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  • 1
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    Online Resource
    Abstract TP303: The Effect of Telemedicine in IV-tPA Time Metrics of Acute Ischemic Stroke on and After-hours at Medically Underserved versus Non-medically Underserved Areas
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: Telemedicine (TM) may alleviate disparities in patients with acute ischemic stroke (AIS) in rural or medically underserved areas (MUAs) by increasing access to specialists. AIS metrics may also differ between patients who present to emergency rooms during nonworking hours. We compared time metrics and outcomes of AIS patients who received intravenous tissue plasminogen activator (IV-tPA) via TM during on-hours and after-hours at hospitals in MUAs with those during on-hours and after-hours at hospitals in non-MUAs. Methods: We identified suspected AIS patients who received IV-tPA via TM from 9/2016 - 12/2017. We compared baseline characteristics, time metrics, and outcomes between the after-hours (5pm-7:59am) and on-hours (8am-4:59pm) patients in MUAs and non-MUAs. Wilcoxon rank-sum test, Chi-square test, or Fisher’s exact test were used for two-group comparisons. Results: Of 662 patients evaluated via TM, 297 were seen during on-hours, and 365 after-hours; with 462 patients seen at non-MUA sites and 200 at MUA sites. There were no significant differences in baseline characteristics aside from racial demographics (Table 1). There was no difference in door-to-needle-time between all groups, in spite of small differences of door to CT (non-MUA sites were 5 minutes longer after hours than MUA sites, p=0.002) and onset to door time (MUA being 10 minutes longer on hours than non-MUA, p=0.027). Outcomes were slightly poorer for MUA compared to non-MUA, including discharge disposition (home: 53.9% vs 63.7%, p=0.004) and modified Rankin Scale (mRS≥4: 43% vs 27%, p=0.001). Conclusions: TM can provide AIS patients at spoke hospitals with 24/7 access to stroke specialists and standard of care evaluation and treatment. Lack of resources in MUA could be the reason for poorer outcomes however further research is needed.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.TP303
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 2
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    Abstract WP307: Lone Star Stroke Consortium TeleStroke Registry (LESTER)
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background: The Lone Star Stroke Consortium TeleStroke Registry (LESTER) currently consisting of 3 academic hub centers and 25 partner spokes is a statewide initiative organized by UTHealth to understand practice patterns of acute stroke management via telemedicine (TM) in Texas, a state with one of the largest rural populations in the US. Methods: All presumed stroke patients for whom a TM consultation has been obtained in the network are entered into a web-based, HIPAA-compliant database from 9/2013 to 3/2016. 90-day mRS and disposition are obtained by a standard phone interview. Results: A total of 3390 TM consults were performed: 57.3% acute ischemic stroke (AIS); 8.6% TIA; 1.4% ICH; 32.3% non-stroke related diagnoses (Table). Half of the cases were 〈 65 years of age. Overall 38.3% of AIS cases received tPA and 12.5% of all cases were transferred to a hub. tPA rates varied from 19% to 50% and transfer rates varied from 0% to 37.5% among spokes with at least 10 AIS consults. Conclusions: In this statewide registry of telestroke organized by academic health centers, TM leads to substantially high rates of tPA administration for AIS cases compared with national treatment rates in the US. TM provided by academic centers also leads to low rates of transfer from spoke hospitals, suggesting improvement in allocation of healthcare resources.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.wp307
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 3
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    Online Resource
    Abstract TP288: Does Transferring Patients to Stroke Centers Increase Length of Stay
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Abstract: Objective: Due to geographic disparities in stroke care, many acute ischemic stroke (AIS) patients are transferred to stroke centers for treatment with intravenous (IV) tissue plasminogen activator (tPA) or for post-tPA care. Advances in stroke treatment have improved patient outcomes and decreased hospital lengths of stay (LOS). Hypothesis: We hypothesize that post-tPA patients transferred to stroke centers have longer LOS than those presenting to our emergency department (ED). Methods: In a retrospective chart review from 2/14 - 5/15, we identified 400 patients who received tPA and were treated at our facility. Nine patients with in-hospital stroke were excluded. Baseline characteristics and clinical variables were abstracted. We compared the LOS (days - admit to discharge) of those presenting to our ED with those who were transferred to our facility. The baseline characteristics and clinical outcomes were compared between the two groups. Results: Table 1 depicts baseline characteristics and clinical variables. Of the 391 patients included, 181 (46.3%) received tPA after presenting to our ED, and 210 (53.7%) patients were treated with tPA and transferred to our facility. The median length of stay was the same for the two groups (p=0.43). There was no difference in most baseline characteristics or clinical outcome variables, though arrival NIHSS was slightly lower in the transferred group (9 vs 11, p 〈 0.05). Conclusion: There was no difference in LOS or any clinical outcomes between the ED and transferred patients. Additionally, transferred patients did not receive more advanced procedures such as intra-arterial therapy or hemicraniectomy. Further studies exploring non-tPA patients and transient ischemic attack patients would be informative, as well as non-home, discharge location relative to the patient’s residence.