Telestroke Program Research Articles

Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success.

Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.

Abstract TP99: Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success

Background: Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at the spoke hospital who were participating in a newly established inpatient telestroke program in order to identify implementation barriers and facilitators. Methods: This was a formative evaluation relying on semi-structured qualitative interviews with sixteen inpatient providers (physicians and nurse practitioners) that have utilized inpatient telestroke services. Interviews were conducted with providers at spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. Results: Fifteen themes were identified in the data and mapped to the i-PARIHS framework. Themes related to the innovation (telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of advanced practice providers, and challenges with nurse empowerment. With regards to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. Conclusion: This study identified barriers and facilitators in launching an inpatient telestroke program within a health system, highlighting the importance of leveraging facilitators and addressing barriers for effective implementation and continuity.

Abstract 94: Sex Disparities in a Telestroke Network: From Treatment Times to Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with >40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p<0.01) and more likely to be to be African American (20.4% vs16.8%, p<0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p<0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p<0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p<0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p<0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p<0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p<0.001)). More males were discharged home (62.4% vs 60.4%, (p<0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p<0.001) and hospice (3.9% vs 2.9%, p<0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

Abstract 80: Predictors of Door-to-Needle Time in the Veterans Health Administration National Telestroke Program

Introduction: The Veterans Administration (VA) National Telestroke Program (NTSP) increases access to stroke specialists across the VA enterprise. Unlike most telestroke networks, VA hospitals are not integrated into a hub-and-spoke model and most Veterans present to VA emergency departments by personal vehicle, rather than emergency medical services (EMS). Predictors of Door-To-Needle (DTN) time in Veterans receiving tPA via telestroke may differ from community telestroke systems. Methods: A logistic regression model was applied using operations data to identify patient and hospital characteristics predictive of DTN times < 60 minutes. Predictors variables included patient demographics, National Institute of Health Stroke Scale score, Last Known Well time on arrival, rurality, integration with EMS routing systems, local neurology service, VA-designated facility complexity status, time from arrival to CT and time from CT to treatment. Results: Among (N=448) Veterans treated via Telestroke from 2017 to 2022, 32% (n=142) received tPA < 60 minutes. No significant differences were observed between groups in terms of patient characteristics (Table). Significant differences were seen in hospital characteristics of complexity status (p=0.013), time from arrival to CT (p<0.001), and time from CT to treatment (p<0.001). The odds of receiving tPA < 60 minutes were 12.4 times greater for patients with a door to CT time of < 10 minutes (95% CI 6.7, 23.2) and 28.5 times greater for patients with a CT to treatment time < 40 minutes (95% CI 14.5, 56.5). Conclusions: Our data clearly demonstrate that achieving target times of < 10 minutes for arrival to CT and < 40 minutes for CT to treatment increases the odds of receiving tPA in < 60 minutes. This finding underscores the importance of improving stroke systems within VA hospitals to facilitate these key target times.

Abstract WP87: To Walk-In or Not to Walk-In: Effects of ED Mode of Arrival on Acute Stroke Treatment and Hospitalization Outcomes in a Large Integrated Healthcare System

Background: Prior studies reported that only half of stroke patients arrived at emergency departments (ED) via emergency medical services (EMS). We sought to assess predictors of ED mode of arrival and its effects on acute stroke care and inpatient outcomes in a large racial-ethnically diverse cohort. Methods: In 2016, we launched a system-wide standardized telestroke program for 21 certified stroke centers. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. This study cohort included non-cancelled stroke alerts seen by Telestroke in 2021. Assessment included demographics, ED arrival mode , initial NIH Stroke Scale (NIHSS), neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, hospital length of stay and discharge disposition. Clustered logistic regression was used to evaluate ED arrival mode’s effects on short-term outcomes. Results: Of the 7744 stroke alerts seen by Telestroke in 2021, 3264 (42.2%) were non-canceled. Among these, 2014 (61.7%) were in the early window (0-4.5 hours from last seen well). More of those arriving in the early window came via EMS compared to those seen in the extended window [1625 (80.7%) versus 729 (58.3%) respectively]. Among non-canceled ED stroke alerts, compared to patients who arrived via EMS, walk-in patients were younger, more Hispanic, had lower initial NIHSS scores, longer times for ED to contact Telestroke, slower DTN times, but less mortality [Table]. In multivariate analysis, walk-in patients were less likely to have a DTN time within 30 minutes (OR=0.37, 95% CI 0.25-0.34; p=<0.001). Conclusions: In our cohort, there were several differences between walk-in patients and those who arrived via EMS. Further research is needed to understand these differences, the reasons for choosing walk-in, and whether ED mode of arrival affects clinical outcomes.

