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An Internet-based examination system enables stroke patients to be treated as rapidly in rural communities as they are in bigger hospitals with stroke teams, researchers have found.
A study of 194 stroke patients in eight rural Georgia hospitals seen via the REACH system by stroke team members at an academic medical center showed most patients got clot-dissolving tPA in less than two hours, says Dr. David Hess, chair of the Medical College of Georgia Department of Neurology and lead author on the study published in the September issue of Stroke.
The clot buster, tissue plasminogen activator, which received Food and Drug Administration approval in 1996 as the first and still the only approved stroke treatment, must be given within three hours of symptoms.
"While we have a three-hour window, the evidence suggests that if you treat patients with tPA in under two hours or, even better, under 90 minutes, you improve your outcome," says Dr. Hess. "We actually look upon it as though we have a two-hour stroke window now."
Sixty percent of the 30 patients treated with tPA between March 2003-February 2004 got the drug in under two hours; 23 percent were treated in 90 minutes or less. "I think it argues that the REACH system doesn't just treat patients who never got treated before, but it treats them fast," says Dr. Hess.
Eighty percent of the 700,000 strokes that occur annually in the United States are clot-based but only a small percentage of patients get tPA because of delays in patients seeking treatment and limited availability of stroke teams to assess and treat them when they do, Dr. Hess says.
Sam Wang, a research scientist who is now a second-year medical student at MCG, developed the REACH – Remote Evalution for Acute Ischemic Stroke – system that has a portable station at the remote site and can be accessed by a stroke specialist from any computer with Internet access. Staff at the remote hospital reach the on-call member of MCG's stroke team by calling a 24-hour Emergency Communications Center.
A study published in the October 2003 rapid-access issue of Stroke showed essentially no difference in the results of patients seen via REACH and in person.
The newer study showed none of the treated patients had symptomatic brain hemorrhages, a potential side effect of tPA. It also indicates use of the system became more efficient over time, dropping onset to treatment time from 143 minutes in the first 10 patients to 111 minutes in the last 20.
Rural hospitals tend to have quieter emergency rooms than their big-city counterparts so patients typically are seen rapidly and have little or no wait for a confirmatory computerized tomography scan, Dr. Hess says. "There are some concerns that telemedicine would be too slow, there would be too many delays. This shows you can treat quickly. If this works in a very difficult environment with small hospitals, it's a model of what can be done in the state of Georgia or any state," says Dr. Hess.
In fact, state lines are the primary boundary for REACH because physicians have to be licensed to practice in the state where the patient is being seen, he says. National stroke care criteria could eliminate that problem, he adds.
MCG is working with the Southeast Affiliate of the American Heart Association to help develop a statewide stroke plan for Georgia. The national association wants every state to have such a plan, Dr. Hess says.
The Georgia Research Alliance helped MCG develop a business plan that could make REACH available to other states by detailing the installation, training and relationship building required for a successful program, he says.
Stroke care became more lucrative for hospitals recently when Medicare tripled their reimbursement for stroke care, but physicians are not paid to take call for such after-hour services, so staffing can be a problem, Dr. Hess says.
Georgia hospitals participating in the existing network include McDuffie Regional Medical Center, Thomson; Emanuel County Medical Center, Swainsboro; Washington County Regional Medical Center, Sandersville; Wills Memorial Hospital, Washington; Jenkins County Hospital, Millen; Jefferson Hospital, Louisville; Elbert County Hospital, Elberton; and Morgan County Hospital, Madison.