Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care
2009; Lippincott Williams & Wilkins; Volume: 40; Issue: 7 Linguagem: Inglês
10.1161/strokeaha.109.192361
ISSN1524-4628
AutoresLee H. Schwamm, Heinrich J. Audebert, Pierre Amarenco, Neale R. Chumbler, Michael Frankel, Mary G. George, Philip B. Gorelick, Katie Horton, Markku Kaste, Daniel T. Lackland, Steven R. Levine, Brett C. Meyer, Philip M. Meyers, Victor Patterson, Steven K. Stranne, Christopher J. White,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeStrokeVol. 40, No. 7Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRecommendations for the Implementation of Telemedicine Within Stroke Systems of CareA Policy Statement From the American Heart Association Lee H. Schwamm, MD, FAHA, Co-Chair, Heinrich J. Audebert, MD, Co-Chair, Pierre Amarenco, MD, FAHA, Neale R. Chumbler, PhD, Michael R. Frankel, MD, Mary G. George, MD, MSPH, Philip B. Gorelick, MD, FAHA, Katie B. Horton, RN, MPH, JD, Markku Kaste, MD, FAHA, Daniel T. Lackland, DrPH, FAHA, Steven R. Levine, MD, FAHA, Brett C. Meyer, MD, Philip M. Meyers, MD, FAHA, Victor Patterson, MB, FRCP, Steven K. Stranne, MD, JD, Christopher J. White, MD, FAHA and Lee H. SchwammLee H. Schwamm , Heinrich J. AudebertHeinrich J. Audebert , Pierre AmarencoPierre Amarenco , Neale R. ChumblerNeale R. Chumbler , Michael R. FrankelMichael R. Frankel , Mary G. GeorgeMary G. George , Philip B. GorelickPhilip B. Gorelick , Katie B. HortonKatie B. Horton , Markku KasteMarkku Kaste , Daniel T. LacklandDaniel T. Lackland , Steven R. LevineSteven R. Levine , Brett C. MeyerBrett C. Meyer , Philip M. MeyersPhilip M. Meyers , Victor PattersonVictor Patterson , Steven K. StranneSteven K. Stranne , Christopher J. WhiteChristopher J. White and and on behalf of the American Heart Association Stroke Council; Council on Epidemiology and Prevention; Interdisciplinary Council on Peripheral Vascular Disease; and the Council on Cardiovascular Radiology and Intervention Originally published7 May 2009https://doi.org/10.1161/STROKEAHA.109.192361Stroke. 2009;40:2635–2660Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 7, 2009: Previous Version 1 In 2005, the American Stroke Association formed a task force on the development of stroke systems to propose a new framework for stroke care delivery that would emphasize linkages rather than silos in the chain of stroke survival and provide a blueprint for large organizations or state and federal agencies on how to implement a more coordinated approach to stroke care.1 The stroke systems of care model (SSCM) recommends implementation of telemedicine and aeromedical transport to increase access to acute stroke care in neurologically underserved areas, as do the latest American Stroke Association guidelines for the early management of adults with ischemic stroke.2 The present report was commissioned by the American Heart Association to address how telemedicine might help address current barriers to improved stroke care delivery in the United States within the framework of the SSCM.Telemedicine has been defined broadly as "the use of telecommunications technologies to provide medical information and services" (p 483).3 Technically, this encompasses all aspects of medicine practiced at a distance, including use of telephone, fax, and electronic mail technology, as well as the use of interactive full-motion integrated video and audio, that brings together patients and providers separated by distance.4 In the early part of the twentieth century, electrocardiograms and electroencephalograms were transmitted over ordinary analogue telephone lines, and in 1920, medical advice service for sea craft via Morse code and voice radio was established. Expensive and cumbersome 2-way closed-circuit television systems used in the 1960s to transmit radiographs and evaluate patients have been replaced by low-cost, personal computer–based solutions for videoconferencing and transmission of physiological data from clinics or patient homes or from inaccessible sites such as ships, aircraft, and geographically remote regions.5Telemedicine has been proposed as an alternative means of managing many different diseases and conditions over the past few decades, and a review of the barriers to implementation and the challenges to sustainability in general is useful in the consideration of telemedicine for stroke (telestroke). For telemedicine to transform the world of health care as the Internet has transformed the world of commerce, several barriers must be overcome. These include (1) defining the types of specialties suited to telemedicine practice, (2) addressing licensure and liability laws that traditionally have been regulated at the state level, (3) developing acceptable policies relating to the privacy and confidentiality of information exchanged over telemedicine, (4) simplifying the process of requesting and delivering telemedicine