Abstract WMP36: Quality Improvement for Improved Ischemic Stroke Large Vessel Occlusion Door-In-Door-Out Times at an Urban Primary Stroke Center Integrated Health System

Background: Stroke patients who present to an Emergency Department (ED) with an acute ischemic stroke (AIS) due to a large vessel occlusion (LVO) and are eligible for endovascular stroke therapy (EST) require rapid transfer to a facility capable of EST. Nationwide data for 2022 suggest that 19% of LVO patients are transferred for EST within 90 minutes. Our practice center is a large urban community-based Primary Stroke Center, part of a spoke and hub integrated system. In 2022, we had a median door-in-door-out (DIDO) time of 98 min with 33% percent of cases under 90 min (n = 12). Purpose: Knowing the importance of early reperfusion, we implemented a quality improvement project using a pre-post design to improve our DIDO times for patients with AIS due to LVO, with a goal of achieving a median DIDO time of 75 min or less. Methods: Our approach was multidisciplinary. We completed comprehensive chart reviews focusing on critical time points and reviewed recent literature (2022 - 2023) for best practices. We created an ED interdisciplinary DIDO workgroup which developed and implemented a DIDO checklist after education and socialization. In March 2023, we created a dedicated regional neuro transfer hub to address changes with EMS notification and response to expedite LVO transfers. Other DIDO literature recommendations were already in place, including the use of a regionalized telestroke program. Best practices identified but not implemented focused on Emergency Medical Services (EMS), such as holding a rig while completing imaging, providing enroute reports, and conducting joint drills post-COVID. Results: After the implementation of the DIDO checklist, DIDO times decreased to 82 minutes from August 2022 to July 2023 (a decrease of 16 min), with 44% of cases under 75 mins (n = 9). Our median time for 2023 (January - July) is 68 min (n = 2). Conclusion: Transfer of LVO patients is a low-volume, high-risk event, but one where every minute matters for optimal patient outcomes. The DIDO checklist was a helpful aid for staff to ensure key steps were completed timely, leading to a decrease in DIDO times.

Abstract HUP10: Sex Disparities In A Telestroke Network: From Treatment Times To Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with >40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p<0.01) and more likely to be to be African American (20.4% vs16.8%, p<0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p<0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p<0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p<0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p<0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p<0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p<0.001)). More males were discharged home (62.4% vs 60.4%, (p<0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p<0.001) and hospice (3.9% vs 2.9%, p<0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

The effectiveness of telehealth for chronic neurological disorders in rural or underserved areas

Background The shortage of neurologists in rural areas limits patient access, making it hard for those with neurological conditions to receive timely care. Long travel distances are a barrier, often resulting in worsened health outcomes. The review aims to assess the current landscape of tele-neurology, examining existing services, evaluating patient outcomes, and identifying challenges and legal concerns. Methods This review brings together insights from multiple studies and programs, with a particular focus on initiatives like the clinical video tele-health (CVT) system created by the Veterans Health Administration, allowing neurologists to deliver direct care to veterans. We also look into the web-based tele-stroke program established by the University of South Carolina, enabling neurologists to oversee acute ischemic stroke patients in rural Emergency Departments in collaboration with local ED physicians. Additionally, we explore global partnerships in telemedicine that are being tailored for tele-neurology. Results Tele-neurology has demonstrated significant potential in delivering quality neurological care, resulting in high patient satisfaction and notable time and cost savings. The TRUST-tPA trial established a tele-stroke network connecting ten community hospital emergency rooms to a centralized stroke center, effectively serving patients unable to reach stroke units within the critical 4.5-hour window.

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.

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.

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.

