Figure 41.1. Stroke death rates in relation to availability of neurologists in Alabama. From CDC Heart Disease and Stroke Maps. A. Stroke death rates, total population aged 35+, 1991-1998. B. Neurologists.
To ensure equitable access to acute stroke care within a region, pre-hospital and hospital organizations must work together to pre-specify a communication and transfer plan for any patient arriving at any given location. Hospitals with available stroke physicians and specialized resources for endovascular therapy should accept responsibility for collaborating with other facilities within their region to promote access to advanced acute stroke care [10].
In most regions, such informal relationships exist, in the form of consults via plain old telephone service (POTS). Over a simple telephone connection, advice is given “blindly” without the ability to evaluate a patient’s neurologic exam or CT scan, interview multiple family members, and based on the description of a local physician with variable stroke experience. While there are advantages to a telephone stroke system because of its relative safety [11] and wide availability, a direct comparison study suggested that telemedicine is associated with reduced mortality after stroke and required less correction of initial impressions [12]. In cases where the available information does not foster confidence, a transfer might be initiated without administration of t-PA with the hope that the patient can be evaluated in person at the receiving hospital. In such cases, eligible patients may miss the time window for administration while in transit.
Stroke outcomes in a region can be improved by developing a system of care around an infrastructure that addresses the needs of the stroke patient through all phases of their care. This involves the entire time-treatment spectrum from prevention to rehabilitation. The components of an ideal stroke system have been defined elsewhere[10] and are summarized in Table 41.2.
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Table 41.2. Components of an ideal stroke system (adapted from the American Stroke Association’s Recommendations [10].
Telemedicine can be a tool within a stroke system that offers safe and effective universal access to acute stroke care [11,13,14] (Table 41.3.). In addition to telemedicine-supervised t-PA administration for neurologically underserved areas, it can allow the retention of appropriate patients while referring high-risk and interventional cases to a comprehensive stroke center. When transferred patients are first consulted via telemedicine, the receiving doctors (and patients) are at a distinct advantage of having already been introduced and may pick up the course in mid-treatment rather than initiating new assessments upon arrival at the comprehensive stroke center. Telestroke can increase use of tPA at spoke sites and decrease time to tPA administration [14,15].
