Telestroke Consultation Research Articles

Poisson Modeling Predicts Acute Telestroke Patient Call Volume.

Background: Predicting the frequency of calls for telestroke and emergency teleneurology consultation is essential to prepare staffing for the immediate management of time-sensitive strokes. In this study, we evaluate Poisson distribution count data using a generalized linear model that predicts the volume of hourly telestroke calls over a 24-h period. Methods: We performed an Institutional Review Board approved retrospective cohort review of patients (January 2019-December 2022) from an institutional telestroke database at a large nonprofit multihospital system in the United States. All patients ≥18 years with a telestroke activation were included. Telestroke calls were quantified in frequency per day and analyzed by multiple time and date intervals. Poisson probability mass function (PMF) and cumulative distribution function (CDF) were used to predict call probabilities. A univariable Poisson regression model was fit to predict call volumes. Results: A total of 8,499 patients at 21 hospitals met inclusion criteria, the mean calls/day were 5.82 ± 2.54, and mean calls/day within each hour increment ranged from a minimum of 0.07 from 5 a.m. to 6 a.m. to a maximum of 0.45 from 7 p.m. to 8 p.m. The Poisson distribution was the most appropriate parametric probability model for these data, confirmed by the fit of the data to the expected distributions corresponding to the calculated means. The predicted probabilities of call frequencies by hour were calculated using the Poisson PMF and CDF; the probability of two or fewer calls/day by hour ranged from 98.9% to 99.9%. Univariable Poisson regression modeled an increase of future calls/day from 6.7 calls/day in July 2023 to 7.6 calls/day in October 2025. Conclusion: Poisson modeling closely fits telestroke call volumes, predicts the future volumes, and can be applied to any health system in which the mean call volume is known, which may inform the number of physicians needed to cover calls in real-time.

Abstract 34: Achieving a 30 Minute Door to Needle Time in a Primary Stroke Center via Telestroke

Background: Despite efforts made within the Emergency Department (ED), delays in the administration of thrombolytic time via telestroke remain. A Primary Stroke Center (PSC) aimed to reduce door-to-needle time (DTN) by focusing on ED, EMS, CT and physician staff regarding: door-to-CT process, importance of time goals, IV thrombolysis, and early activation of Telestroke. Methods: A retrospective analysis examined patients who arrived to a PSC and received a telestroke consult in the ED from January 2020 to June 2023. A change in the stroke alert process (January 2023) focused on early notification of stroke alert, CT and telestroke. Thus we compared data from prior to the change in process (January 2020 - December 2022) to after changing the process (January 2023 - June 2023). Primary outcome was a comparison of door-to-needle time (DTN) before and after changing the stroke alert process which was analyzed using a quantile regression specifying the median. Secondary outcomes included: DTN goals within 30, 45, 60 minutes and proportion of IV thrombolysis utilizing hierarchical binomial logistic regressions. Additional outcomes were door-to-CT head (DTCT) and door-to-telestroke (DTSR) analyzed via median regression adjusted for age, NIHSS and arrival modality. All outcomes were adjusted for age, NIHSS and arrival modality (EMS versus private vehicle). Results: Overall 1160 ED telestroke consults occurred the study, with a mean age ± SD of 68.75 ± 15.48. There were 989 consults before and 171 consults after the process change. After changing the ED stroke process, there was a reduction in DTN of 29.26 minutes [95% Confidence Interval (CI), 17.45 - 41.08], p < 0.0001. DTN goals of 30, 45 and 60 minutes were met more often after the change compared to prior, all adjusted p < 0.005. A higher proportion of IV thrombolysis rates occurred after the process change [21 (12.3%) versus 79 (8.0%)], adjusted Odds Ratio (aOR) = 2.18 [95%CI 1.27 - 3.75], p = 0.005. There were significant reductions in DTCT and DTSR after changing the process, all p < 0.001. Conclusion: A standardized workflow with emphasis on early stroke alert and CT resulted in a significant reduction of DTN, and allowed a PSC with telestroke to consistently achieve DTN < 30 minutes.

