Ilana Spokoyny, MD
Heffner DL, Thirumala PD, Pokharna P, Chang YF, and Wechsler L. Outcomes of Spoke-Retained Telestroke Patients Versus Hub-Treated Patients After Intravenous Thrombolysis: Telestroke Patient Outcomes After Thrombolysis. Stroke. 2015
The American Stroke Association and The Joint Commission have designated Primary Stroke Centers as “hospitals that meet standards to support better outcomes for stroke care” and Comprehensive Stroke Centers as “hospitals that meet standards to treat the most complex stroke cases”. Ideally, all stroke patients would be treated at these hospitals, by specialists who understand the complex pathophysiology and potential complications associated with stroke. However, transport is often costly and time-consuming, and families are burdened with traveling a long distance to be with their loved one. In addition, delaying other medical treatment in order to transport to a stroke center may be dangerous.
With the development of telemedicine technology, we are able to provide advanced stroke care to patients who previously had no access to stroke specialists as a result of their isolated geographical location. Telemedicine has increased the tPA treatment rates in stroke patients at local hospitals. Some of these patients are treated locally then transferred to the hub hospital, and others are treated and remain at the local hospital for the duration of their post-stroke care. A study of the UPMC telestroke network found similar safety and functional outcomes in patients treated at local hospitals using telemedicine compared to those patients treated with tPA at the telestroke hub hospital.
The authors of this study delved further into differences in post-stroke care of 272 patients treated with IV tPA at a telestroke hub, 73 “drip-and-ship” patients, and 134 “drip-and-stay” patients treated at a local hospital who completed their treatment locally. Patients who had endovascular treatment were excluded. For the “drip-and-stay” patients, the telemedicine consultant was only involved in the patients’ care for the first 24 hours, then the local neurologists took over. Of 134 “drip-and-stay” patients, 95 were treated before the spoke hospitals received Primary Stroke Center certification.
The “drip-and-stay” patients were older than the hub patients (76 vs 72), had less severe strokes (NIHSS 9.5 vs 12.7, p<0.001) and fewer large vessel occlusions (12% vs 36%, p<0.001) than the hub patients. These are expected findings as more severe strokes are often transferred to a hub center for intervention or higher level of neurocritical care. There was no difference in onset- or door-to-needle times, nor in rates of symptomatic intracranial hemorrhage.
However, the “drip-and-stay” patients also had higher risk of adjusted in-hospital mortality (OR 13.3) and longer length of stay (OR 4.7 to stay longer than 6 days) compared to the hub patients. The “drip-and-stay” patients had lower risks of intubation and fever compared to hub patients. The other post-stroke complications (pneumonia, UTI, GI bleed, constipation, seizure, new onset AFib, MI, and falls) were similar among groups.
The “drip-and-stay” patients who were deceased at 90 days had lower NIHSS scores than the hub patients deceased at 90 days (14.4 vs 18.7, p=0.005). Several factors may have confounded this finding – older age of “drip-and-stay” patients, and causes of death which did not depend on NIHSS (and which occurred at similar rates among groups). Drip-and-stay patients also had decreased long-term survival (p<0.001) compared to hub patients. The “drip-and-ship” patients were similar to the hub patients on baseline characteristics as well as outcomes.
There was no difference in most post-stroke complications, although the local hospitals may have been less efficient at treating these given the longer lengths of stay. The difference in NIHSS is likely due to more severe strokes being transferred to the hub hospital (either for endovascular intervention or a higher level of care), but may also reflect an underestimate of NIHSS score by telemedicine as compared to in-person evaluation. Since the outcome measures are adjusted for age and baseline NIHSS, if the NIHSS recorded via telemedicine consult was underestimated, the outcome measures may not have differed as much between the spoke and hub hospitals.
Ideally, as more local hospitals become Primary Stroke Center certified, stroke codes will be taken exclusively to PSCs, then transferred as needed to CSCs for higher level of care. The results of this study do not indicate, however, a major shift in outcomes as local sites became PSC certified. As part of a coordinated telestroke system, implementation of quality measures regarding post-stroke care will be critical to ensuring that patients treated via telemedicine who remain locally have the best possible overall care (both acute and post-stroke). The telestroke consultant may wish to remain available to local physicians for ongoing management, and we should make efforts to include treating providers at local hospitals in stroke education and quality improvement initiatives. Additionally, more studies are needed to confirm these findings before discounting the quality of post-stroke care at local hospitals.