Using Telemedicine to Facilitate Thrombolytic Therapy for Patients with Acute Stroke

Choi, John Y.; Porche, Nichole A.; Albright, Karen C.; Khaja, Aslam M.; Ho, Victor S.; Grotta, James C.

doi:10.1016/s1553-7250(06)32025-9

Cited by 30 publications

(37 citation statements)

References 12 publications

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“…Many studies have demonstrated the utility of telestroke for assessing stroke severity [9][10][11][12] and for increasing the use of tPA among eligible patients. [13][14][15][16][17] Our findings add to this body of literature supporting the value of telestroke for improving tPA administration rates among patients with ischemic stroke presenting to community hospitals. We found that telestroke can be implemented safely and effectively in community hospitals, and that the beneficial effects (increased tPA utilization) occurred quickly after implementation without a significant lag period and without any corresponding change in complications.…”

Section: Discussionsupporting

confidence: 57%

Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

Zachrison

Shen

Sangha

et al. 2016

TPJ

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Context: There is substantial hospital-level variation in use of tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Telestroke services can bring neurologic expertise to hospitals with fewer resources.Objective: To determine whether implementation of a telestroke intervention in a large integrated health system would lead to increased tPA utilization and would change rates of hemorrhagic complications.Design: A stepped-wedge cluster randomized trial of 11 community hospitals connected to 2 tertiary care centers via telestroke, implemented at each hospital incrementally during a 1-year period. We examined pre-and postimplementation data from July 2013 through January 2015. A 2-level mixed-effects logistic regression model accounted for the staggered rollout.Main Outcome Measures: Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications.Results: Of the 2657 patients, demographic and clinical characteristics were similar in pre-and postintervention cohorts. Utilization of tPA increased from 6.3% before the intervention to 10.9% after the intervention, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients (odds ratio = 2.0; 95% confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of the 10 were at least as likely to administer tPA as the highest-volume center.Conclusion: Telestroke implementation in a regional integrated health system was safe and effective. Community hospitals' rates of tPA utilization quickly increased and were similar to the largest-volume tertiary care center.

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Section: Discussionsupporting

confidence: 57%

Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

Zachrison

Shen

Sangha

et al. 2016

TPJ

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“…Our experience over the last two years reveals that with minimal training the medical personnel at the non-tertiary emergency departments treated 21% of patients with intravenous tPA with generally comparable outcome to historical control. The 'doorto-needle' times were acceptable and the risk of symptomatic cerebral hemorrhage was similar to reports in the literature [8][9][10][11][12][13][14][15][16] . The 90-day mortality was also comparable to published [8][9][10][11][12][13][14][15][16] .…”

Section: Discussionsupporting

confidence: 84%

“…A recent randomized control study comparing videoconferencing with computed tomography (CT) image review to telephone consultations without CT image review showed similar outcome at 90 days 8 . Other smaller studies have also published encouraging results [9][10][11][12][13][14][15][16] .…”

Section: Original Articlementioning

confidence: 86%

“…For management of acute stroke, telemedicine is relatively new technology. A handful of sites have published their experience over the last five years [8][9][10][11][12][13][14][15][16] . While most sophisticated programs require the two-way videoconference with access to real time viewing of the cranial CT scans, there is also experience where the CT images are reviewed locally by the radiologist and the telephone consultation occurs with no direct visual examination of the patient through videoconferencing 8 .…”

Section: Discussionmentioning

confidence: 99%

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Telestroke in Northern Alberta: A Two Year Experience with Remote Hospitals

Khan¹,

Shuaib²,

Whittaker

et al. 2010

Can. j. neurol. sci.

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Stroke is a common neurological emergency and remains a major cause of short and long-term disability worldwide 1 . Thrombolysis with intravenous tissue plasminogen activator (tPA) can result in a significantly better outcome if the treatment is offered early 2 . Despite evidence from several studies showing consistently better results in tPA treated patients, less than 8% of ischemic stroke patients receive intravenous tPA 3,4 . Many factors contribute to the relatively low rate of intravenous tPA treatment. Among them late arrival to a comprehensive stroke centre is a major factor. In the NINDS trial over 16000 stroke victims were screened and among them 50% arrived too late to be treated 5 . Late arrival to hospital is particularly important in countries where the population is spread over a large geographical area.ABSTRACT: Background: Thrombolysis in acute ischemic stroke is usually performed in comprehensive stroke centres. Lack of stroke expertise in remote small hospitals may preclude thrombolysis. Telemedicine allows such management opportunities in distant hospitals. Methods: We report our experience in managing acute stroke over a two-year time period with telestroke. The University of Alberta Hospital acted as the 'hub' and seven remote hospitals as 'spoke'. The neurologist at the 'hub' provided stroke expertise to the local physician using either a two-way video link or telephone. Cranial CT scans were transmitted to 'hub'. Education sessions were held before the initiation of the program. Results: Of 210 patients 44 (21%) received thrombolysis at the 'spoke' sites. In 34/44 (77%) two-way video link was available while in 10/44 (23%) telephone was used. Five (11.4%) patients experienced intracranial hemorrhage after thrombolysis, 2 (4.5%) were symptomatic. Favorable (mRS=0-1) outcome at three months was 16/40 (40%) and mortality was 9/40 (22.5%). Four patients were lost to follow-up. There was no significant three months outcome difference between two-way video link and telephone consultation (P = 0.689). Over two years the number of acute stroke transfers decreased from 144 to 15 at one of the 'spoke' sites, a 92.5% decline. Conclusion: It is possible to successfully treat patients with acute ischemic stroke at remote sites through videoconferencing or telephone consultation. Telestroke can also lead to a significant reduction in the number of patients requiring transfer to a tertiary care centre.RÉSUMÉ: Télé-AVC dans le nord de l'Alberta : une expérience de deux ans dans des hôpitaux situés en région éloignée. Contexte : La thrombolyse dans l'accident vasculaire cérébral (AVC) ischémique aigu est habituellement effectuée dans des centres intégrés de soins de l'AVC. Le manque d'expertise dans le domaine de l'AVC dans les petits hôpitaux situés en région éloignée est un obstacle à la thrombolyse. La télémédecine permet d'y pallier dans les hôpitaux situés en région. Méthodologie : Nous rapportons notre expérience dans la prise en charge de l'AVC aigu au cours d'une période de deux ans au moyen de té...

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“…42 Telestroke/telemedicine data suggest that remote acute stroke patient examinations at rural hospital settings are feasible and have good inter-rater reliability compared to those of a face-to-face on-site examiner. [43][44][45][46][47][48][49][50][51][52][53] Teleneurology and telestroke do have certain barriers, legal issues, credentialing, and technical limitations that must be mentioned, however. 54 Barriers for setting up a telemedicine network for remote stroke evaluation include conceptual distrust among the referring hospital system (physicians, administrators, nurses, etc) and concern on the part of consulting neurological subspecialists unfamiliar with the sophisticated system that it may not provide a reliable and secure consultation portal.…”

Section: How Can Teleneurohospitalists Impact Patient Care?mentioning

confidence: 99%

Future Neurohospitalist

Freeman

Barrett

Vatz³

et al. 2012

The Neurohospitalist

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Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time. Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services. Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option. The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected. We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.

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Using Telemedicine to Facilitate Thrombolytic Therapy for Patients with Acute Stroke

Cited by 30 publications

References 12 publications

Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

Telestroke in Northern Alberta: A Two Year Experience with Remote Hospitals

Future Neurohospitalist

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