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.tp288
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
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  • 4
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    Online Resource
    Abstract TMP78: Time From Consult Page to Tissue Plasminogen Activator Treatment Over Telestroke Decreases With Experience
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Introduction: Formal telestroke (TS) training for neurovascular fellows (NVFs) is necessary due to growing gaps in acute ischemic stroke (AIS) coverage, yet educational approaches are not well-characterized. Time between when a TS consultant is paged and tPA administration (page-to-needle time, PTNT) can provide an objective measure of proficiency in TS management of AIS. Hypothesis: We hypothesized that NVFs have longer PTNT than neurovascular attendings (NVAs), and PTNT improves with increasing number of TS consults. Methods: We identified suspected AIS patients in our TS registry (7/2013-6/2016) who received tPA while being evaluated remotely by video consultation at one of 17 spokes. Using multivariable quantile regression, we estimated the difference, and 95% confidence interval (CI) of the difference, for median PTNT between NVFs and NVAs. We also report the coefficient of change in PTNT over increasing number of TS consults. Results: Table 1 depicts baseline characteristics. NVFs evaluated 53.7% of 618 tPA cases over TS. NVAs took less time to administer tPA, difference in median PTNT (95% CI): -9 min (-12.3 to -5.7). This difference persisted when adjusted for relative tPA contraindications. For each additional TS consult, PTNT was decreased by 0.07 min for NVFs or NVAs (p=0.02 and 〈 0.01, respectively) (Figure 1). Conclusion: TPA metrics improve with increasing number of TS consults for NVFs and NVAs. PTNT improves by 1 min for approximately every 14 TS consults. Our findings support the importance of integrating TS training into a supervised neurovascular fellowship to increase NVF proficiency in TS prior to independent practice.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.tmp78
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 5
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    Online Resource
    Abstract TMP73: Intra-arterial Transfer Time Metrics Study—Southern California Kaiser Permanente and University of Texas Houston Telestroke Network Experience
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background: The transfer process for patients with large vessel occlusions from a community hospital to an intra-arterial therapy (IAT)-capable center often involves multiple teams of physicians and administrative personnel, leading to delays in care. Objective We compared time metrics for spoke drip-and-ship telemedicine (TM) patients transferred for IAT to comprehensive stroke centers (CSC) in two different health systems: Kaiser Permanente (KP) with an integrated health care system of spokes and a 50 mile range using ambulances for transfer vs UTHealth (UTH), where patients are transferred by helicopter from varying health systems ranging up to 200 miles from the hub. Methods: We retrospectively identified patients in the KP and UTH networks transferred from TM spokes to the CSC (KP—6 spokes and UTH -17 spokes). From 9/15 to 4/16, a total of 79 TM patients (KP-28 patients, UTH-51 patients) were transferred to the respective hubs for evaluation of IAT. Baseline clinical data, transfer, and IAT metrics were abstracted. Results: On average, it takes ~90 minutes for a TM patient to arrive at the CSC hub once accepted by the transfer center. Patients in the KP Network arrive at the hub faster than UTH patients, but IAT metrics/outcomes are comparable. Over 50% of the patients did not undergo IAT on hub arrival mostly due to lack of clot on CTA (20/45) or symptom improvement (9/45). Conclusion: In two large, yet different TM networks, the transfer time from spoke to hub needs to be shortened. Areas for improvement include spoke arrival to transfer acceptance and transfer acceptance to hub arrival. A prospective study is underway to develop best practice time parameters for this complex process of identifying and transferring patients eligible for IAT.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.tmp73
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 6
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    Abstract TP278: Decade-Long Trends in Recanalization Therapy at a Large Regional Comprehensive Stroke Center in Texas
