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Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks
Introduction: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligibl...
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| Published in: | Journal of stroke and cerebrovascular diseases 2019-11, Vol.28 (11), p.104332-104332, Article 104332 |
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| creator | Jagolino-Cole, Amanda L. Bozorgui, Shima Ankrom, Christy M. Vahidy, Farhaan Bambhroliya, Arvind B. Randhawa, Jaskaren Trevino, Alyssa D. Cossey, T.C. Savitz, Sean I. Wu, Tzu-Ching |
| description | Introduction: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. Methods: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. Results: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. Conclusions: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow. |
| doi_str_mv | 10.1016/j.jstrokecerebrovasdis.2019.104332 |
| format | article |
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We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. Methods: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. Results: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. Conclusions: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.</description><identifier>ISSN: 1052-3057</identifier><identifier>EISSN: 1532-8511</identifier><identifier>DOI: 10.1016/j.jstrokecerebrovasdis.2019.104332</identifier><identifier>PMID: 31439524</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>acute stroke care ; Administration, Intravenous ; Aged ; Benchmarking - standards ; Brain Ischemia - diagnosis ; Brain Ischemia - physiopathology ; Brain Ischemia - therapy ; Delivery of Health Care, Integrated - standards ; Female ; Fibrinolytic Agents - administration & dosage ; healthcare delivery systems ; Humans ; ischemic stroke ; Male ; metrics ; Middle Aged ; Outcome and Process Assessment, Health Care - standards ; Patient Care Team - standards ; Practice Patterns, Physicians' - standards ; Registries ; Remote Consultation - standards ; Retrospective Studies ; Stroke - diagnosis ; Stroke - physiopathology ; Stroke - therapy ; Telemedicine ; telestroke ; Thrombolytic Therapy - standards ; Time Factors ; Time-to-Treatment - standards ; Tissue Plasminogen Activator - administration & dosage ; Tomography, X-Ray Computed - standards ; Treatment Outcome ; Videoconferencing - standards ; Workflow</subject><ispartof>Journal of stroke and cerebrovascular diseases, 2019-11, Vol.28 (11), p.104332-104332, Article 104332</ispartof><rights>2019 Elsevier Inc.</rights><rights>Copyright © 2019 Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c404t-a2c5b74001c2f8045d88f1a3f8cf73bf0dbca03e7196d5afb7d452b4c5b20d9f3</citedby><cites>FETCH-LOGICAL-c404t-a2c5b74001c2f8045d88f1a3f8cf73bf0dbca03e7196d5afb7d452b4c5b20d9f3</cites><orcidid>0000-0001-8504-6224 ; 0000-0002-8254-8453</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>315,786,790,27957,27958</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31439524$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Jagolino-Cole, Amanda L.</creatorcontrib><creatorcontrib>Bozorgui, Shima</creatorcontrib><creatorcontrib>Ankrom, Christy M.</creatorcontrib><creatorcontrib>Vahidy, Farhaan</creatorcontrib><creatorcontrib>Bambhroliya, Arvind B.</creatorcontrib><creatorcontrib>Randhawa, Jaskaren</creatorcontrib><creatorcontrib>Trevino, Alyssa D.</creatorcontrib><creatorcontrib>Cossey, T.C.</creatorcontrib><creatorcontrib>Savitz, Sean I.</creatorcontrib><creatorcontrib>Wu, Tzu-Ching</creatorcontrib><title>Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks</title><title>Journal of stroke and cerebrovascular diseases</title><addtitle>J Stroke Cerebrovasc Dis</addtitle><description>Introduction: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. Methods: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. Results: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. Conclusions: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.