Abstract WP44: Assessing Timely Care of WI's Critical Access Hospitals Acute Stroke Patients With a Speed and Efficiency Task Force

Introduction: Data indicates that rural residents are at 30% higher risk of stroke. 2 Thirty percent of Wisconsin’s (WI) residents live in a rural area and are more often served by smaller, critical access hospitals (CAH). WI Coverdell Stroke Program (Coverdell) data entry into Get With The Guidelines-Stroke® (GWTG) for 2022 shows 22.3% of stroke patient’s transfer from a spoke, often CAH, to a larger tertiary or hub hospital. To assist Coverdell participating (CAH) in timely care of acute stroke patients, Coverdell, American Heart Association® (AHA), and 32 CAH’s partnered to form a Speed and Efficiency Taskforce (TF). Methods: An agreed upon charter, framework and data goals were established in May 2022. Metrics of EMS pre-notification, arrival to CT, and door to needle (DTN) times were regularly reviewed. Evaluation of patients arriving within 4.5 hours of last known well (LKW), median DTN, and percent DTN < 60 minutes were analyzed in two arrival windows. Hypothesized differences when comparing arrival windows of 0700-1900 and 1901-0659 were that the 1901-0659 window would have extended treatment times due to lack of 24/7 CT coverage and LKW not validated from others. Results: Data analysis for 2022. N=179 • Arrival to CT: 10 minutes faster in 1901-0659 window • Median DTN: 3 minutes faster in 0700-1900 window (71 vs 74 minutes respectively) • % DTN within 60 minutes: 12% higher compliance in 0700-1900 window Conclusions: Coverdell CAH’s are initiating the CT in a timely manner. Times are lower for arrivals between 1901-0659, ruling out delays due to CT tech non-availability. Delays in DTN treatment times within 60 minutes of arrival are more significant in the 1901-0659 arrival timeframe. The potential causes are a delay in telestroke consult with decision to treat, internal hospital delays in mixing and delivering thrombolytics, CT availability, and family/significant others present. Further research regarding arrival time affecting treatment need to be considered.

Abstract WMP48: The Brain Emergency Management Initiative: Reduction of Embolectomy Transfer Times Using a Novel Telestroke Transfer Protocol

Recent studies of national door-in-door-out times (DIDO) in the Get with the Guidelines Stroke registry found that <30% of transfers for acute interventions were completed within the recommended 120 minute timeframe. There is a critical need for effective emergent transfer protocols to improve outcomes. The Brain Emergency Management Initiative (BEMI) is a telestroke transfer protocol connecting acute stroke patients at hub sites to a spoke center for embolectomy. BEMI includes early activation of helicopter transport, rapid imaging transmission, standardized documentation, and remote patient admission. BEMI has been shown to significantly reduce DIDO and time-of-treatment-decision-to-groin-puncture (TDGP). The aim of this study was to evaluate the sustainability of the BEMI impact on reduction of key transfer metrics. We retrospectively assessed prospectively collected data for patients transferred for embolectomy in our telestroke system. Patients were assessed in 3 groups: pre-BEMI (2013-mid 2016; before protocol, n=32), early-BEMI (mid 2016-2017; initial year of protocol, n=31) and new-BEMI (2018-2023; n=210). Inclusion criteria were emergency telestroke consultation and transfer for acute embolectomy. Exclusion criteria were inpatient telestroke consultation, incomplete data and aborted transfers. Variables were assessed via Chi-square, T-test or Wilcoxon Rank Sum as appropriate. Median times were used given skewedness of data. We evaluated 273 total transfers. Analyses compared BEMI groups to the pre-BEMI group. Median NIHSS was higher in the BEMI groups (pre-BEMI median=10 points vs. early-BEMI=20, p=0.0063 ; vs. new-BEMI=17, p=0.005 ). There were significantly shorter median DIDO and TDGP times in the BEMI groups (DIDO: pre-BEMI median=143 minutes vs. early-BEMI=118, p=0.015 ; vs. new-BEMI=97, p=1.7e-7 ) (TDGP pre-BEMI median=155 minutes vs. early-BEMI=130, p=0.01 ; vs. new-BEMI=125, p=6.8e-14 ). This finding was sustainable from the early to new BEMI groups. Additional time metrics will be assessed in this dataset. The BEMI protocol significantly improved transfer and treatment times in our telestroke network. BEMI may serve as a model for stroke transfer protocols at other centers to assist in improving time metrics.

