Mark R. Etherton, MD, PhD
In this entry, I discuss a recent publication by Mai Nguyen-Huynh and colleagues regarding the results of implementation of a novel telestroke program on administration of intravenous alteplase and door-to-needle (DTN) times.
The ability to reduce DTN times and increase administration of alteplase to eligible ischemic stroke patients is extremely clinically relevant given the established relationship between earlier treatment and likelihood of a good outcome. For this reason, there is much interest in identifying approaches that expedite the ED triage of potential acute ischemic stroke patients. In this article, the authors performed a retrospective analysis of various acute stroke quality measures before and after the combined implementation of a modified Helsinki model with a centralized telestroke program in 21 primary stroke centers across Northern California.
The modified Helsinki protocol is a set of 12 measures designed to expedite alteplase administration including: prenotification, stroke code activation, telestroke evaluation, placement of large bore IV lines, and CT transport, for example. In conjunction with this protocol, a teleneurologist would emergently evaluate the patient and provide recommendations on administration of alteplase. Prior to the implementation of this program, no telestroke was used, and the local ED physician would evaluate the patient and imaging studies prior to consulting a local neurologist.
310 patients who were treated with alteplase prior to the initiation of this telestroke program were compared to 557 patients treated afterwards. After implementation of the telestroke program, the rates of alteplase administration increased (13.1% vs. 17.6%; P<0.001), and median DTN times decreased (53.5 minutes vs. 34.0 minutes; P<0.001). Importantly, rates of symptomatic intracerebral hemorrhage did not change with the new program (3.8% vs. 2.2% before implementation; P=0.29).
The results of this study are promising. A systems-level change in the protocol for triage of acute stroke patients, which is dependent on an emergent telestroke evaluation, can safely improve the administration rates of alteplase and reduce DTN times. The main limitation of this study, however, is that the simultaneous change in the emergency department triage protocol and utilization of telestroke consultations precludes interpretation on the individual impact of telestroke involvement on these stroke quality measures. Moving forward, as telestroke is increasingly utilized for emergent stroke care, future studies should continue to evaluate its impact on stroke quality and outcome measures.
Figure. Impact of Stroke EXpediting the PRocess of Evaluating and Stopping Stroke (EXPRESS) program on door-to-needle (DTN) times and alteplase use.