Abstract WMP72: Acute Ischemic Stroke In Asians In A Large Integrated Health Care Delivery System

Background: Stroke is a major problem in Asia where more than half of the world population resides. Asian Americans are among the fastest growing racial-ethnic groups in the US, yet the incidence of stroke subtypes, stroke risk factors and outcomes have been largely unstudied in Asian Americans. We assessed acute stroke alert presentations in Asians compared to whites in a large integrated health care delivery system. Methods: In 2016, Kaiser Permanente Northern California launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. We evaluated all non-cancelled stroke alerts evaluated by Telestroke in 2019. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, and discharge disposition. Results: We identified 427 Asian and 1262 White patients with potential acute ischemic stroke. Compared with whites, Asians were younger, just as likely to arrive via EMS and arrived quicker from their last known well time, but presented with more severe NIHSS, were more likely to have bleeding on the initial head CT, and less likely to receive IV thrombolytic within 30 minutes from ED arrival (Table). Asians had less detected LVO, but those with LVO were transferred out for thrombectomy faster compared with whites. There were less stroke mimics in Asians presenting with stroke alerts, and no difference in inpatient mortality compared with whites. Conclusions: Several differences existed between Asian and white patients evaluated by Telestroke as non-cancelled stroke alerts. Further research is needed to understand these differences and assess outcomes for Asians as well as major Asian subgroups presenting with acute ischemic stroke.

Abstract WP85: Stroke Prevalence In Arkansas's Delta

Background: Telestroke hospitals in the southern Arkansas Delta participating in the American Heart Associations (AHA) Get With the Guidelines® (GWTG) are challenged with medically disadvantaged, vulnerable patient populations. The Delta is largely rural with a poverty rate higher than the US National average and residents suffer a 10 year lower life expectancy of when compared to neighboring northern counties. To determine the Delta’s influence on stroke recognition and outcomes, we examined 3-digit zip code, age at stroke occurrence, race, transport mode to diagnosing hospital, patient disposition at discharge, and stroke type in calendar years (CY) 2019 to 2021. Methods: We retrospectively reviewed the AHA GWTG Stroke data for the University of Arkansas for Medical Sciences (UAMS) Institute for Digital Health & Innovation (IDHI) - Telestroke Program 2019 to 2021, from 47 of the Programs 58 participating hospital sites. Transport mode included transfers from other hospitals, emergency medical services (EMS) transport, or privately owned vehicle/taxi (POV). Patient age significance was determined using ANOVA and categorical differences with chi square analysis. Results: Data totals were 13,721 entries with 4,571, 4,478 and 4,672 entries by CY. Ages at stroke onset were among the lowest in the zip codes from Delta areas with a median age of 66 compared to the median age of 69 for Arkansas as a whole. Percentages of stroke among Black or African Americans were the highest in Delta areas in all CYs p=0.002, p<0.0001 and p<0.0001, respectively. Patient disposition at discharge with increased discharges home vs. hospice was significant by race at all CY’s p=0.01; =0.017; =0.012, respectively. Black or African Americans had an increased %death vs. Whites in 2021, 3.7% vs. 2.8%, respectively. Transport mode was significant in 2021 with increased percentages of EMS transport of ischemic and hemorrhagic strokes and increased POV transport of transient ischemic attacks (< 24 hours) TIAs X 2 =535; p<0.0001. Delta regions experienced a higher percentage of TIAs and ischemic strokes X 2 =836; p<0.0001. Conclusions: Delta areas remain at risk for increased stroke mortality for Black or African Americans and younger populations.

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 > 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.

Telestroke Infrastructure, Processes, and Support Needs: A Survey of Hospitals in Five States.

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs.

National Telestroke Program Reduces Transfer Rates, Benefitting Patients and Hospitals

National Telestroke Program Reduces Transfer Rates, Benefitting Patients and Hospitals

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program

ObjectivesAccess to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP). MethodsWe identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect. ResultsNTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care. ConclusionsTelestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

Impact of Telestroke Implementation on Emergency Department Transfer Rate.