Abstract WP216: Results of a Pediatric Stroke Program Utilizing Stroke Telemedicine Across a Fifteen Hospital Healthcare System in Southern California

Background: The recognition of pediatric stroke symptoms is challenging. A regionwide pediatric stroke program utilizing an educational initiative across 15 emergency departments (ED) coupled with telemedicine was developed to standardize the process for immediate access to stroke experts and decrease door-to-intervention times. This study evaluates the impact of this intervention. Methods: Data from the pre- (1/2020-12/2021) vs post-intervention (1/2022-7/2023) including baseline demographics, volumes, and process measure timeframes: Door-to-Telestroke Page, Door-to-CT Interpretation, Door-to-Telestroke Call Back, and Door-to-Needle Time were abstracted. Chi-Square and Wilcoxon Rank Sum were used for statistical analysis. Results: There were a total of 92 Telestroke consults, with more in the post group: 35(38%) pre vs 57(62%) post (p=0.04). 52% were female with mean age of 12 (±1.2) years. 78(85%) were stroke mimics: 74% had non-cerebrovascular or migrainous neurological disorders as primary diagnoses. 7(7.6%) patients had interventions: 4(4.3%) thrombolytics, 9(9.7%) arterial or venous thrombectomies. 51% were discharged home and 43% were transferred to an acute care facility for higher level of care. There was no difference between pre- and post-implementation median [IQR] Door-to-Telestroke Page (17.5[14-21] vs 15[11-18] mins); Door-to-CT Interpretation (29[25-32] vs 27[23-29] mins) and Door-to-Needle Time. Median Post Door-to-Telestroke Call Back was faster (pre: 20[17-22] vs post: 16.0[13-18] mins [p=0.03]). Conclusion: Systemwide ED education coupled with telemedicine in implementing pediatric stroke systems of care in a large integrated healthcare system improves access to stroke specialists and time-based metrics in this low-volume, high-risk patient population.

Abstract WMP7: Impact of Telestroke Access in a Rural Setting

Background: Despite decades long adoption as the standard-of-care for ischemic stroke, the majority of eligible patients do not receive intravenous thrombolysis (IVT), with underutilization especially pronounced in rural areas. Telestroke, however, may help alleviate this geographical healthcare disparity. The current study aims to identify the impact of implementing a mature telestroke network within a rural setting. Methods: Retrospective review of a prospectively maintained telestroke database from a large rural tertiary care comprehensive stroke center covering 31 spoke hospitals spanning critical access hospitals to primary stroke centers between 10/2021-02/2023. Data was compared to a previous review period (01/2016-12/2018; comprised of 8 spokes) and the statewide IVT rates recorded in GWTG. Data analysis conducted via descriptive statistics and Fisher’s (two-tailed) exact test. Results: 1801 telestroke consults were performed; 41.4% (746/1801) were ineligible for acute stroke intervention. 39% (410/1055) of eligible patients were treated with IVT (vs. 33% [317/959] previously, p = 0.068), representing 58% (410/708; vs 24% [107/448] previously, p < 0.001) of statewide total IVT administration. Symptomatic hemorrhage (sICH) was 3.0%, overall 30-day mortality was 5.6%, and sICH mortality was 1.0%. IVT deferred most commonly: low NIH (44%), mimics (21%), coagulopathy (8%), followed by other. 22% (396/1801) of total consults were transferred from the originating site (vs. 34% [305/890] previously, p < 0.0001) of which 10% (42/396) underwent EVT. Discussion: The impact of expanding a rural telestroke network continued to produce high IVT rates (nearly double the national average) with safety outcomes (sICH, mortality) at or below national standards. Additionally, a large network has significantly increased the proportion of patients remaining at originating sites, optimizing both tertiary and local centers’ resources. The value of a regional telestroke hub is further underscored by the significant increase in statewide IVT attributed to network consults. However, further strategies are needed to better educate rural providers on acute stroke to reduce the rate of ineligible consults and streamline use of telestroke services.

The Role of Ophthalmology in Tele-Stroke Consults for Triaging Acute Vision Loss.