</description><subject>acute stroke care</subject><subject>Administration, Intravenous</subject><subject>Aged</subject><subject>Benchmarking - standards</subject><subject>Brain Ischemia - diagnosis</subject><subject>Brain Ischemia - physiopathology</subject><subject>Brain Ischemia - therapy</subject><subject>Delivery of Health Care, Integrated - standards</subject><subject>Female</subject><subject>Fibrinolytic Agents - administration & dosage</subject><subject>healthcare delivery systems</subject><subject>Humans</subject><subject>ischemic stroke</subject><subject>Male</subject><subject>metrics</subject><subject>Middle Aged</subject><subject>Outcome and Process Assessment, Health Care - standards</subject><subject>Patient Care Team - standards</subject><subject>Practice Patterns, Physicians' - standards</subject><subject>Registries</subject><subject>Remote Consultation - standards</subject><subject>Retrospective Studies</subject><subject>Stroke - diagnosis</subject><subject>Stroke - physiopathology</subject><subject>Stroke - therapy</subject><subject>Telemedicine</subject><subject>telestroke</subject><subject>Thrombolytic Therapy - standards</subject><subject>Time Factors</subject><subject>Time-to-Treatment - standards</subject><subject>Tissue Plasminogen Activator - administration & dosage</subject><subject>Tomography, X-Ray Computed - standards</subject><subject>Treatment Outcome</subject><subject>Videoconferencing - standards</subject><subject>Workflow</subject><issn>1052-3057</issn><issn>1532-8511</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><recordid>eNqVkM1OGzEUhS3UCkLaV6i8rCpN8C8zYZfw0yKlUInQreWxr4uTyTjYk6C8PY4GEItuWPlK_nzu8YfQD0pGlNDTk8VokboYlmAgQh3DVifr04gROs6A4JwdoAGVnBWVpPRTnolkBSeyPELHKS0IoVRW8hAdcSr4WDIxQNu_Onpd-8Z3O6xbiy-g0TvsWzyHBvp1-M_DLnnjdYsnDcQO61Vo_-G7db5Le1S_h2-gewpxeYYneQSLXYj4N3TRGzyF1jysdFymL-iz002Cry_nEN1fXc7PfxWz25_X55NZYQQRXaGZkXUpcnHDXEWEtFXlqOauMq7ktSO2NppwKOn41Ert6tIKyWqRXzFix44P0fc-dx3D4yZXVCufDDSNbiFskmKckpITxklGpz1qYkgpglPr6HPZnaJE7f2rhfqff7X3r3r_OeTby75NvQL7FvEqPAOzHoD8662HqJLxWQtYH8F0ygb_kX3Pm5SmUg</recordid><startdate>201911</startdate><enddate>201911</enddate><creator>Jagolino-Cole, Amanda L.</creator><creator>Bozorgui, Shima</creator><creator>Ankrom, Christy M.</creator><creator>Vahidy, Farhaan</creator><creator>Bambhroliya, Arvind B.</creator><creator>Randhawa, Jaskaren</creator><creator>Trevino, Alyssa D.</creator><creator>Cossey, T.C.</creator><creator>Savitz, Sean I.</creator><creator>Wu, Tzu-Ching</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0001-8504-6224</orcidid><orcidid>https://orcid.org/0000-0002-8254-8453</orcidid></search><sort><creationdate>201911</creationdate><title>Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks</title><author>Jagolino-Cole, Amanda L. ; Bozorgui, Shima ; Ankrom, Christy M. ; Vahidy, Farhaan ; Bambhroliya, Arvind B. ; Randhawa, Jaskaren ; Trevino, Alyssa D. ; Cossey, T.C. ; Savitz, Sean I. ; Wu, Tzu-Ching</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c404t-a2c5b74001c2f8045d88f1a3f8cf73bf0dbca03e7196d5afb7d452b4c5b20d9f3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>acute stroke care</topic><topic>Administration, Intravenous</topic><topic>Aged</topic><topic>Benchmarking - standards</topic><topic>Brain Ischemia - diagnosis</topic><topic>Brain Ischemia - physiopathology</topic><topic>Brain Ischemia - therapy</topic><topic>Delivery of Health Care, Integrated - standards</topic><topic>Female</topic><topic>Fibrinolytic Agents - administration & dosage</topic><topic>healthcare delivery systems</topic><topic>Humans</topic><topic>ischemic stroke</topic><topic>Male</topic><topic>metrics</topic><topic>Middle Aged</topic><topic>Outcome and Process Assessment, Health Care - standards</topic><topic>Patient