Efficiency of Thrombolytic Administration

In the first 27 months of our own TeleStroke experience,30 26 consultations were requested; 12 began within 3 hours of symptom onset. Eight of these 12 patients had acute ischemic stroke, of which 2 were not treated due to mild deficits. Three were diagnosed with TIA or migraine, and one with a subdural hematoma not detected at the local facility. For the 12 acute cases for whom rapid diagnosis and management was essential, we determined the mean times from symptom onset to start of TeleStroke consultation and from consultation start to drug delivery or to determination of rt-PA ineligibility (shown in Fig. 10.4).

FIGURE 10.4 The mean time (in minutes) among stages of rt-PA administration documented in published studies demonstrates that TeleStroke interventions in community hospitals compare favorably to conventional mechanisms of care in urban (U) and rural (R) patient populations. TeleStroke patients were treated at a community or rural hospital separate over videoconferencing by a remotely located stroke expert, whereas patients presenting through conventional mechanisms were treated by on-site stroke physicians. Interval mean times have been interpolated if not explicitly reported. The ''door-to-consult'' time in the Ontario study includes interfacility transfer time because patients referred from rural centers were transferred to this rural tertiary care center before the initial stroke consultation. (Adapted with permission from Rosenthal ES Schwamm LH. Telemedicine and stroke. Wootton R, Patterson, V; editors. Teleneurology, London: RSM Press Ltd.; 2005; p 53-66.)

FIGURE 10.4 The mean time (in minutes) among stages of rt-PA administration documented in published studies demonstrates that TeleStroke interventions in community hospitals compare favorably to conventional mechanisms of care in urban (U) and rural (R) patient populations. TeleStroke patients were treated at a community or rural hospital separate over videoconferencing by a remotely located stroke expert, whereas patients presenting through conventional mechanisms were treated by on-site stroke physicians. Interval mean times have been interpolated if not explicitly reported. The ''door-to-consult'' time in the Ontario study includes interfacility transfer time because patients referred from rural centers were transferred to this rural tertiary care center before the initial stroke consultation. (Adapted with permission from Rosenthal ES Schwamm LH. Telemedicine and stroke. Wootton R, Patterson, V; editors. Teleneurology, London: RSM Press Ltd.; 2005; p 53-66.)

The REACH system in southern Georgia (United States) and the TEMPiS system in Germany reported decreased latency to rt-PA delivery on a larger scale. REACH system investigators reported 194 acute stroke consultations delivered via telemedicine. The time from symptom onset to rt-PA delivery decreased from 143 minutes in the first 10 patients treated to 111 minutes in last 20 patients; of 30 patients treated with rt-PA, 23% were treated in 90 minutes or less and 60% were treated within 2 hours without any incidence of post-treatment symptomatic intracerebral hemorrhage.38 In 2004, the second year of the TEMPiS system, 115 patients in telemedi-cine-networked community hospitals and 110 patients in stroke centers received rt-PA for acute ischemic stroke or TIA. Patients treated at networked community hospitals encountered shorter mean prehospital latency times than academic stroke centers (onset to admission 64 minutes vs. 74 minutes) and equivalent door-to-treatment times (134 minutes vs. 135 minutes, p = 0.81).39

TeleStroke consultation can therefore be performed quickly. Its efficiency compares quite favorably to the management of patients in rural Ontario40 who receive rt-PA after transfer from a rural hospital to a tertiary-care center (the so-called "ship and drip'' model). The patients located in rural Ontario had a mean total time of 138 minutes between presentation at the rural facility and drug delivery at the tertiary-care center. The door-to-bolus time at the community hospitals linked to our TeleStroke service was 106 minutes, only 36 minutes longer than that measured by the urban acute stroke service in Houston, which permitted a mean door-to-bolus time of 70 minutes.6 Whereas the door-to-consult time within a telemedi-cine system may decrease with training and practice, interfacility transfer times, such as those observed in Ontario, are not easily shortened.

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