), and 478 skilled nursing facility discharges (9.5%). There were 28 patients who left against medical advice (0.6%). The symptomatic hemorrhage rate in this population was 1.1% (92), and there were 234 patient deaths (4.7%). Conclusion: A large-scale teleneurology platform for the emergent treatment of patients presenting with AIS symptoms is both safe and feasible. Due to the heterogeneity of this patient and hospital population, higher level refinement of this analysis to include hyperacute metrics, transfer data, and more comprehensive clinical and functional outcomes is warranted.
Background: Thrombolysis with alteplase is the standard of care for treatment of eligible patients presenting with acute ischemic stroke (AIS). Telestroke physicians must use available information to make timely treatment decisions remotely. Through this practice, an unusual subset of patients presenting multiple times with symptoms of AIS has emerged. This study describes the largest known sample of this multiple-encounter population within a single teleneurology practice spanning 34 states. Methods: A retrospective observational study of the experience of a single teleneurology practice serving over 400 hospitals from July 1, 2015 to August 1, 2018 was performed. The alteplase patient database was queried to identify patients with multiple telestroke encounters (n=56). Demographic and clinical data were abstracted. Results: Within the queried period, 56 patients were identified to have had multiple encounters with the teleneurology practice, 37 males and 19 females. Of these, 29 were seen twice, 10 were seen three times, 8 were seen four times, and 9 had five or more encounters. Four patients received care in multiple states. Alteplase was administered on more than one encounter in 45 patients, with a maximum alteplase administration of 4 times in a single patient. The overall alteplase rate was 54.6% (106 of 194 encounters). The median NIHSS score for patients seen in multiple encounters was 5. Of the 56 patients, 98.2% had stroke risk factors, 42.9% had noncerebrovascular neurological comorbidities, and 42.9% had psychiatric disease history. All patients presented with at least one motor symptom, while 64.3% presented with a sensory symptom, 26.8% presented with aphasia, and 55.4% presented with other neurological symptoms. Conclusions: The observance of multiple teleneurology encounters for patients presenting with AIS symptoms and receiving alteplase at high rates is anecdotal and not yet largely described. History of cerebrovascular disease is a risk factor for recurrent stroke, but the true composition of this patient population is undefined. Given the associated risks and resource utilization involved with alteplase, future study of the characteristics and disease mechanism of this population is warranted.
Background: Administration of alteplase is the standard of care for eligible patients presenting with symptoms of acute ischemic stroke (AIS). Telemedicine is increasingly being used to deliver acute stroke care to patients without in-person access to stroke expertise. This study reviews the alteplase experience and outcomes of the largest known teleneurology network spanning 34 states and distributed across a heterogeneous multihospital population. Methods: Data was abstracted from internal medical records systems and relevant medical records obtained from partner hospitals. A retrospective analysis on the prospectively maintained database of patients who have received alteplase was performed. Data was collected from December 1, 2015 to June 30, 2018. Outcome analysis was restricted to those patients with available complete discharge data. Collected data included demographics, stroke severity, symptomatic intracranial hemorrhages (sICH), discharge disposition and mortality. Results: The analysis revealed 6199 patients as having received alteplase during the study period. Of these, 56.7% had discharge information available. The mean patient age was 69.7 years, with a mean age of 71.8 years for females and 67.4 for males. The median initial NIHSS was 7, with 30.3% of patients presenting with NIHSS ≤4 and 8.5% initially presenting with initial NIHSS ≥21. Only 19.7% of patients were transferred to another facility. Clinical outcomes data were available for 3327 patients (53.7%). There were 1536 home discharges (46.2%), 626 acute rehabilitation discharges (18.8%), and 283 skilled nursing facility discharges (8.5%). The sICH rate in this population was 0.9% (29) and there were 136 patient deaths (4.1%). Conclusion: Large-scale teleneurology for the treatment of patients presenting with symptoms of AIS is feasible, with clinical outcome data similar to other published studies. Further refinement of this data, to include subgroup analyses, transfer patterns, and more comprehensive clinical outcomes is warranted.
Background: Thrombolysis with alteplase is the standard of care for the treatment of eligible patients presenting with acute ischemic stroke (AIS). Many hospitals do not have access to in-person cerebrovascular expertise, and utilize telestroke services for the remote diagnosis and treatment of AIS. Through this practice, an unusual subset of patients with multiple presentations having received thrombolysis several times has emerged. This study describes the largest known sample of this multiple-encounter population within a single teleneurology practice spanning 39 states over 4 years. Methods: A retrospective observational study of the experience of a single teleneurology practice serving over 400 hospitals from July 1, 2015 to June 30, 2019 was performed. The alteplase patient database was queried to identify patients with both multiple telestroke and multiple alteplase encounters. Demographic and clinical data were abstracted. Outcome analysis was restricted to those patients with available complete discharge data. Results: Within the queried period, 71 patients were identified to have had multiple encounters with the teleneurology practice, 46 males and 25 females. Of these, 36 patients were seen twice, 18 were seen three times, 10 were seen four times, and 7 had five or more encounters, with the maximum number of encounters of 26. Seven patients received care in multiple states. The overall alteplase rate was 58.2%. Alteplase was administered on more than one encounter in all 71 patients, with a maximum alteplase administration of 4 times in a single patient. The median NIHSS score in this population was 5. Of the 71 patients, all had stroke risk factors, 36.6% had noncerebrovascular neurological comorbidities, and 36.6% had psychiatric disease history. The symptomatic hemorrhage rate in this population was 0%. Conclusion: The observed phenomena of recurrent teleneurology encounters for patients presenting with suspected AIS symptoms and receiving alteplase at increased rates is not well-described and is poorly understood. Given the inherent risk and resource utilization associated with thrombolysis, further analysis of the characteristics of this patient population is warranted.
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