Remote Evaluation of Acute Ischemic Stroke in Rural Community Hospitals in Georgia

Abstract

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.

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

“…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.…”

Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care

“…The authors conducted both a bedside and a remote evaluation for 20 patients who presented in rural community hospitals and found that the correlation between the 2 modalities was very strong. 42 In 2005, MCG researchers published data on 194 acute stroke patient consultations provided between March 2003 and May 2005, which included 30 patients treated with tPA. 43 The authors concluded that their system "permits the rapid and safe use of tPA in rural community hospitals" (p 2018) and that time and experience help reduce onset to treatment time.…”

“…The consultant evaluates the data and makes a recommendation regarding thrombolytic therapy, and this recommendation is communicated to the mobile cart in the spoke hospital and can be added to the medical record. 42 In designing the system, the MCG team and the initial rural community hospital partners focused on ease of use. MCG made site visits to the early partner spoke hospitals and consulted extensively with the rural hospital emergency department staff in the design of the program.…”

A Review of the Evidence for the Use of Telemedicine Within Stroke Systems of Care

“…The feasibility of performing the NIHSS-telestroke during actual thrombolytic consultations has been demonstrated in multiple observational cases series. The originating sites (ie, clinical setting where the patient is physically located) include (1) a remote Maryland facility using ISDN connections and a restructured NIHSS-telestroke (23 telemedicine cases), 38 (2) an isolated Massachusetts island hospital (24 telemedicine cases), 39 (3) 12 German community hospitals within an ISDN network (1123 cases), 40 (4) 2 Texas community hospitals using a fiberoptic network (328 cases), 41 (5) 8 rural Georgia hospitals using a cell phone or regular telephone service for audio and a 1-way videoconferencing system (75 patients 42 and 194 patients 43 ), and (6) 4 California community hospitals using HQ-VTC. 44 Assessing NIHSS reliability during remote acute telestroke consultations is problematic because acute telestroke consults are generally performed when local neurological evaluations are unavailable.…”