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