Care Team - standards</topic><topic>Practice Patterns, Physicians' - standards</topic><topic>Registries</topic><topic>Remote Consultation - standards</topic><topic>Retrospective Studies</topic><topic>Stroke - diagnosis</topic><topic>Stroke - physiopathology</topic><topic>Stroke - therapy</topic><topic>Telemedicine</topic><topic>telestroke</topic><topic>Thrombolytic Therapy - standards</topic><topic>Time Factors</topic><topic>Time-to-Treatment - standards</topic><topic>Tissue Plasminogen Activator - administration & dosage</topic><topic>Tomography, X-Ray Computed - standards</topic><topic>Treatment Outcome</topic><topic>Videoconferencing - standards</topic><topic>Workflow</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Jagolino-Cole, Amanda L.</creatorcontrib><creatorcontrib>Bozorgui, Shima</creatorcontrib><creatorcontrib>Ankrom, Christy M.</creatorcontrib><creatorcontrib>Vahidy, Farhaan</creatorcontrib><creatorcontrib>Bambhroliya, Arvind B.</creatorcontrib><creatorcontrib>Randhawa, Jaskaren</creatorcontrib><creatorcontrib>Trevino, Alyssa D.</creatorcontrib><creatorcontrib>Cossey, T.C.</creatorcontrib><creatorcontrib>Savitz, Sean I.</creatorcontrib><creatorcontrib>Wu, Tzu-Ching</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of stroke and cerebrovascular diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Jagolino-Cole, Amanda L.</au><au>Bozorgui, Shima</au><au>Ankrom, Christy M.</au><au>Vahidy, Farhaan</au><au>Bambhroliya, Arvind B.</au><au>Randhawa, Jaskaren</au><au>Trevino, Alyssa D.</au><au>Cossey, T.C.</au><au>Savitz, Sean I.</au><au>Wu, Tzu-Ching</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks</atitle><jtitle>Journal of stroke and cerebrovascular diseases</jtitle><addtitle>J Stroke Cerebrovasc Dis</addtitle><date>2019-11</date><risdate>2019</risdate><volume>28</volume><issue>11</issue><spage>104332</spage><epage>104332</epage><pages>104332-104332</pages><artnum>104332</artnum><issn>1052-3057</issn><eissn>1532-8511</eissn><notes>ObjectType-Article-1</notes><notes>SourceType-Scholarly Journals-1</notes><notes>ObjectType-Feature-2</notes><notes>content type line 23</notes><abstract>Introduction: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. Methods: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. Results: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. Conclusions: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>31439524</pmid><doi>10.1016/j.jstrokecerebrovasdis.2019.104332</doi><tpages>1</tpages><orcidid>https://orcid.org/0000-0001-8504-6224</orcidid><orcidid>https://orcid.org/0000-0002-8254-8453</orcidid></addata></record> |
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| ispartof | Journal of stroke and cerebrovascular diseases, 2019-11, Vol.28 (11), p.104332-104332, Article 104332 |
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| subjects | acute stroke care Administration, Intravenous Aged Benchmarking - standards Brain Ischemia - diagnosis Brain Ischemia - physiopathology Brain Ischemia - therapy Delivery of Health Care, Integrated - standards Female Fibrinolytic Agents - administration & dosage healthcare delivery systems Humans ischemic stroke Male metrics Middle Aged Outcome and Process Assessment, Health Care - standards Patient Care Team - standards Practice Patterns, Physicians' - standards Registries Remote Consultation - standards Retrospective Studies Stroke - diagnosis Stroke - physiopathology Stroke - therapy Telemedicine telestroke Thrombolytic Therapy - standards Time Factors Time-to-Treatment - standards Tissue Plasminogen Activator - administration & dosage Tomography, X-Ray Computed - standards Treatment Outcome Videoconferencing - standards Workflow |
| title | Variability and Delay in Telestroke Physician Alert among Spokes in a Telestroke Network: A Need for Metric Benchmarks |
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