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In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

ABSTRACT:The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy. INTRODUCTION Telehealth: Opportunity to Reduce the Costs and Burden of Cardiovascular Disease and StrokeThe United States finds itself at a pivotal moment in the history of medicine when the annual growth in US healthcare spending increased to 5.3% in 2014, up from 2.9% in 2013, after 5 consecutive years of historically low growth.1 Spending on federal healthcare programs continues to grow significantly.2 Regardless, the need to provide high-quality care continues. More than 85 million Americans (≈26% of the US population) suffer from cardiovascular disease (CVD), and nearly 7 million (2.2%) are stroke survivors. CVD and stroke cost the US healthcare system more than $320 billion and $33 billion, respectively, each year, and by 2030, annual costs of CVD and stroke are projected to balloon to nearly $1 trillion.3 Now more than ever, strategies are needed to increase the value of health care by increasing the quality of care and lowering costs.Enhancing patient access to care via telehealth is an important strategy to help address this challenge. Telehealth, as defined by Office for the Advancement of Telehealth, comprises the use of telecommunications and information technologies to share information and to provide clinical care, education, public health, and administrative services at a distance. 4 Telehealth is a broad term that encompasses many digital health technologies, including telemedicine, eHealth, connected health, and mHealth. Telehealth is a new method of enabling care delivery that has the potential to help transform the healthcare system, to reduce costs, and to increase quality, patient-centeredness, and patient satisfaction. [5][6][7] In particular, telehealth may increase access and convenience for patients with CVD and stroke.8 This is especially true for vulnerable patients with CVD or stroke who, because of their geographical location, physical disability, advanced chronic disease, or difficulty with POLICY STATEMENTSsecuring transportation, may not otherwise access specialty healthcare services. 6,7 Yet, telehealth is underused for the management of CVD and stroke, and several barriers to the successful implementation of telehealth interventions for CVD and stroke exist, including cultural, financial, and legal or regulatory const...

e3T elestroke is one of the most successful applications of telemedicine, bringing the experience of stroke experts to hospitals lacking appropriate stroke expertise. The number and extent of telestroke networks continue to grow in the United States and throughout the world. As telestroke matures, monitoring practice quality and outcomes becomes essential to Purpose-Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. Methods-A literature search was undertaken to examine the current status of telestroke and relevant quality indicators.The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. Results-Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation. (Stroke. 2017;48:e3-e25.

A retrospective chart review was performed on all patients with a discharge diagnosis of ischemic stroke during a 1-year period from Background and Purpose-The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. Methods-A retrospective chart review was performed from February 2013 to February 2014. Results-A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (20%) and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). Conclusions-Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis. (Stroke. 2016;47:668-673.