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. Suppl_1 ( 2018-01-22)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. Suppl_1 ( 2018-01-22)
    Abstract: Introduction: Recanalization therapy (RT) is the cornerstone of acute ischemic stroke (AIS) management. We present 10-year trend in RT at our center, and explore effects of increasing telemedicine (TM) access and a Mobile Stroke Unit (MSU). Methods: We identified suspected AIS patients between 01/01/2007-12/31/2016 from our prospectively managed registry. Patients presented directly (DP), were transferred-in (TP) from a regional referring hospital with or without TM consultation, or via the MSU. Pre-established TM/MSU period was from 01/01/2007-12/31/2011. We used logistic regression to explore temporal trends among patient groups, report odds ratios (OR) with 95% confidence intervals, and quantile regression to determine the difference in median (DIM) treatment times. Results: We reviewed 9,464 suspected AIS cases. 44.8% were in pre-TM/MSU and 55.2% TM/MSU period. Over 10 years, the proportion of DP has significantly reduced [OR 0.84 (0.83-0.86)], whereas non-TM TP has increased [OR 1.05 (1.03-1.06)] . In TM/MSU period, the proportion of TM patients has significantly increased each year [OR 2.00 (1.85-2.16)]. Fig. 1 shows the proportional distribution. 29.3% of patients were treated with tPA; significantly higher during the TM/MSU period compared to pre-TM/MSU [(31.5% vs 21.5%, OR 1.21 (1.11 - 1.33)] . Median onset to needle time was significantly shorter for the TM/MSU period [140(99-193) vs 157(119-198), DIM -17(-10.7,-23.2)], as was the proportion of symptomatic intracranial hemorrhage (sICH) [(1.7% vs 4.2%), OR 0.40(0.25-0.64)] . With each increasing year, a significantly greater proportion of patients were discharged home after controlling for age and NIHSS [OR 1.12 (1.10-1.14)]. Conclusion: Over a decade, we saw a steady increase in proportion of tPA treated cases. With the introduction of TM and the MSU at our institution, more AIS patients received RT, with faster onset to treatment, fewer sICH complications, and improved discharge disposition.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.49.suppl_1.TP278
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
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  • 7
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    Online Resource
    Abstract P282: Which Telestroke Transfers to the Hub Expire or Receive Hospice Within 48 Hours of Arrival?
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. Suppl_1 ( 2021-03)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. Suppl_1 ( 2021-03)
    Abstract: Introduction: Telestroke (TS) expands access to acute stroke care and facilitates swift transfer of patients to tertiary stroke centers. However, patients transferred from spoke hospitals who expire shortly after arrival raises the question of whether there is opportunity to predict futility of transfer to a higher level of care. We examined acute ischemic stroke (AIS) patients transferred to our hub from TS spoke hospitals and identified who expired or went on to hospice within 48 hours of arrival. Methods: In our TS network, we identified AIS patients who were transferred from spoke hospitals following TS consultation (9/2015 - 12/2018). We compared demographic and clinical characteristics of patients who expired or went on to hospice within the first 48 hours versus those who did not. Hospice decision time was determined by chart review for documentation of goals of care discussions. Results: Of 530 transfers to the hub, there were 32 (6%) patients who expired or went on to hospice within 48 hours. Compared to those who did not, these patients had increased age (OR 1.08; 95% CI 1.05-1.12), higher incidence of atrial fibrillation (OR 2.24; 95% CI 1.02-4.90) or cancer (OR 3.04; 95% CI 1.17-7.87), higher pre-morbid mRS (OR 5.14; 95% CI 1.57-16.88), and higher NIHSS (OR 1.23; 95% CI 1.16-1.31). Interestingly, the same characteristics were also significantly different in those who expired or went on to hospice beyond 48 hours. There was no significant difference in demographic characteristics of sex and race/ethnicity. There was also no significant difference in the frequency of treatment with tPA or IAT; of the 32 patients who expired or went on to hospice within 48 hours, 21 (66%) had received tPA and 3 (9%) had undergone IAT. Palliative care was consulted for 31 (97%) of those patients. Conclusions: A relatively small but significant proportion of TS transfers to our hub expired or went on to hospice within 48 hours. These patients were characterized by increased age, poorer pre-stroke functional status and high stroke severity. In light of the current strain on resources with the pandemic, telepalliative services may help to better serve certain patients, in particular those who are elderly or debilitated, at spoke hospitals without the need for transfer to hub.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.52.suppl_1.P282
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 8
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    Online Resource
    Abstract TP252: Extended Window TPA is Safe at Community Emergency Departments via Telestroke
