Internet-based Stroke Exam Speeds Treatment In Rural Areas

A study of194 stroke patients in eight rural Georgia hospitals seen via the REACHsystem by stroke team members at an academic medical center showed mostpatients got clot-dissolving tPA in less than two hours, says Dr. DavidHess, chair of the Medical College of Georgia Department of Neurologyand lead author on the study published in the September issue of Stroke.

Theclot buster, tissue plasminogen activator, which received Food and DrugAdministration approval in 1996 as the first and still the onlyapproved stroke treatment, must be given within three hours ofsymptoms.

“While we have a three-hour window, the evidencesuggests 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 strokewindow now.”

Sixty percent of the 30 patients treated with tPAbetween March 2003-February 2004 got the drug in under two hours; 23percent were treated in 90 minutes or less. “I think it argues that theREACH system doesn’t just treat patients who never got treated before,but it treats them fast,” says Dr. Hess.

Eighty percent of the700,000 strokes that occur annually in the United States are clot-basedbut only a small percentage of patients get tPA because of delays inpatients seeking treatment and limited availability of stroke teams toassess and treat them when they do, Dr. Hess says.

Sam Wang, aresearch 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 beaccessed by a stroke specialist from any computer with Internet access.Staff at the remote hospital reach the on-call member of MCG’s stroketeam by calling a 24-hour Emergency Communications Center.

Astudy published in the October 2003 rapid-access issue of Stroke showedessentially no difference in the results of patients seen via REACH andin person.

The newer study showed none of the treated patientshad symptomatic brain hemorrhages, a potential side effect of tPA. Italso indicates use of the system became more efficient over time,dropping onset to treatment time from 143 minutes in the first 10patients to 111 minutes in the last 20.

Rural hospitals tend tohave quieter emergency rooms than their big-city counterparts sopatients typically are seen rapidly and have little or no wait for aconfirmatory computerized tomography scan, Dr. Hess says. “There aresome concerns that telemedicine would be too slow, there would be toomany delays. This shows you can treat quickly. If this works in a verydifficult environment with small hospitals, it’s a model of what can bedone in the state of Georgia or any state,” says Dr. Hess.

Infact, state lines are the primary boundary for REACH because physicianshave to be licensed to practice in the state where the patient is beingseen, he says. National stroke care criteria could eliminate thatproblem, he adds.

MCG is working with the Southeast Affiliate ofthe American Heart Association to help develop a statewide stroke planfor Georgia. The national association wants every state to have such aplan, Dr. Hess says.

The Georgia Research Alliance helped MCGdevelop a business plan that could make REACH available to other statesby detailing the installation, training and relationship buildingrequired for a successful program, he says.

Stroke care becamemore lucrative for hospitals recently when Medicare tripled theirreimbursement for stroke care, but physicians are not paid to take callfor such after-hour services, so staffing can be a problem, Dr. Hesssays.

Georgia hospitals participating in the existing networkinclude McDuffie Regional Medical Center, Thomson; Emanuel CountyMedical Center, Swainsboro; Washington County Regional Medical Center,Sandersville; Wills Memorial Hospital, Washington; Jenkins CountyHospital, Millen; Jefferson Hospital, Louisville; Elbert CountyHospital, Elberton; and Morgan County Hospital, Madison.