Observational Study of Telephone Consults by Stroke Experts Supporting Community Tissue Plasminogen Activator Delivery

Abstract

Objectives Barriers to intravenous (IV) tissue plasminogen activator (tPA) use in ischemic stroke include limited treatment experience of community physicians. Models of acute stroke care have been designed to address these limitations by providing community support. These include support by telephone or televideo, with or without subsequent transport to tertiary care centers. The authors describe the frequency, characteristics, and effect of community phone consultations to a 24/7 stroke “hotline” staffed by stroke physicians at an academic stroke center using such a model. Methods Twelve intervention hospitals participating in the INcreasing Stroke Treatment through Interventional behavior Change Tactics (INSTINCT) trial were provided a single-access number (“hotline”) for expert consultation on tPA use. Experts consisted of stroke-trained physicians at an academic medical center. Hotline use was not mandated by the study protocol, nor was patient transfer required. Consultants were required to record all treatment questions in a web-based log. All patients discussed over the hotline and/or treated with tPA in an INSTINCT hospital underwent multi-level chart review by trained nurse coordinators. Cases were linked to logged hotline calls, based on the time of treatment and the initial treating hospital. Physician adjudicators assessed appropriateness of tPA treatment, presence of deviation from standard guidelines, and treatment complications (intracranial hemorrhage [ICH], systemic hemorrhage, or death). Results Over 27 months, there were a total of 204 hotline calls regarding 116 patients. Ninety-one percent of calls were between 8 am and midnight, 77% of questions explored issues of eligibility for IV tPA, particularly for minor stroke or improving stroke (26%). A total of 243 patients were treated with IV tPA at the 12 intervention hospitals, 54 of which were following hotline consult. Seventy-six percent of hotline patients in whom tPA was recommended actually received tPA, while 2% of those in whom tPA was not recommended received the medication. There were no differences in protocol deviations (27.8% hotline group vs. 23.8% non-hotline group), incidence of symptomatic ICH (5.6% vs. 7.3%), or in-hospital mortality (5.6% vs. 13.2%). No medical-legal issues have been reported for any case in the study. Conclusions Providing tPA decision-making support via telephone consult to community physicians is feasible and safe. Consultants may play a more prominent role in determining tPA ineligibility than acceptance. Future work should include a real-time survey of physician providers to ascertain such potential qualitative benefits of a stroke hotline.

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

“…It has previously been reported in uncontrolled reports of patients treated with intravenous tPA, 6,42,91,115 pretelestroke/ posttelestroke implementation evaluations, 131 comparisons between telemedicine-guided thrombolysis and in-personinitiated thrombolysis, 36,[120][121][122]132 and comparisons of telephone-and telemedicine-based thrombolysis. 36,133 Mortality after thrombolysis was reported as an outcome in a randomized trial of telephone and telemedicine acute stroke consultations, with no difference found between the modalities.…”

“…[127][128][129] Although telemedicine including video examination equipment is mentioned, it remains unclear how many patients treated with tPA were remotely assessed in the latter studies. Mortality at 90 days has been reported in a limited number of cohorts of uncontrolled studies and reports, 93,116 comparisons between telemedicine-guided thrombolysis and in-person-initiated thrombolysis, 99,119,124 an observational study of telephone versus telemedicine thrombolysis, 91 and 2 randomized controlled trials. 5,136 Longer-term mortality after thrombolysis by telestroke has been described for unselected stroke patients in an uncontrolled study, 117 pretelestroke/posttelestroke implementation evaluations, 131,137 and a comparison of hospitals within a telestroke unit network and matched conventional hospitals, 134,135 as well as 1 randomized controlled trial.…”

“…In one study, phone consultation for acute stroke was found to be feasible when provided by a hotline to stroke experts at an academic medical center. 91 A randomized trial of phone-only versus video-enabled consults showed that the 2 approaches differed in quality of decision making. 5 The method of consultation is ideally recorded for analysis by method.…”

Gestão em rede no atendimento ao acidente vascular cerebral: revisão integrativa de literatura

“…Dentre os achados, a qualificação dos profissionais aparece, com muita ênfase, como aspecto fundamental para o funcionamento da programação estratégica de forma sincronizada (Brandão et al, 2022;Demaerschalk;Bobrow;Paulsen, 2008;Kapral et al, 2013;Kodankandath et al, 2017;López-Cancio et al, 2018;Majersik et al, 2012;Polivka;Polivka;Rohan, 2018;Sanossian et al, 2015;Whetten et al, 2018).…”

“…Em regiões escassamente povoadas (Majersik et al, 2012) ou em zonas rurais (Klingner et al, 2018;Majersik et al, 2012), há maior dificuldade em levar tecnologias como protocolos de roteamento, por exemplo.…”