Advances in telemedicine have allowed physicians to provide care in areas that were previously geographically or practically inaccessible. Roughly 70% of all US hospital have less than 200 bed capacity and nearly 50% have fewer than 100 beds. These smaller hospitals often do not have specialists available for bedside patient care, making them potential beneficiaries of telemedicine medical specialty services. In 2005, the American Stroke Association proposed implementing telemedicine services in effort to increase access to acute stroke care in neurologically underserved areas such as small hospitals. Tele-stroke services have since become established across the country and are now utilized by approximately 30% of US hospitals. By reducing the time between presentation and evaluation by a stroke specialist, tele-stroke programs have successfully increased patient access to life-saving treatment with tissue-plasminogen activator (t-PA) treatments. This change has been especially profound remote and underserved community hospitals. However in the evaluation of acute vision loss, an area where ophthalmology and stroke care overlap, increased reliance on tele-stroke services has contributed to some unique challenges. Acute vision has a complex differential and is commonly a result of conditions other than stroke. When tele-stroke services are engaged for the evaluation of acute vision loss, the neurologist is asked to make medical decisions without complete information about the eye. This situation can expose patients to costly or inappropriate testing, unnecessary hospitalizations, or lead to delayed diagnosis and treatment of non-neurologic conditions of the eye. The goal of this paper is to provide an overview of the overlap between stroke and vision loss, highlight the challenges inherent in using tele-stroke in evaluating acute vision loss and to offer our comments on how increased communication between emergency medicine, ophthalmology, and neurology services can ensure that patients with vision loss receive the highest standard of care in all hospitals.

Use of Telestroke to Improve Access to Care for Rural Patients With Stroke Symptoms.

Cerebrovascular accident, or stroke, is a common cause of death or disability. Timely diagnosis and intervention are critical for improving survival rates and reducing the long-term effects of stroke. For patients with ischemic stroke, thrombolytic drugs and endovascular intervention are time-sensitive treatment options. Patients living in rural areas often do not have access to rapid consultation with specialized neurologic teams for diagnosis and treatment of stroke. The use of telemedicine in the form of a telestroke consultation can improve timely diagnosis and treatment for rural patients exhibiting stroke symptoms. A telestroke program was implemented in the upper Midwest. A team of 4 interventional neurologists provided telestroke consultation to a comprehensive stroke center and 5 other acute stroke-ready rural hospitals. A tiered stroke alert algorithm and telestroke workflow chart were developed to help health care professionals at rural sites determine eligibility for telestroke consultation. A teleneurologist connected with the originating site, and the National Institutes of Health Stroke Scale could be completed remotely with assistance from the originating site. Telestroke has increased the percentage of patients receiving thrombolytics in less than 60 minutes, and door-to-needle time has decreased. Rural patients with stroke symptoms may experience a delay in care or stroke diagnosis due to distance to specialized neurologic services. Telestroke consultation is a successful method for timely diagnosis of stroke and recommendation for treatment.

Demonstration of High Diagnostic Accuracy for Cerebral Ischemia in a Large Academic Hub-and -Spoke Telestroke Network

ObjectiveTo determine the diagnostic accuracy of the initial telestroke consultation in a large academic hub-and-spoke telemedicine network. Patients and MethodsThis retrospective study includes all patients evaluated for cerebral ischemia through video telestroke consultation in a large academic hub-and-spoke telemedicine network from January 1, 2019 to December 31, 2020. A detailed chart review was conducted to identify the initial suspected diagnosis and final diagnosis. Cerebral ischemia was defined as acute ischemic stroke and transient ischemic attack. All other diagnoses were defined as stroke mimics. Data were organized into continuous and categorical variables. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, area under the curve (AUC), and likelihood ratio (LR+) for the telestroke-consultation diagnosis were calculated while using the final diagnosis as the gold standard diagnosis. ResultsA total of 1043 patients met the inclusion criteria. The final diagnosis of cerebral ischemia was made in 63.5% of all patients (539 of the 1043 with acute ischemic stroke,123 of the 1043 with transient ischemic attack). Stroke mimic was diagnosed in 36.5% patients (381 of the 1043). The sensitivity and specificity of telestroke evaluation for diagnosis of cerebral ischemia were 97.1% and 81.4%, respectively. Positive predictive value was 90.1%, and negative predictive value was 94.2%. Overall diagnostic accuracy was 91.4%, with an LR+ of 5.21 and AUC of 0.89. ConclusionThis study highlights the high diagnostic accuracy of telestroke providers in diagnosing cerebral ischemia. Further research exploring the application of teleneurology in the nonstroke setting and other medical subspecialties is warranted.

