Abbas Kharal, MD, MPH, and Richa Sharma, MD, MPH
Jagolino-Cole AL, Bozorgui S, Ankrom CM, Bambhroliya AB, Cossey TD, Trevino AD, et al. Benchmarking Telestroke Proficiency: Page-to-Needle Time Among Neurovascular Fellows and Attendings. Stroke. 2017
Telestroke management is built into the curriculum of many vascular neurology fellowships and affords fellows (NVF) the opportunity to achieve proficiency in this modality. This study demonstrates that the page-to-needle time, or PTNT, is higher among NVFs compared to NVAs. As a result, the authors are suggesting that PTNT is a metric of proficiency. Given lower PTNT among NVAs compared to NVFs, there is an assumption that further training may decrease PTNT and, transitively, increase proficiency. As such, there may be a benefit in greater emphasis of dedicated telestroke training during fellowship.
There is an inherent truth in the logic that additional training can result in decreased PTNT just by sheer procedural repetition to learn the logistics of data-gathering by the phone, video, and imaging from an outside institution. However, perhaps the process is also faster for NVAs compared to fellows due to the attendings’ greater body of experiences seeing numerous patients with each stroke syndrome, treating them acutely, and then following the clinical course in the rehabilitation and subacute phase. Thus, proximal care of stroke patients longitudinally may aide in faster decision-making for remote, telestroke patients. Given that most vascular neurology fellowships are only one clinical year, it is thus critical that telestroke training does not supersede rotations, which require direct patient contact throughout the spectrum of the disease, since it is this contact which informs the decision-making process in the practice of telestroke.
The greatest controversy and confounding factor that may account for the longer PTNT of NVFs in the current study is that the amount of exposure and volume to telestroke consults for NVFs was much less compared to NVAs. NVFs only performed telestroke consults during the day and only when on dedicated telestroke rotations, which are no more than 8 weeks per year. These results may not be generalizable to all NVFs, especially those at programs who perform telestroke consults throughout the year for a significant amount of their fellowship training. Another significant controversial factor is that at most centers, an NVF must discuss each telestroke consult first with an attending before making a final decision to administer IV-tPA, whereas attendings do not have to discuss with a second person and, therefore, can make tPA decisions immediately on their own. In such cases, extra time is inevitably added to PTNT time by NVFs to ensure patient safety.
Moreover, given that they are still trainees, NVFs are much more risk averse when making life-changing decisions on whether or not to administer tPA compared to NVAs. Therefore, NVFs will most likely spend more time in going over the entire list of possible relative and absolute contraindications one by one, obtaining relevant labs, history and medications, which may further add time to PTNT. The authors did not mention if both NVFs and NVAs had a formal list of contraindications in front of them which they all formally reviewed to standardize the time spent by each in obtaining pertinent information. Furthermore, with regards to the extra thoroughness of NVFs, the NVF consults were more likely to have relative contraindications. Could this higher rate of relative contraindications have been due to the fact that NVFs were asking more about them compared to NVAs? We suspect this is quite possible!
There are certainly many areas that can be improved upon to decrease the PTNT in this ever-evolving era of telestroke. Firstly, comparing PTNT across other centers with variable volumes of telestroke consults would be interesting and informative. Since not all vascular fellowship programs are able to offer the same amount of exposure to telestroke consults across the board, comparing PTNT across high-volume and low-volume centers may add insight into whether more exposure and volume is, in fact, the reason for better PTNT times for NVAs. At some centers, fellows see more firsthand telestroke consults than attendings. Whether or not NVFs at such centers have higher PTNT compared to NVAs who do them less frequently is also an area of research worth exploring. This would answer whether volume and frequency of exposure to telestroke consults during training could provide comparable or even better PTNT times than NVAs who do them less frequently.