By Stacey Kusterbeck
Telestroke services allow patients in rural communities to obtain stroke consultations to which they otherwise might not have had access. “The faster treatment decisions are made for a stroke patient, the more likely they are to have better outcomes, such as decreased rates of morbidity and mortality,” says Chelsey Kuznia, BSN, RN, SCRN, stroke program manager for the Essentia Health Comprehensive Stroke Center in Fargo, ND.
At Essentia Health, a telestroke consult program provides six hospitals in rural areas (in Minnesota and North Dakota) with coverage by interventional neurologists. The program speeds the diagnosis and treatment for patients from rural communities with signs of stroke. “The process begins with the initiation of a stroke alert,” says Kuznia.
If a patient is within the window for IV thrombolytics (less than 4.5 hours from last known well time), a call is made to notify the teleneurologist that a consultation is needed. Essentia uses a tiered stroke alert process.
A patient with a last known well time of 4.5 hours is considered a Level 1 stroke alert. A Level 2 stroke alert indicates the patient’s last known well time is between 4.5 to 24 hours. A Level 3 stroke alert is called for patients with a last known well time greater than 24 hours or whose symptoms have resolved. “The call for a telestroke consult can be made regardless of the patient’s last known well time, but is primarily completed only for Level 1 stroke alerts, since those patients are being considered for IV thrombolytics,” Kuznia explains.
The telestroke cart is brought into the room, and preparations are made in case a video connection is needed. The teleneurologist calls back via phone, and discusses the patient’s case with the onsite provider. Together, the two healthcare providers decide if a video assessment to perform the NIH Stroke Scale is needed to determine the plan of care.
Once the discussion or video connection has been completed and recommendations have been made, the onsite provider places orders and continues caring for the patient. Depending on the facility’s capabilities, a consult is placed for the onsite stroke team provider to see the patient, or an order is placed to transfer the patient to a higher level of stroke care.
Kuznia and colleagues analyzed 42 telestroke cases that occurred in 2022.1 Stroke diagnosis was confirmed in 25 of those patients. Of those 25 patients, 14 received thrombolytics; 18 were discharged home, three were discharged to skilled nursing facilities, one was discharged to an inpatient rehabilitation unit, one was discharged to hospice, and two died.
After the telestroke program was implemented, the percentage of patients receiving thrombolytics in under 60 minutes increased, and the average door-to-needle time decreased. In the year before the telestroke program was implemented, 11 of 15 eligible patients received thrombolytics in less than one hour, and there was a mean door-to-needle time of 61 minutes. After the telestroke program was implemented, 11 of 12 eligible patients received thrombolytics in less than one hour, with a mean door-to-needle time of just 38 minutes.
“Telestroke is an excellent service to use as an addition to a healthcare facility’s stroke code process to improve overall stroke metrics,” Kuznia concludes.
For EDs considering telestroke technology, Kuznia strongly recommends involving frontline staff in the process from the beginning. “Consistent use, education, and timely follow-up is essential for successful implementation of this technology,” Kuznia explains.
In the world of neurology, telestroke is seen by many as an obvious solution to the neurologist shortage. “But I’d never seen the perspective of emergency medicine [EM] providers on the value of telestroke,” says Jennifer Juhl Majersik, MD, MS, director of the University of Utah Stroke Center.
Majersik and colleagues surveyed 48 EM providers shortly after participation in a telestroke consult to find out their perception of how telestroke changes management of stroke patients.2 Respondents reported the most common reason for using telestroke was to obtain an expert opinion on whether the patient was a candidate for tPA. None of the EM providers believed their medical knowledge was questioned or doubted because of the decision to use telestroke services.
Almost all of EM providers expressed a strong confidence in their ability to diagnose acute ischemic stroke and to make decisions regarding tPA. However, only 10% were confident in their ability to determine thrombectomy eligibility. “This made sense because that field in particular has moved very quickly in the past few years,” Majersik observes.
Of the EM providers who administered tPA, 85% said they would not have done so without telestroke consultation. Written comments made by the providers indicated they were more comfortable making decisions on tPA if the decision was supported by a neurologist.
For 60% of patients, telestroke changed the diagnosis. Most of the EM providers (86%) reported feeling more confidence in their ability to manage future stroke cases as a result of telestroke consultation. “None of the providers resented our presence, and all thought we added to their care,” Majersik reports.
Emergency care providers should work closely with their administrators when choosing a telestroke provider. For instance, emergency physicians (EPs) may just want a simple “yes/no” on thrombolysis and thrombectomy. Other EPs may be in need of a relationship with a larger center where they can transfer patients. Still others may need targeted education, case review, or some help with quality improvement. Administrators are more likely to simply look at the cost of a telestroke program, and may disregard those additional issues. “It’s important that the needs of emergency physicians be considered in choosing a network,” Majersik says.
REFERENCES
1. Hendrickx L, Kuznia C, Maneval L. Use of telestroke to improve access to care for rural patients with stroke symptoms. Crit Care Nurse 2023;43:49-56.
2. Majersik JJ, Wong KH, O’Donnell SM, et al. Telestroke value through the eyes of emergency medicine providers: A counterfactual analysis. Heliyon 2023;9:e14767.
In the year before the telestroke program was implemented, 11 of 15 eligible patients received thrombolytics in less than one hour, and there was a mean door-to-needle time of 61 minutes. After the telestroke program was implemented, 11 of 12 eligible patients received thrombolytics in less than one hour, with a mean door-to-needle time of just 38 minutes.
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