When Dr. Steven R. Levine and Dr. Mark Gorman first proposed that emergency physicians in small rural hospitals link up via bedside video cameras to stroke specialists in large urban hospitals to triage stroke patients, they named the concept "telestroke."
"I never thought it would catch on," Dr. Levine said in a recent interview.
It was 1999, and while thrombolysis with tissue plasminogen activator (TPA) had by then been approved for 3 years, only about 1% of acute ischemic stroke patients in the United States were receiving it, when as many as half could potentially have been eligible.
One important reason for the underuse of TPA was that smaller and more rural hospitals did not have neurologists available to respond to stroke calls. Patients would have to be transported to larger centers to receive intravenous TPA, and by the time they arrived, many would have missed the time window – which published guidelines have now determined to be up to 4.5 hours after a stroke – when TPA can be safely administered.
Dr. Levine, currently professor of neurology and emergency medicine at SUNY Downstate Medical Center in Brooklyn, N.Y., and a leading researcher and proponent of telestroke, envisioned a spoke-and-hub model of care in which smaller hospitals would be linked by video to larger ones with neurologists available, in active shifts, for two-way consults (Stroke 1999;30:464-9).
TPA could be initiated in the emergency departments of the spokes, and higher-risk patients would be transferred to hub hospitals with dedicated stroke centers once a drip was started.
Early adopters included Massachusetts General Hospital, which began building on the spoke-and-hub model and proving the concept in study after study. "We were the first to demonstrate that the NIH stroke scale could be done with equivalent reliability over telemedicine, and to show that a neurologist could interpret information on a laptop computer as effectively as a radiologist could on expensive imaging systems," said Dr. Lee H. Schwamm, professor of neurology at Harvard University and director of the Partners TeleStroke center, a 30-hospital network run out of Massachusetts General and Brigham and Women’s Hospital, both in Boston.
In 2009, on the strength of evidence showing that telestroke programs increased TPA administration rates, Dr. Schwamm and colleagues, including Dr. Levine, drafted a policy statement for the American Heart Association (Stroke 2009;40:2635-60) advocating the creation of telestroke networks wherever resources were available. More recent evidence has shown telestroke to be cost-effective compared with conventional care (Neurology 2011;77:1590-8; Stroke 2012;43:A3077).
Currently there are at least 27 networks up and running in the United States and Canada, along with 14 in Europe, following spoke-and-hub models. Some comprise a handful of hospitals; others, dozens. Many have existed for only a few years.
North American telestroke programs can now boast TPA rates between 10% and 20% of patients admitted for stroke, even in very rural networks, when the U.S. national average is estimated to be about 5%. In Europe, established programs are reporting TPA rates between 12% and 17%, according to a recent meta-analysis (Curr. Opin. Neurol. 2012;25:5-10).
Dr. Charles H. Tegeler, professor of neurology and head of the telestroke program at Wake Forest Baptist Medical Center in Winston-Salem, N.C., said in an interview that his program, which started in 2009 and now incorporates nine network hospitals, has seen TPA administered in 27% of patients who receive a video stroke consultation. And many patients are receiving TPA in hospitals that, before joining the network, did not administer it.
About 45% of patients receiving a telestroke consultation through one of the network hospitals are transferred to Wake Forest Baptist, or another dedicated stroke center of the patient’s choice, for additional evaluation and management. Depending on local resources and expertise, those treated with TPA may be transferred under a treatment model known as "drip and ship." The rest remain at the network hospital for ongoing care, or "drip and keep."
Rayetta Johnson, R.N., stroke program manager for Wake Forest Baptist, said in an interview that an important factor in its success has been achieving close cooperation, through training seminars and other forms of outreach, with hospital emergency department staff at all levels. The program also reached out extensively to local emergency medical services accustomed to rerouting stroke patients to larger hospitals. "Having EMS on board is extremely important," Ms. Johnson said.
Barriers to Adoption
If telestroke programs are cost effective and improve TPA rates dramatically, why aren’t they more widespread?