Telestroke networks are associated with improved outcomes from acute ischemic stroke (AIS) and facilitate greater access to care, particularly in underserved regions. These networks also have the potential to influence patient disposition through avoiding unnecessary interhospital transfers. This study examines the effect of implementation of the VA National Telestroke Program (NTSP) on interhospital transfer among Veterans. We analyzed patients with AIS presenting to the emergency departments of 21 VA hospitals before and after telestroke implementation. Transfer rates were determined through review of administrative data and chart review and patient and facility-level characteristics were collected to identify predictors of transfer. Comparisons were made using t test, Wilcoxon rank sum, and χ 2 analysis. Multivariable logistic regression with sensitivity analysis was conducted to assess the influence of telestroke implementation on transfer rates. We analyzed 3,488 stroke encounters (1,056 pre-NTSP and 2,432 post-NTSP). Following implementation, we observed an absolute 14.4% decrease in transfers across all levels of stroke center designation. Younger age, higher stroke severity, and shorter duration from symptom onset were associated with transfer. At the facility level, hospitals with lower annual stroke volume were more likely to transfer; 1 hospital saw an increase in transfer rates following implementation. After adjusting for patient and facility characteristics, the implementation of VA NTSP resulted in a nearly 60% reduction in odds of transfer (odds ratio 0.39 [0.19, 0.77]). In addition to improving treatment in acute stroke, telestroke networks have the potential to positively affect the efficiency of interhospital networks through disposition optimization and the avoidance of unnecessary transfers.

Abstract WMP30: How To Beat The Metrics With Telestroke: A Community Hospital Primary Stroke Center Experience

Background and Issues: A community hospital primary stroke center (PSC) faced many challenges including inconsistent local neurology coverage as well as inefficient in-hospital workflows. This led to a decrease in number of patients treated with IV thrombolytics, a decline in meeting stroke metrics, and challenges in maintaining PSC certification. Purpose: To implement a Telestroke system of care that would provide advanced acute stroke management in a community hospital with the goal of improved stroke workflows, stroke metrics, and quality of care. Methods: In 2019 a 172-bed community hospital PSC collaborated with a Telestroke program at a Comprehensive Stroke Center. This collaboration led to significant changes including ED physician leadership, standardized protocols with an increase in stroke alerts, EMS engagement, pre-mixing thrombolytics, dedicated stroke coordinator and education of all key personnel. The primary outcome measures were volume of stroke alerts, rate of thrombolytic use, and median door to needle before and after telemedicine implementation. Results: After one year of Telestroke utilization, the number of stroke alerts increased from 88 in 2018 to 256 in 2020 (290% increase). The number of patients receiving thrombolytics increased by 440% (10 in 2018 to 44 in 2020). Median door to needle time decreased from 56 mins in 2018 to 41 mins in 2020, an improvement of 15 minutes. Conclusions: Telestroke is a consistent and effective way to assess patients with suspected acute stroke in a community hospital setting. Key factors to its successful implementation include dedicated ED physician leadership, consistent protocol application, education and data sharing for motivation and continuous process improvement. In conclusion, Telestroke use increased access to stroke neurologists and improved thrombolysis rates and stroke outcomes.

Abstract 151: Effects Of Tenecteplase On Acute Stroke Treatment Processes And Outcomes In A Large Community Cohort

Background: Published data suggests tenecteplase (TNKase) is non-inferior to alteplase for acute ischemic stroke treatment. TNKase has certain advantages over alteplase including single-bolus administration. We evaluated TNKase performance in all acute stroke patients in a large integrated healthcare system. Methods: In 2016, we launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. In November 2020, we transitioned all centers to use TNKase for qualifying stroke patients presenting within 4.5 hours of last time known well. Selection criteria were the same as those for alteplase. Our study cohort included all potential acute stroke patients evaluated by telestroke. We compared the TNKase cohort treated during 12/1/20 - 3/31/21 to the alteplase cohort during 5/1/20 - 8/31/20. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, large vessel occlusion, rate of intracranial hemorrhage (ICH), discharge outcomes, percent with mRS (0-2) and mortality at 90 days with 95% CI. Results: Study cohort had 301 patients treated with TNKase and 248 patients with alteplase. Average age was about 70 years. Compared to alteplase, TNKase was associated significantly with faster door-to-needle (DTN) and door-in-door-out (DIDO) times [Table]. TNKase cohort had a larger percentage of stroke mimics. There was a trend of less symptomatic hemorrhage seen with TNKase. Multivariate model revealed that TNKase treatment was less likely to have 90-day mortality (OR=0.56, 95% CI 0.33-0.96, p=0.04). Percent 90-day favorable mRS score (0-2) was no different between the cohorts. Conclusions: We have successfully and safely transitioned to using TNKase for acute stroke treatment in our community setting. Compared to alteplase, TNKase cohort achieved faster DTN and DIDO times and less 90-day mortality. Further evaluation is needed to examine 90-day mRS in larger cohorts.