consultations while also improving the training and education of the end users (eg, patients and providers), (5) developing financial models for reimbursement of provider time spent on consultation via telemedicine (teleconsultation), and (6) gaining acceptance of the practice by patients, providers, and payers.6–9Licensure and liability laws may result in the most formidable barriers to the expanded use of telemedicine, while at the same time failing to provide sufficient protection for consumers. Mutual recognition of licensing laws across state medical boards coupled with a universal standard of care for teleconsultation may be necessary to erode the barriers to full implementation.10 Health services research suggests that telemedicine applications can be cost-effective and improve continuity of care for patients within organizations that can adapt to new technology easily. New management priorities and organizational structures may be necessary for the benefits of telemedicine to be realized, including substantial investments in training in these new technologies for physicians and nurses.11 The 2 factors that may be the biggest barriers to provider adoption and utilization are inadequate provider training (especially when the equipment installed includes features that are more complex and sophisticated than necessary) and the role of the provider as the gatekeeper to telemedicine access.9The direct involvement of providers in the development of disease-specific telemedicine systems greatly enhances their acceptance and adoption, but there are few published studies of failed telemedicine implementations to quantify the extent to which provider buy-in may be essential.12 Although it seems clear that the benefits of such a systematic implementation of telestroke could be readily generalized to the care of patients with other diseases, the lessons learned from prior telemedicine implementations suggests that adoption in one area does not necessarily lead to rapid and simple adoption in other areas. Careful attention to the barriers listed above will be needed to successfully implement crossover applications of the telestroke model.Use of interactive full-motion audio and video for acute stroke care was first reported in the early 1990s, but Levine and Gorman13 were the first to coin the term telestroke for the use of high-quality interactive telemedicine in acute stroke intervention. Over the past 2 decades, this model has been adopted and implemented by multiple different types of healthcare organizations across the United States and abroad.14 As technology matures, systems that today require dedicated high-bandwidth telecommunications networks (eg, speeds in excess of 300 kilobits per second of synchronous duplex communication) and dedicated external videoprocessor chips will soon be able to perform high-quality videoconferencing (HQ-VTC) with inexpensive, commercially available portable computers with standard integrated software and hardware options.The core steps of an acute stroke clinical encounter include rapid neurological assessment, review of brain imaging, and clinical formulation (eg, exclusion of stroke mimics and assessment of patient eligibility for intravenous thrombolytic therapy, investigational stroke clinical trials, or more advanced stroke services). Telemedicine-enabled acute stroke consultation supports the remote review of transmitted medical images at appropriate resolution with the industry standard DICOM (digital imaging and communications in medicine) digital format, established in 1982 by the American College of Radiology and the National Electric Manufacturers Association.15 The clinical evaluation is performed over interactive full-motion integrated video and audio (videoconferencing) with common industry standards for far-end camera control, video transmission, and compression such as MPEG (Motion Picture Experts Group) and CIF (common intermediate format) to define resolution and frame rates of projection. Audio transmission incorporates algorithms to reduce the echo and distortion that are common to medical environments.With the potential to facilitate each of these steps, telemedicine technology provides specialists with the data necessary to assist clinicians at the bedside in stroke-related decision making for patients presenting at distant or underequipped facilities. There are now a growing number of telestroke programs established in the United States and Europe (Tables 1 and 2), ranging from small partnerships between individual campuses of a single hospital system to large multihospital affiliations in which nonprofit, academic medical centers or tertiary hospitals serve as the hubs (eg, centralized specialty care stroke centers) to a network of spokes (eg, rural or community hospitals that lack readily available stroke expertise around the clock). The reported numbers of telestroke consultations