Diagnostic accuracy of telestroke consultation: a Louisiana based tele-network experience.

Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.

Analysis of Telestroke Usage in Rural Critical Access Emergency Departments.

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

Use of Simulation to Develop Telestroke Skills in Trainees (S10.009)

<h3>Objective:</h3> To create an educational intervention to prepare neurology residents for telestroke encounters. <h3>Background:</h3> Telemedicine has become increasingly common in the post-COVID era and is now a part of most clinical practices. There is a need for residency training programs to incorporate telemedicine teaching into their curriculum. Telestroke is a well-established practice and way to bring neurovascular clinical expertise into settings where an in-person stroke specialist may not be available. Skills and professionalism important in a remote telestroke consult apply to all types of telemedicine encounters. <h3>Design/Methods:</h3> Our telestroke OSCE (objective structured clinical examination) case was developed by our neurology faculty in conjunction with a simulation specialist. Two standardized actors were trained to impersonate an acute stroke patient and a bedside provider in an emergency room setting. The neurology resident learner was in a separate room and acted as a stroke specialist, communicating with the standardized actors and conducting an NIHSS using a live video interface. Following the encounter, immediate feedback was given by a faculty observer and the standardized actor rated resident performance using a checklist. After OSCEs were completed, the residents were debriefed in a group setting and a learner feedback survey was collected (1–5, least-most). <h3>Results:</h3> Out of 15 resident participants, 8 completed the learner survey (53%). They reported feeling fairly well-prepared for the OSCE (4±0.5) and rated their performance overall well (4.3±0.5). Many learners identified instructing the standardized remote provider in the NIHSS virtually as the most challenging aspect in the encounter. All learners indicated that this OSCE should be repeated for future residency classes. <h3>Conclusions:</h3> We demonstrated that a telestroke simulation is a useful tool to directly observe residents, offer immediate feedback and review telemedicine best-practices. It is a feasible, valued and important part of our dynamic neurology residency curriculum. <b>Disclosure:</b> Dr. Lillemoe has nothing to disclose. Dr. Kurzweil has nothing to disclose. Dr. Sabadia has nothing to disclose. Dr. Pleninger has nothing to disclose. Dr. Lewis has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Seminars in Neurology. Dr. Lewis has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Clinical Neuroscience. Dr. Giglio has nothing to disclose. Sondra Zabar has nothing to disclose.

The impact of race and ethnicity on acute telestroke care: A multistate experience

Previous analyses suggest that ethnic and racial differences exist in acute stroke care including thrombolytic treatment rates. The current study evaluates ethnic or racial differences in acute stroke treatment within a multi-state telestroke program. Acute telestroke consultations seen in the Emergency Department in 203 facilities and 23 states were extracted from the Telecare by TeleSpecialistsTM database. Cases were reviewed for age, race, ethnicity, sex, last known normal time, arrival time, treatment with thrombolytic therapy, door-to-needle (DTN) time, and baseline National Institutes of Health Stroke Scale score. Race was defined as Black, White, or Other; ethnicity was defined as Hispanic or non-Hispanic. The current study included 13,221 acute telestroke consultations consisting of 9890 White, 2048 Black, and 1283 patients classified as Other. A total of 934 patients were Hispanic and 12,287 patients were non-Hispanic. There were no statistically significant differences noted in thrombolytic treatment rates when comparing White (7.9%) patients with non-White patients (7.4%), p = 0.36, or comparing Black (8.1%) with non-Black patients (7.8%), p = 0.59. In addition, there were no statistically significant differences in treatment rates comparing Hispanic (6.3%) with non-Hispanic (7.9%) patients, p = 0.072. We noted no measurable differences in DTN times by race or ethnicity. Contrary to previous reports, we failed to detect any significant differences in thrombolytic treatment rates and DTN times by race or ethnicity among stroke patients in a multistate telestroke program. These findings support the hypothesis that telestroke may mitigate racial and ethnic disparities which may be attributable to local variability in stroke procedures or access to healthcare.

