Original contribution
A Web-based Telestroke System Facilitates Rapid Treatment of Acute Ischemic Stroke Patients in Rural Emergency Departments

https://doi.org/10.1016/j.jemermed.2007.06.041Get rights and content

Abstract

Patients in rural communities lack access to acute stroke therapies. Rapid administration of thrombolytic therapy increases the likelihood of a favorable outcome in ischemic stroke. We aimed to detail the safety, feasibility, and treatment times of thrombolytic therapy with a web-based telestroke system. At the Medical College of Georgia, we have developed a telestroke system (Remote Evaluation of Acute IsCHemic Stroke; REACH) in which emergency physicians in surrounding counties may consult stroke specialists at our institution. The web-based system allows the stroke consultant to obtain history, examine the patient with live video, and review computed tomography. A recommendation is made regarding the administration of tissue plasminogen activator (tPA) before patient transport to the tertiary medical center. A systematic review of the literature was conducted regarding the use of tPA in academic and community hospitals. Symptomatic hemorrhagic transformation and stroke onset-to-treatment times were compared between the REACH network and other stroke care delivery systems. Between February 2003 and March 2006, 50 patients were treated with intravenous tPA using the REACH telestroke system. There was one (2%) symptomatic hemorrhage. The mean onset-to-treatment time was 127.6 min (95% confidence interval 117.1–138.0) using REACH compared with 145.9 min (95% confidence interval 126.9–164.9) in our Emergency Department and 147.8 min in other published systems. REACH, a web-based telestroke system, facilitates the safe administration of thrombolytic therapy to patients within rural communities suffering an acute ischemic stroke.

Introduction

Stroke is the leading cause of serious neurologic disability in the United States (1). Each year there are an estimated 700,000 new and recurrent strokes, of which more than 80% are ischemic (2). It has now been more than 10 years since the results of the NINDS (National Institute of Neurological Disorders and Stroke) trials, which led to the approval by the Food and Drug Administration of intravenous (i.v.) tissue plasminogen activator (tPA) within a 3-h window for treatment of patients with acute ischemic stroke (3). In fact, a meta-analysis of three tPA trials demonstrated that rapid treatment, within 90 min of symptom onset, produced an odds ratio of 2.8 for a favorable outcome at 3 months, compared with 1.6 between 90 and 180 min (4).

Despite the benefits of thrombolytic therapy, the vast majority of patients with acute ischemic stroke do not receive i.v. tPA (5). There are numerous impediments to the administration of thrombolytic therapy. The most common reasons for non-treatment are presentation beyond the therapeutic window and minor or rapidly improving signs and symptoms. Although not all patients with an acute ischemic stroke will be candidates for thrombolysis, less than half of patients presenting within 3 h and without a contraindication are treated (6). Obstacles to tPA administration are likely greater in small and rural hospitals. In these settings, there is a lack of neurologists or other stroke specialists, and rapid detailed neurologic and radiographic assessment of stroke patients may not be possible. It is these limitations in the availability of radiologic and neurologic resources that have been cited by the Society of Academic Emergency Medicine in their reluctance to mandate thrombolytic therapy as the standard of care across all medical treatment settings (7). These concerns are supported by evidence of increased mortality after tPA administration in hospitals that only infrequently use thrombolytic therapy for acute ischemic stroke (8).

At the Medical College of Georgia (MCG), we have developed a “telestroke” system to facilitate the treatment of acute ischemic stroke patients who present to small, rural emergency departments (EDs) (9). The REACH (Remote Evaluation of Acute IsCHemic Stroke) system allows a stroke specialist from MCG to guide the on-site emergency physician in making the decision about the appropriate use of tPA in a specific patient. The REACH consultant can speak with the emergency physician, patient, and family, review vital signs and laboratory values, visually assess the patient's neurologic status, and review the computed tomography (CT) scan. In this article, we document the results of our first 50 tPA treatments using the REACH system. Emphasis is placed on onset-to-treatment (OTT) times and symptomatic hemorrhagic transformation (SICH; symptomatic intracerebral hemorrhage), and these results are compared with those achieved in our own ED (which does not use the REACH system) as well as published results from academic and community hospitals.

Section snippets

Study Design, Setting, and Population

In February 2003, a rural telestroke “hub and spoke” network providing acute stroke consultations to EDs in underserved areas of East Central Georgia was established (Figure 1). This network has grown from the initial two rural sites at Emanuel Medical Center in Swainsboro, Georgia and McDuffie Regional Medical Center in Thomson, Georgia to comprise a total of nine hospitals located between 32.5 and 102.8 miles from the “hub” at MCG (Figure 2). The mean hospital size in the network is 49 beds,

Results

All stroke consultant recommendations, whether for or against the administration of tPA, were agreed upon and carried out by the emergency physicians at the rural hospitals. Only the patients who received i.v. tPA using the system are included in this analysis. None of the subjects refused follow-up. As of March 2006, 50 patients had received i.v. tPA through the use of the REACH system. The mean age of the treated patients was 63 years. Sixty percent of the treatment group was female and 48%

