"One of the challenges we have is, yes, we have a great device and if you happen to have your stroke on the cath table, you’re in great luck," he said. "But if you transfer multiple times or there’s a delay in getting the patient evaluated sufficiently, then it diminishes the chance of getting a good outcome."
Telemedicine comes of age
If feasible, patients should be transported to the closest available certified primary care stroke center or comprehensive stroke center, which in some cases may involve air transport or hospital bypass.
Dr. Bart Demaerschalk
An estimated 40% of Americans, however, live in remote or rural areas without direct access to a comprehensive stroke center. For these patients, the updated guidelines emphasize the use of telemedicine to extend expert stroke care and optimize the use of intravenous rtPA, said guideline coauthor Dr. Bart M. Demaerschalk, professor of neurology at Mayo Clinic in Phoenix, which serves as a hub for 12 hospitals across Arizona with limited or no neurologic support.
"Even if air transport is available, the patients generally arrive when the respective treatment window is already closed," he said. "So telemedicine often means the difference between no treatment whatsoever, which is the usual case, and treatment."
The guidelines recommend teleradiology systems approved by the FDA or "an equivalent organization" for sites without in-house imaging expertise for prompt review of brain CT and MRI scans in patients with suspected acute stroke. When it’s not physically possible for a stroke team physician to be at the bedside, telemedicine should also be established so that more hospitals can potentially meet the criteria to become acute stroke-ready hospitals and primary stroke hospitals.
Telemedicine may also be cost effective, according to a recent study coauthored by Dr. Demaerschalk. It reports that a telestroke network model with one hub and seven spoke hospitals would result in 45 more patients getting intravenous thrombolysis and 20 more getting endovascular stroke therapies per year compared with usual care, and was associated with an estimated annual cost savings of $358,435 or $109,080 for each spoke hospital (Circ. Cardiovasc. Qual. Outcomes 2013;6:18-26).
Fellow guideline coauthor Dr. David Z. Wang, who has established one of the largest teleneurology networks in the country with 27 spoke hospitals in the OSF St. Francis Medical Center’s stroke network in Peoria, Ill., said the emphasis on telemedicine recognizes that there is a shortage of neurologists and radiologists, and that stroke care isn’t always as simple as giving a shot of rtPA. When they first started the teleneurology network in 1997, emergency physicians did not feel comfortable diagnosing stroke or giving rtPA. Over the years, however, things began to change as these hospitals, some as small as 20 beds, gained more experience with teleneurology, including feedback on the final diagnosis.
"Our hospitals in these smaller, rural areas, they all feel very comfortable now making a diagnosis," he said. "They make a phone call to us and jointly make a decision, offer treatment expediently and then ship them over to our center. The mentality has changed ... we’re providing better care."
Many guidelines committee members had financial ties with drug manufacturers and device makers.