Telestroke value through the eyes of emergency medicine providers: A counterfactual analysis

ObjectivesEmergency Medicine (EM) provider experiences consulting telestroke (TS) are poorly studied. In this qualitative study, we aimed to determine how TS changes patient management and to measure TS effects on EM provider confidence with acute ischemic stroke (AIS) treatment. Materials and methodsWe designed a survey for EM providers querying perceptions of TS value, confidence with treating AIS, and counterfactuals regarding what EM providers would have done without TS. Eligible EM providers participated in an audio-visual TS consult within a 6-state TS network between 11/2016–11/2017. ResultsWe received 48 surveys (response rate 43%). The most common reason (71%) for using TS was tPA eligibility expert opinion. Most EM providers (94%) thought the patient/family were satisfied with TS and none felt their medical knowledge was doubted because of using TS. EM providers had high confidence in diagnosing AIS (95%) and tPA decision-making (86%), but not in determining thrombectomy eligibility (10%). Among EM providers who administered tPA, 85% said tPA would not have been given without TS consultation. TS consultation changed patient diagnosis in 60% of all patients and treatment plans in 56% of non-stroke patients. Most EM providers (86%) had increased confidence in their knowledge of future stroke patient management. Nearly all TS consults (93%) resulted in EM providers being more likely to use TS again. ConclusionsTS consult frequently results in both patient management change and increased EM knowledge of stroke management with increased likelihood of repeat usage. Discomfort in determining eligibility for thrombectomy points to educational opportunities.

Abstract WP32: Addressing Disparate Clinical Stroke Resources With A Telestroke Taskforce

Introduction: Telestroke can enhance the timeliness and overall quality of stroke care for rural populations geographically separated from higher level stroke centers. To help hospitals utilize this resource, the Wisconsin (WI) Coverdell Stroke Program (Coverdell) and American Heart Association® (AHA) partnered with 15 hospital systems for a Telestroke Taskforce (TF) which met monthly June 2021-February 2022. Methods: A TF Charter and Framework guided the work. Framework items included: decision to call, telestroke consult, treatment and transfer decision, feedback, and patent satisfaction. Challenges, successes, WI consensus criteria, WI document development, Get With The Guidelines® (GWTG), resource needs and availability were addressed for these items. A manual and two videos were developed. The first video is a four clinician panel across four hospital systems sharing perspectives on telestroke implementation. Second, a demonstration video of conducting the National Institutes of Health Stroke Scale (NIHSS) via telestroke was produced to assist those unfamiliar with the process. The WI Telestroke Toolkit, which includes the charter, framework and established resources, will be published to the Coverdell website in Fall 2022. Results: Five measures were assessed quarterly Q1 2021-Q1 2022 among WI hospitals entering into GWTG® • Proportion of stroke patients w/ telestroke consult - 16.9ppt increase • Thrombolytic administration rate - 0.2ppt increase • Mechanical endovascular rate - 0.6ppt increase • Median time to consult - 2 minute reduction • Door-in-door-out times - 1 minute reduction Conclusions: Measure improvement, given the timeframe, is likely due to an increased focus on telestroke associated with the TF. As the Toolkit is shared and utilized by hospitals, we are hopeful for continued improvement. The Toolkit will be updated annually. Future considerations are to formally evaluate TS recipient satisfaction.

Abstract 79: Long-term Patterns Of Patient Transfer In A Regional Telestroke Network