Discussion

Several strategies have been implemented to overcome the “rural penalty” of acute stroke care. Traditionally, these require either transportation of the patient from the rural hospital to a tertiary care center before thrombolytic therapy, or treatment recommendations made via the telephone (21, 25, 26, 27). However, because “time is brain,” delays inherent in transportation before treatment reduce the number of potential candidates for tPA, and increase the likelihood of disability in those

Conclusions

The REACH network was devised to extend the potential benefits of thrombolytic therapy to acute ischemic stroke patients residing in the rural communities that surround our institution. We have demonstrated both the safety and feasibility of administering thrombolytic therapy using our telemedicine system. In addition, treatment can be initiated rapidly, increasing the likelihood of a favorable outcome. The risk of SICH using REACH seems to be at the lower end of the range reported in other

References (34)

  • Prevalence of disabilities and associated health conditions among adults—United States, 1999

    MMWR Morb Mortal Wkly Rep

    (2001)
  • Heart disease and stroke statistics—2005 update

    (2005)
  • Tissue plasminogen activator for acute ischemic strokeThe National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group

    N Engl J Med

    (1995)
  • W. Hacke et al.

    Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials

    Lancet

    (2004)
  • B.T. Bateman et al.

    Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002

    Stroke

    (2006)
  • I.L. Katzan et al.

    Utilization of intravenous tissue plasminogen activator for acute ischemic stroke

    Arch Neurol

    (2004)
  • J.G. Adams et al.

    The Society for Academic Emergency Medicine position on optimizing care of the stroke patient

    Acad Emerg Med

    (2003)
  • P.U. Heuschmann et al.

    Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality: the German Stroke Registers Study Group

    Stroke

    (2003)
  • S.R. Levine et al.

    “Telestroke”: the application of telemedicine for stroke

    Stroke

    (1999)
  • S. Wang et al.

    Remote evaluation of acute ischemic stroke in rural community hospitals in Georgia

    Stroke

    (2004)
  • S. Wang et al.

    Remote evaluation of acute ischemic stroke: reliability of National Institutes of Health Stroke Scale via telestroke

    Stroke

    (2003)
  • H. Adams et al.

    Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association

    Stroke

    (2005)
  • G.W. Albers et al.

    Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study

    JAMA

    (2000)
  • K.M. Chapman et al.

    Intravenous tissue plasminogen activator for acute ischemic stroke: a Canadian hospital's experience

    Stroke

    (2000)
  • D. Chiu et al.

    Intravenous tissue plasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice

    Stroke

    (1998)
  • A.P. Dick et al.

    IV tPA for acute ischemic stroke: results of the first 101 patients in a community practice

    Neurologist

    (2005)
  • M. Grond et al.

    Early intravenous thrombolysis for acute ischemic stroke in a community-based approach

    Stroke

    (1998)
  • Cited by (86)

    • TeleStroke

      2021, TeleStroke
    • The Association Between Stroke Mortality and Time of Admission and Participation in a Telestroke Network

      2020, Journal of Stroke and Cerebrovascular Diseases
      Citation Excerpt :

      Telestroke networks are designed in a hub and spoke system in which the stroke center (hub) provides high-quality stroke care to distance sites that do not have a stroke center (spokes). For example, the Remote Evaluation for Acute Ischemic Stroke telestroke network is a telehealth program aimed at improving stroke outcomes in rural hospitals of Georgia and South Carolina through more efficient diagnosing and treatment for acute ischemic stroke patients.8 There is an increasing amount of evidence that suggests that telestroke is feasible, safe, and effective in treating acute ischemic strokes.6,9,10

    • Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

      2019, Preventive Medicine
      Citation Excerpt :

      A trial examining the impact of using navigators to support community transitions in stroke survivors reported lower rates of 30-day emergency department visits and hospital readmissions in the intervention group (0% and 3.3% respectively) when compared with a usual care control group (83% and 42%) (Kitzman et al., 2017). Three trials evaluated telehealth systems to remotely examine and monitor stroke survivors (Audebert et al., 2009; Demaerschalk et al., 2010; Switzer et al., 2009). One trial observed that a tele-stroke system intervention was associated with a significant reduction of mean onset-to-treatment time (127.6 min in the intervention group vs 145.9 min in the control group) (Switzer et al., 2009).

    • Ischemic Stroke Transfer Patterns in the Northeast United States

      2019, Journal of Stroke and Cerebrovascular Diseases
      Citation Excerpt :

      Some hospitals that met the definitions for transferring and receiving hospitals did not contribute any edges to the network of hospitals, as they had fewer than 5 transfers to or from any other hospital in any year. There have been many calls for development and improvement of stroke systems of care,7,16-19 as well as descriptions of processes implemented to improve stroke systems.20-23 To our knowledge, ours is the first topological description and spatial analysis of stroke systems of care in the United States.

    View all citing articles on Scopus
    View full text