Remote Supervision of IV-tPA for Acute Ischemic Stroke by Telemedicine or Telephone Before Transfer to a Regional Stroke Center Is Feasible and Safe

Abstract

Background and Purpose-Because of a shortage of stroke specialists, many outlying or "spoke" hospitals initiate intravenous (IV) thrombolysis using telemedicine or telephone consultation before transferring patients to a regional stroke center (RSC) hub. We analyzed complications and outcomes of patients treated with IV tissue plasminogen activator (tPA) using the "drip and ship" approach compared to those treated directly at the RSC. Methods-A retrospective review of our Get With the Guidelines Stroke (GWTG-Stroke) database from 01/2003 to 03/2008 identified 296 patients who received IV tPA within 3 hours of symptom onset without catheter-based reperfusion. GWTG-Stroke definitions for symptomatic intracranial (sICH), systemic hemorrhage, discharge functional status, and destination were applied. Follow-up modified Rankin Score was recorded when available. Results-Of 296 patients, 181 (61.1%) had tPA infusion started at an outside spoke hospital (OSH) and 115 (38.9%) at the RSC hub. OSH patients were younger with fewer severe strokes than RSC patients. Patients treated based on telestroke were more frequently octogenarians than patients treated based on a telephone consult. Mortality, sICH, and functional outcomes were not different between OSH versus RSC and telephone versus telestroke patients. Among survivors, mean length of stay was shorter for OSH patients but discharge status was similar and 75% of patients walked independently at discharge. Conclusions-Outcomes in OSH "drip and ship" patients treated in a hub-and-spoke network were comparable to those treated directly at an RSC. These data suggest that "drip and ship" is a safe and effective method to shorten time to treatment with IV tPA. (Stroke. 2010;41:e18-e24.)Key Words: stroke Ⅲ telemedicine Ⅲ thrombolysis I ntravenous tissue plasminogen activator (IV tPA) is FDA approved for acute ischemic stroke (AIS) within the first 3 hours of symptom onset. 1 Previous studies have shown that IV tPA is underused and that only 3% to 4% of AIS patients receive thrombolytic treatment. 2 A majority of acute stroke patients present to hospitals that lack 24/7 availability of a stroke specialist, 3,4 are managed by generalists, 5 and many do not receive tPA at the presenting facility. 6,7 If practitioners opt for transfer to a regional stroke center (RSC) for initiation of tPA, delays may preclude delivery of tPA.Hub-and-spoke networks have been developed to allow IV tPA to be initiated at an outlying spoke hospital (OSH) under the supervision of a vascular neurologist at the designated RSC hub who provides assistance in the diagnosis and management of AIS via telephone 8 or telemedicine-enabled ("telestroke") 9 consultation before transfer. This practice has been referred to as "drip and ship." 10 The evidence supporting telemedicine for acute stroke care within a hub and spoke network has recently been reviewed and guideline recommendations published. 11,12 Limited data exist comparing the safety and feasibility of patients treated by "drip and ship" 13 versus patie...

The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management

“…The complications and outcomes of 296 patients with acute ischemic stroke were compared with those receiving tPA treatment using ''drip and ship'' treatment and those treated at the regional stroke center. 86 Patients at the ''spoke hospital'' were younger with fewer severe symptoms. The outcomes of the two groups were similar.…”

Overview of key factors in improving access to acute stroke care

“…43 A retrospective analysis of 353 patients with AIS in whom IV-rtPA was administered at an outside spoke hospital (OSH) vs a hub center indicated the safety of administering thrombolysis via telestroke. 44 Results showed no statistically significant differences in the rates of symptomatic intracranial hemorrhage (sICH) (3.87% vs 5.22%; p ϭ 0.58) and in-hospital mortality (14.92% vs 17.39%; p ϭ 0.57). 44 A similar safety profile, showing no difference in the rate of sICH (6% vs 4.5%) or in-hospital mortality (10.6% vs 10.7%), was found in a series of 116 patients with AIS treated with thrombolysis at the OSH vs at the hub hospital.…”

“…44 Results showed no statistically significant differences in the rates of symptomatic intracranial hemorrhage (sICH) (3.87% vs 5.22%; p ϭ 0.58) and in-hospital mortality (14.92% vs 17.39%; p ϭ 0.57). 44 A similar safety profile, showing no difference in the rate of sICH (6% vs 4.5%) or in-hospital mortality (10.6% vs 10.7%), was found in a series of 116 patients with AIS treated with thrombolysis at the OSH vs at the hub hospital. 45 In summary, immediate visual-audio interaction would increase patient access to stroke therapy and transfer for potential endovascular treatment.…”

The missing button sign as a tool for detecting proximal internal carotid artery occlusion

“…This practice has been found to be both safe and feasible compared to the initiation of tPA at a regional stroke centre. 9,10 Some regional hospitals may not have the capability to perform CTA, and for these hospitals, the early identification of ICAO using the MBS can be helpful, as it would allow the stroke centre time to prepare the IA thrombolysis to be ready upon the patient's arrival.…”