Background: Telestroke has been increasingly adopted by hospitals with limited access to neurological expertise and is often followed by transfer for a higher level of care. We sought to characterize factors independently associated with patient transfers after telestroke consultation in our regional telestroke network. Methods: We studied all telestroke consults from our urban comprehensive stroke center from 1/1/2005 to 06/30/2022 using the records in our telehealth portal. We examined the annual proportion of transfers among all consults overall and stratified by 6 levels of NIHSS severity and 4 levels of spoke hospital rurality. We used generalized linear mixed models to evaluate the association between transfer and patient demographics, hospital characteristics, use of video and care quality metrics (timeliness and tPA use), accounting for clustering by spoke hospital. Results: We identified 20,618 consecutive telestroke consults, of which 5,276 (25.6%) were transferred (602 cases excluded with unknown transfer status). The proportion of transfers decreased significantly over the study period (Figure). Decreases were observed for all rurality strata and all but the most severe strokes. After adjusting for temporal trends, factors independently associated with transfer included younger age, male gender, more severe stroke, and tPA use (Table). Conclusion: In our regional telestroke network, the proportion of transfers decreased substantially from 2005 to 2022 overall and across almost all patient and hospital groups. Telestroke may facilitate capacity management and retaining care in lower cost community settings, which may increase healthcare value.

Abstract TP45: Demonstration Of High Diagnostic Accuracy Of Cerebral Ischemia In A Large Academic Hub And Spoke Telestroke Network

Introduction: Telestroke facilitates emergent assessment of patients with suspected acute ischemic stroke (AIS) to identify candidates for acute interventions. The diagnostic accuracy of the telestroke consultation of a large academic hub and spoke telemedicine network has yet to be investigated. The goal of our study is to determine the diagnostic accuracy of the initial telestroke consultation. Methods: This is an IRB-exempt retrospective study including all patients evaluated for cerebral ischemia via video telestroke consultation in a large academic hub and spoke telemedicine network from 2019 to 2020. Detailed chart review was conducted to identify initial suspected diagnosis and final diagnosis. Cerebral ischemia was defined as AIS and transient ischemic attack (TIA). All other diagnoses were defined as stroke mimics. Data was organized into continuous and categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, area under the curve (AUC) and likelihood ratio (LR+) for the initial telestroke consultation diagnosis were calculated while using the final diagnosis as the gold standard diagnosis. Results: A total of 1043 patients met inclusion criteria. Final diagnosis of cerebral ischemia was made in 63.5% of all patients (539/1043 with AIS,123/1043 with TIA). Stroke mimic was diagnosed in 36.5% patients (381/1043). The sensitivity and specificity of telestroke evaluation for diagnosis of cerebral ischemia were 97.1% and 81.4%, respectively. PPV was 90.1%, and NPV was 94.2%. Overall diagnostic accuracy was 91.4% with a LR+ of 5.21 and AUC of 0.89. The most common stroke mimics were metabolic encephalopathy (13.7%, 52/381), migraine (10.8%, 41/381) and seizure (10.5%, 40/381). Conclusions: This study highlights the high diagnostic accuracy of telestroke providers to diagnose cerebral ischemia and stroke mimic in a large academic hub and spoke network. Further research is needed to investigate methods to improve our diagnostic accuracy further, as well as explore the application of tele-neurology in the non-stroke setting.

Abstract WP37: Prehospital Stroke Scales Outperform National Institutes Of Health Stroke Scale In Predicting Large Vessel Occlusion In A Large Telestroke Network

Introduction: Prehospital telestroke is increasingly utilized in mobile stroke units and telemedicine-enabled ambulances for acute ischemic stroke (AIS). While the NIHSS remains the standard for telestroke assessment, simpler scales have been validated to help paramedics recognize large vessel occlusion (LVO) strokes but have not been evaluated in a traditional telestroke network. We aimed to determine the accuracy of common LVO scales in a large academic telestroke practice. Methods: This retrospective study included all telestroke consults performed in a large academic telestroke network from 2019 to 2020. Patients were excluded if no NIHSS or vessel imaging was performed. We recorded presenting NIHSS, site of vessel occlusion, and discharge diagnosis. LVO was defined as an acute occlusion of the internal carotid artery and/or M1 middle cerebral artery. The NIHSS was used to calculate 7 LVO scales (RACE, C-STAT, FAST-ED, 3I-SS, PASS, VAN, and G-FAST). Diagnostic performance was assessed by calculating sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy using the established thresholds of each scale. These results were compared to NIHSS at thresholds of 6, 8, and 10. Area under curve (AUC) was calculated using c-statistics by treating scales as continuous variables. Results: A total of 625 patients were included, 373/625 (59.7%) of which were diagnosed with AIS at discharge. LVO was identified in 78/625 (12.5%) patients. VAN was the most sensitive prehospital stroke scale (83.3%), whereas 3I-SS ≥ 4 was the most specific (95.2%). Both the RACE and FAST-ED scales demonstrated superior accuracy and AUC compared to the NIHSS (Table 1). Conclusions: To our knowledge, this is the first study assessing LVO scale accuracy in a large telestroke network. As use of prehospital telestroke grows, this study highlights several scales that may allow for faster prehospital triage decisions without sacrificing accuracy.

