- Some 20 hospitals in northern California are using telemedicine carts to treat stroke patients almost twice as fast as the national average for stroke treatment.
The hospitals, all part of the Kaiser Permanente network, are using the Stroke EXPRESS (EXpediting the Process of Evaluating and Stopping Stroke) program to improve the time between when a patient is seen and when the clot-busting medication r-tPA is administered. Through the program, stroke specialists are able to evaluate stroke patients at those 21 hospitals via a telemedicine cart and prescribe r-tPA when necessary.
According to a study published this month in the journal Stroke, 87 percent of stroke patients in those hospital were treated within 60 minutes – the recommended “door-to-needle” time put forth by the American Heart Association and American Stroke Association. Nationally, less than 30 percent of stroke patients are treated within this window.
More importantly, according to the Kaiser Permanente study, 73 percent of stroke patients in those hospitals were treated within 45 minutes and 41 percent were treated within 30 minutes; the average “door-to-needle” time was 34 minutes.
“Processes that used to happen sequentially during a stroke alert, one after another, are now happening at the same time, allowing us to quickly, safely and confidently provide evaluation and treatment with intravenous r-tPA to stroke patients who can benefit,” Jeffrey Klingman, MD, chairman of the Chiefs of Neurology for Kaiser Permanente Northern California and a co-author of the study, said in a press release issued by Kaiser Permanente.
Stroke EXPRESS was launched in September 2015 in Kaiser Permanente’s 21-hospital northern California network, with researchers comparing 337 patients treated before the program’s implementation with 557 patients treated in the program.
According to Kaiser officials, a “stroke alert” is sounded when paramedics notify a Kaiser Permanente hospital of an incoming stroke patient. A neurologist assesses the patient, either in person or via telemedicine, upon the patient’s arrival, and pharmacists are directed to have r-tPA ready should a radiologist confirm via imaging that the patient is a candidate for the drug.
“When a stroke happens, minutes matter,” Mai Nguyen-Huynh, MD, MAS, a vascular neurologist and research scientist with the Kaiser Permanente Division of Research and lead author of the study, said in the press release. “Faster treatment with intravenous r-tPA, which dissolves the stroke-causing clot and restores blood flow to the brain, is strongly associated with better functional outcomes for stroke patients.”
In July 2016, Kaiser Permanente released the results of a similar telestroke study conducted in the health system’s 14-hospital southern California network.
In that study of some 2,500 stroke patients, almost 75 percent were treated more quickly than the national standard for “door-to-needle” treatment.
“Our findings add to the existing body of evidence supporting the value of telestroke programs for improving tPA [tissue plasminogen activator] administration rates among ischemic stroke patients at hospitals which may have limited resources or access to neurological expertise,” Adam L. Sharp, MD, a researcher at Kaiser Permanente’s Southern California Department of Research & Evaluation and lead author of the study, said in a press release.
“These findings have important implications for future delivery of stroke care,” that study, published in The Permanente Journal, concluded. “Particularly in hospitals with limited local resources and/or limited access to neurologic expertise, telestroke is an important tool to aid in the evaluation and treatment of potential stroke. We specifically found that unwarranted hospital variability in stroke care could be eliminated through a standardized telestroke program. Additionally, telestroke may aid in triage and transfer decisions and in identifying patients potentially eligible for endovascular intervention or patients who might otherwise benefit from transfer to a stroke center.”
About a year ago, the AMA and ASA jointly released a scientific statement on quality measures and outcomes for the use of telemedicine in stroke cases, marking the first time that clinical standards have been proposed for the treatment.
"Telestroke has evolved over the last decade and is now used quite extensively to take care of acute stroke patients in the U.S. and the rest of the world," Lawrence R. Wechsler, MD, chairman of the AHA/ASA writing committee, told Medscape in November 2016. "Because of this we felt it was time to bring out this statement, which provides a structure against which hospitals can measure the quality of their telestroke programs so patients can be assured of getting the quality they deserve."
Earlier this year, the American Telemedicine Association added telestroke to its growing library of practice guidelines to ensure “standardization around the assessment, diagnosis, management and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies.”
“The telestroke guidelines are the culmination of best evidence, clinical experience and consensus amongst many experts,” Bart M. Demaerschalk, MD, MSc, FAHA, FRCP(C), a professor of neurology, chairman of the Mayo Clinic College of Medicine’s Cerebrovascular Diseases Division and director of synchronous (telemedicine) care at the Mayo Clinic Center for Connected Care, said in the ATA press release. “Once implemented, the guidelines will enable more patients with acute stroke to receive timely expert assessments and treatments no matter their geographic location.”