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Introduction: Recent studies support tPA for acute ischemic stroke (AIS) patients presenting beyond 4.5 hours from last known well (LKW), if established infarct is not evident on advanced imaging. Many community hospitals, where AIS patients may be managed via telestroke (TS), lack advanced imaging capability and hesitate to administer off-label tPA. In our TS network, physicians adhere to an extended window tPA (EW) protocol also used in the hub emergency room; eligibility includes NIHSS≤25, 〈 1/3 MCA territory hypodensity on CT brain, and off-label tPA consent. Here, we characterize patients receiving EW via TS and investigate safety. Methods: We identified 1,150 AIS patients who received tPA via TS (9/2015-12/2018). We compared baseline characteristics between patients who received EW (arrival 〉 4.5 hrs) and those who received standard window tPA (SW, arrival ≤4.5 hrs). We explored clinical outcomes and describe incidence of adverse effects from tPA. Results: Forty patients received EW, with median ASPECTS of 9 (Q1-Q3: 9-10). Median LKW to arrival time was 491 mins with EW and 66 mins with SW (p 〈 0.0001, Table 1). EW led to few tPA complications; symptomatic intracranial hemorrhage incidence was 2%. EW was given for more severe stroke than SW (median NIHSS 10 vs 7, p=0.011). Both groups had comparable baseline characteristics, except a higher rate of tobacco use with EW. EW patients had longer length of stay (median 5 vs 3, p=0.023) and were more likely to be discharged to rehab than home (OR: 2.05 (1.01 4.15), p=0.046), however a small number of EW patients precludes in-depth comparative outcomes analysis. Conclusions: Our data suggest that EW is safe via TS for select patients with favorable CT, in settings that may lack advanced imaging capability. A specified mismatch between NIHSS and acute ischemia on plain CT is not part of our EW protocol, however EW is more likely given for severe stroke in our TS network. Small sample size warrants further study on clinical outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.TP252
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 9
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    Online Resource
    Abstract P887: Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics Within a Telestroke Network
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. Suppl_1 ( 2021-03)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. Suppl_1 ( 2021-03)
    Abstract: Introduction: Little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care. Methods: We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. Single imputation using fully conditional specification was conducted to impute missing values in NIHSS (N=103). We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke. Results: Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients) (Table 1), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration or incidence of MT utilization (Table 1 & 2). Conclusion: There was a lack of racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care beyond our single-network review, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.52.suppl_1.P887
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 10
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    Abstract WP271: Door to Page Time to Initiate a Telemedicine Consult Varies Among Spoke Hospitals for Acute Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Introduction: Although telemedicine (TM) has increased tPA use for acute ischemic stroke (AIS), there are delays between when an AIS patient enters the ED and when the TM consultant is paged. We identified predictors of delayed door-to-page time (DTP) for AIS patients evaluated on TM. Hypothesis: We investigated spoke characteristics associated with the time between patient arrival and the TM code stroke page. Methods: We identified suspected AIS patients in our telestroke registry who were evaluated by video consultation at one of 15 spoke hospitals within six hours of symptom onset (9/2015-3/2016). We compared DTP among spokes and identified factors associated with prolonged DTP. Results: Median DTP was 22 minutes (12-38, Q1-Q3). Of 382 cases 44.0% had DTP ≤20 minutes and 13.5% 〉 60 minutes (Figure). There was no significant difference in DTP among patients of different age, gender, race/ethnicity, and stroke severity (Table). Hospitals with fewer beds, no pre-notification protocols, location in a medically underserved area (MUA), and less in-house neurology availability had delayed DTP. Conclusions: Bed capacity, pre-notification, location in a MUA, and in-house neurology availability are associated with prolonged DTP. While retrospective in nature, our study confirms the utility of pre-notification for spoke hospitals. Further investigation is needed to understand why smaller hospitals and spokes in a MUA have longer DTP, and how in-house neurology coverage affects DTP. In addition, standardized acute stroke metrics over TM are needed.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.wp271
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
    detail.hit.zdb_id: 1467823-8
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