Background and Purpose-Despite Food and Drug Administration approval of tissue-type plasminogen activator (tPA) for stroke, obstacles in the US health care system prevent widespread use. The Remote Evaluation for Acute Ischemic Stroke (REACH) program was developed to address these obstacles in rural settings. We have previously shown the reliability of the REACH system in performing a valid National Institutes of Health Stroke Scale (NIHSS) evaluation at the Medical College of Georgia (MCG). We now report on the performance of the system since its deployment in 5 rural hospitals in east Georgia. Methods-The rural emergency department (ED) staff can activate a Code REACH protocol 24 hours per day, 7 days per week by calling the Emergency Communications Center (ECC, an in-house dispatch center) at MCG, who pages the on-call consultant. The consultant calls back the ECC and is connected to the waiting ED. Simultaneously, using any broadband-connected workstation, the consultant logs in to the REACH system, allowing performance of an NIHSS evaluation, review of the computerized tomography (CT) images transmitted by the local radiology staff, and then the consultant can speak to the patient and family to verify time of onset. Results-The REACH system has evaluated 75 patients from March 2003 to April 2004, and 12 have received tPA, all without intracranial hemorrhage complications. NIHSS scores ranged from 0 to 30, with a mean of 14.3 (SDϭ8.7, median 11.5). The mean onset to door time was 70.9 minutes (SDϭ70.8, median 50), the mean door to consult time was 45.1 minutes (SDϭ39.8, median 34), and the mean door to NIHSS completion was 62.9 minutes (SDϭ50.8, median 51). The mean onset to needle time was 135.33 minutes (SDϭ51.45, median 134.5). Conclusion-The REACH system enables remote stroke physicians to direct the local ED staff to administer tPA in rural settings where thrombolytics were not previously used. REACH may be used as a rapid consult tool to provide the same quality of stroke care to patients in rural hospitals as is given in tertiary stroke centers. This supports our endeavor to bring stroke expertise to rural community hospitals. (Stroke.

The following telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies. Although telestroke practices may include the more broad utilization of telemedicine across the entire continuum of stroke care, with some even consulting on all neurologic emergencies, this document focuses on the acute phase of stroke, including both pre-and in-hospital encounters for cerebrovascular neurological emergencies. These guidelines describe a network of audiovisual communication and computer systems for delivery of telestroke clinical services and include operations, management, administration, and economic recommendations. These interactive encounters link patients with acute ischemic and hemorrhagic stroke syndromes with acute care facilities with remote and on-site healthcare practitioners providing access to expertise, enhancing clinical practice, and improving quality outcomes and metrics. These guidelines apply specifically to telestroke services and they do not prescribe or recommend overall clinical protocols for stroke patient care. Rather, the focus is on the unique aspects of delivering collaborative bedside and remote care through the telestroke model.

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Background and Purpose-Development of stroke networks is critical to bringing guideline-driven stroke care to rural, underserved areas. Methods-A Web-based telestroke tool, REACH, was developed to provide a foundation for a rural stroke network that delivered acute stroke consults 24 hours per day 7 days per week to 8 rural community hospitals in Georgia. Results-There were 194 acute stroke consults delivered. Thirty patients were treated with tissue plasminogen activator (tPA). The mean National Institutes of Health Stroke Score (NIHSS) was 15.4, and the median NIHSS was 12.5. The mean onset to treatment time (OTT) was 122 minutes. The OTT dropped from 143 minutes in the first 10 patients treated to 111 minutes in last 20 patients. Of the 30 patients treated with tPA, 23% (7) were treated in Յ90 minutes and 60% (18) were treated within 2 hours. There were no symptomatic intracerebral hemorrhages. Conclusions-The REACH telestroke system permits the rapid and safe use of tPA in rural community hospitals. Over time, the system became more efficient and OTT decreased. Key Words: tissue plasminogen activator Ⅲ stroke, acute Ⅲ stroke, ischemic Ⅲ telemedicine I n rural communities, stroke care often does not adhere to published guidelines, and the use of tissue plasminogen activator (tPA) for stroke is infrequent. 1 Poor compliance with tPA treatment guidelines can lead to high rates of symptomatic intracranial hemorrhage and complications. 2 Telemedicine, including telephone use, has been used to increase tPA administration rates. [3][4][5][6][7][8][9] However, the lack of reliable information from the remote site has prevented many stroke specialists from advising tPA treatment over the telephone. Transfer of patients to regional hospitals by helicopter and ground transportation is an option, but critical time can be lost in the transfer process. 10 Recent analyses show that the shorter the onset to treatment time (OTT), the better the functional outcome. 11 Stroke care is often fragmented in the United States, and there is an urgent need to develop systems of stroke care. 12 In rural Georgia, we developed a low-cost telestroke tool that enables a stroke specialist to review patient video, perform an NIHSS, review the computed tomography (CT) scans in real time, interact with local Emergency department (ED) staff with a graphical interface, and to make a recommendation on tPA use via any broadband-connected workstation. This system called REACH has permitted the use of tPA in rural community hospitals where tPA was not used previously. 3,13 In this report, we demonstrate that tPA can be administered safely and rapidly using the REACH system with short OTTs. Table. Before the institution of the REACH telestroke system, only 1 of these hospitals had formalized acute stroke care guidelines, and only 2 of these hospitals had tPA available in the pharmacy. MethodsThe REACH system hardware and software has been described previously. 3,13 All consultants have telestroke privileges at all the 8 hospitals. Medical College o...