Abstract 118: Expanded Tele-stroke Coverage In Community Hospitals Improves Care For Stroke Patients And Reduces Transfers

Background: Minor ischemic strokes and transient ischemic attacks account for more than a third of ER stroke admissions (21% and 15%, respectively). Most small community hospitals lack adequate coverage by stroke service necessitating transfer of stroke patients to comprehensive stroke centers. Methods: We studied the effect of implementing telestroke service in all regional hospitals and emergency departments affiliated with Promedica Toledo Hospital, a comprehensive stroke center (CSC). This service is carried out by stroke-trained advanced practice providers under supervision of vascular neurologists. Coverage included acute ED assessments of stroke patients, inpatient telestroke consults and follow ups. We propose that this comprehensive telestroke service will improve care of stroke patients presenting to community hospitals, decrease the number of transfers to CSC. It will improve numbers and timing of IV thrombolysis. Results: The total stroke alerts from affiliated locations before implementing telestroke service (2018 and 2019 and first half of 2020), and after implementing the service (since July 2020, 2021, and 2022) were 4817 and 4900, respectively. In pre-telestroke years, about 43% of patients were transferred to the CSC for acute stroke care while during post-telestroke years were 28% with 34.8% reduction on transfers. Among transferred patients, stroke mimickers' percentage decreased from 21% to 8%. There was a 14.5% increase in the number of IVT patients after implementing telestroke service but door to needle time did not change. Conclusion: This is the first reported experience of utilizing stroke-trained APPs to expand telestroke coverage for both ED and inpatient services at community hospitals. There was a decrease in number of transfers to CSC, keeping patients at their local communities. It also increased the number of IV thrombolytic treatments and reduced the number of stroke mimickers' transfers.

Abstract TMP58: Telestroke Evaluation And Treatment Of CRAO: Current Practice And Opportunities For Improvement

Background: The VA National Telestroke Program (NTSP) provides acute care to more than 60 facilities nationwide. Central retinal artery occlusion (CRAO), is not an acute stroke per se but may trigger a telestroke consult; management of these patients is not standardized. The purpose of this project was to examine clinical characteristics, telestroke evaluation, and visual outcomes for patients with monocular vision loss seen in the NTSP. Methods: This was a retrospective chart review of NTSP consults from 3/2018 -6/2021. We identified cases by review of all patients with non-stroke/TIA diagnosis and reviewed all those with monocular visual symptoms. Data were obtained from the NTSP dataset and subsequent chart review including: time of symptom onset to NTSP consult, initial and follow-up (f/u) diagnosis and visual acuity (VA), carotid imaging results, receipt of tPA, and type of f/u. Descriptive data were summarized for all patients, those with f/u, and those with final diagnosis of retinal ischemia. Results: Of the 40 patients identified, mean time to presentation was &gt; 8 hours, 3 were treated with tPA, and 31 (78%) had f/u with ophthalmology/optometry (Table). Among 31 patients with f/u, 42% (N = 13) had final diagnosis of retinal ischemia (CRAO/BRAO, venous occlusion or retinal TIA); 11 (36%) had another ocular diagnosis, 3 (10%) had other retinal pathology and 4 (13%) had a non-ocular diagnosis. Only 3 of 13 (23%) had improved VA at f/u, one of these three had received tPA. Conclusion and potential impact: Fewer than 50% of acute telestroke patients who present with monocular vision loss have a final diagnosis of CRAO, most present far outside the thrombolysis window, and visual outcomes among those with retinal ischemia are poor. Efforts focused on improving acute diagnosis of CRAO via tele-retina imaging and reducing patient time to presentation are needed prior to testing standardized thrombolysis treatment protocols for patients with CRAO.