overall and those that lead to thrombolysis show that the use of telemedicine is feasible and has already impacted local stroke care; however, its use must be extended substantially to have a meaningful impact on reducing the burden of stroke disability in our society. Scalability is a challenge that has yet to be demonstrated definitively. Some of these networks began as externally grant-funded pilot programs, whereas others relied on internal institutional capital investments to get started. As the number of states with stroke center certification requirements has increased and the financial viability of telestroke has been demonstrated, third-party stand-alone vendors who are not affiliated with academic institutions have begun to offer services outside of a hub-and-spoke model of care delivery. Because the evidence that supports the practice of telestroke is derived from published experiences of hub-and-spoke networks, they will form the basis of the recommendations in the present report. Because of the evidence that stroke care delivery is improved when delivered in a systematic fashion, the recommendations will focus on the implementation of telestroke within the context of the SSCM for acute stroke care delivery. Further research is warranted to demonstrate whether alternative models of telestroke care delivery can achieve the same positive results. Table 1. Survey of US Telestroke ProjectsCO-DOCDetroit Medical Center Systemwide Stroke InitiativeMethodist Hospital Telestroke ProgramMichigan Stroke NetworkMontana Stroke InitiativeMUSC Reach Stroke NetworkNevada Telemedicine ProgramNew York State Rural Telemedicine InitiativeCO-DOC indicates Colorado Digital Online Consultant; MUSC, Medical University of South Carolina; OSF, the Sisters of the Third Order of St Francis; STRokE DOC, Stroke Team Remote Evaluation using a Digital Observation Camera; STARR, Stroke Telemedicine for Arizona Rural Residents; UPMC, University of Pittsburgh Medical Center; SUNY, State University of New York.This Table only includes a sample of the telemedicine programs that exist in the United States. All programs listed practice telemedicine using interactive, high-bandwidth, full-motion video and audio; include at least 1 hub and 1 spoke hospital; and were operational as of May 2008 (data accurate as of October 2008). Many pilot programs not currently active have been omitted from the Table. Data in this Table were provided by self-report of the program's primary contact or another representative of the program listed at the bottom of the Table.*Additional data provided by REACH CALL, Inc.†Spokes are defined as hospitals with which the hub hospitals have executed a signed letter of intent or other formal agreement to engage in consultations.‡Includes only consultations that involved interactive videoconferencing. Telephone-only consultations are not included in this number.§Program was in operation for only part of the year in 2007.Name of institution(s)Colorado Neurological InstituteWayne State University/ Detroit Medical CenterMethodist Hospital–Park Nicollet ClinicSt Joseph Mercy Oakland HospitalSt Vincent Healthcare, Benefis Healthcare, Billings ClinicMedical University of South Carolina HospitalRenown Institute for NeurosciencesBassett Healthcare, Catholic Health System, Millard Fillmore Gates Circle Hospital, SUNY Upstate Medical UniversityPrimary location of hubDenver, ColoDetroit, MichSt Louis Park, MinnPontiac, MichBillings and Great Falls, MontCharleston, SCReno, NevCooperstown, Buffalo, and Syracuse, NYPrimary contact* (name of person)Christopher Fanale, MDRamesh Madhavan, MDSandra K. Hanson, MDRichard Fessler, MDNicholas Okon, DORobert Adams, MDPaul M. Katz, MDJohn Morley, MDNo. of states served11111111No. of hubs11113114No. of spokes†104431132722No. of telestroke consultations in 2007‡8425§29780§02085No. of telestroke consultations‡ with tPA given in 20071316§10200§055Challenges to the implementation of telemedicine Funding source (choose all that apply): A, institutional/ nonprofit; B, federal government; C, state government; D, third-party payer/commercial insurance; E, for-profit company; F, spoke membership feesC, D, FAA, B, FAA, CA, FA, DA, C, F Hub state regulatory environment (choose all that apply): A, state-based stroke center designation; B, legislation addressing stroke telemedicine in place as of September 2008; C, stroke center self-designation; D, EMS triage to stroke centersAA, DCCNoneCDA Reimbursement for telemedicine (choose all that apply): A, Medicaid; B, third-party payersNoneNoneA, BBANoneBA Hub hospital participation in stroke quality improvement registries (choose all that apply): A, The Joint Commission; B, CDC Paul Coverdell Stroke Registry; C, Get With the Guidelines; D, otherA, D (state stroke registry)A, B, CAA, CA, CA, CA, CA, C Additional malpractice insurance for hub telestroke consultants required (yes/no)YesNoNoNoNoNoNoNo Hub-and-spoke business relationship (choose all that apply): A, contract; B, grant; C, courtesy; D, otherAACCD (stipend from Department of Public Health)ACA, C Spoke affiliation (choose all that apply): A, within hospital network; B, outside hospital networkA, BABA, BBBBA, B(Continued)Table 1. ContinuedOSF Stroke NetworkPartners TeleStroke CenterREACH MCGSacred Heart Regional Stroke CenterSTRokE DOCSTARR NetworkSwedish Medical Center TeleStroke ProgramTexas TelephysiciansUniversity Healthcare Telestroke ProgramUPMC Telestroke NetworkSisters of Third Order of Saint Francis Healthcare SystemMassachusetts General Hospital/ Brigham & Women's HospitalMedical College of GeorgiaSacred Heart Regional Stroke CenterUniversity of California, San Diego Stroke CenterMayo Clinic ArizonaSwedish Medical CenterUniversity of Texas- HoustonUniversity of UtahUniversity of Pittsburgh Medical CenterPeoria, IllBoston, MassAugusta, GaPensacola, FlaSan Diego, CalifPhoenix, ArizSeattle, WashHouston, TexSalt Lake City, UtahPittsburgh, PaDavid Z. Wang, DOLee Schwamm, MDDavid Hess, MDTerry Neill, MDBrett C. Meyer, MDBart Demaerschalk, MDTammy Cress, RN, MSNJames C. Grotta, MDElaine Skalabrin, MDLawrence Wechsler, MD13111111111211111111252111132213613177971714010§4§2§1803815145403223§2§0§16444AA, FA, FAA, BA, CAA, EA, B, C, FA, FNoneA,DBAC,DA, DNoneA, DC, DNoneANoneA, BBANoneNoneANoneBACA, B, CCAA, CA, CAA, CCNoNoNoNoNoNoNoNoNoNoA, DAA, CCB, CACAB, CAA, BA, BA, BABBAA, BB, CATable 2. Survey of European Telestroke ProjectsRUN-FCTRUST-TPATELESTROKE-FINLAND(Unnamed)Telestroke GSTTRUN-FC indicates Réseau des Urgences Neurologiques en Franche Comté; TRUST-TPA, Therapeutic Trial Evaluating Efficacy of Telemedicine (TELESTROKE) in Patients With Acute Stroke; GSTT, Guy's and St Thomas' NHS Foundation Trust; TEMPiS, Telemedic Pilot Project for Integrative Stroke Care in Bavaria/Germany; STENO, Stroke Network of University of Erlangen; TESS, Telemedicine in Stroke in Swabia; SOS, Stroke Ost-Sachsen; UK, United Kingdom; UMTS, universal mobile telecommunications system; and GPRS, general packet radio service.This Table only includes a sample of the telemedicine programs that exist in Europe. All programs listed practice telemedicine using interactive, high-bandwidth, full-motion video and audio; include at least 1 hub and 1 spoke hospital; and were operational as of May 2008. Many pilot programs that not currently active have been omitted from the Table. Data in this Table were provided by self-report of the program's primary contact or another representative of the program listed at the bottom of the Table.*Spokes are defined as hospitals with which the hub hospitals have executed a signed letter of intent to engage in consultations.†Includes only consultations that involved interactive videoconferencing. Telephone-only consultations are not included in this number.‡Program was in operation for only part of the year in 2007.Country/regionFrance/BesançonFrance/ParisFinlandUK/Northern IrelandUK/LondonName of coordination institutionBichat University HospitalHelsinki UniversitySt Thomas' HospitalPrimary contact (name of person)Thierry MoulinPierre AmarencoTurgut TatlisumakVictor PattersonHeinrich Audebert/Antony RuddSpecial focus (eg, prehospital)In-hospitalIn-hospital, thrombolysisIn-hospitalIn hospital, post-acuteIn-hospital, on-callNo. of hubs11111No. of spokes*111053On-call service from homeAverage distance of spoke hospitals to hubs76 km50 km409 km75 kmEstimated stroke patients in spoke hospitals per year350030001000150400No. of telestroke consultations in 2007†1755040‡4018‡No. of telestroke consultations† with tPA given in 2007203021‡07‡Used bandwidth1–2 Mb360 kB1–2 Mb384 kbsG3 (UMTS)Videocommunication2-way2-way2-way2-way1-way video, 2-way audioSetup of stroke wards in spokesYesNoYesNoHospital participation in stroke quality improvement registriesYesNoYes/noNoContinuous stroke education programYesYesYesNoYesFunding source (choose all that apply): A, institutional/nonprofit; B, federal government; C, state government; D, health insurances; E, for-profit companyB, CBB, ACAReimbursement for telemedicine (choose all that apply): A, health Insurances; B, spoke hospitals; C, third-party payers; D, noneDCDData source, other than primary contact(Continued)Table 2. ContinuedTEMPiSSTENOTESSStroke AngelHELIOS NEURONETTeleneurology HeidelbergSOS-NET/SaxoniaGermany/BavariaGermany/BavariaGermany/SwabiaGermany/North BavariaGermany - Saxony, Berlin-Brandenburg, Turingia, WestfaliaGermany/ HeidelbergGermanyKlinikum Munich HarlachingUniversity of ErlangenBezirksklinikum GünzburgNeurologische Klinik Bad Neustadt/SaaleKlinikum AueUniversity of HeidelbergUniversity of DresdenJohannes SchenkelRene HandschuAndrej SchleyerVolker ZieglerGuntram IckensteinChristoph LichyGeorg GahnIn-hospitalIn-hospitalIn-hospitalPrehospitalIn-hospitalIn-hospitalIn-hospital231141115115093577 km80 km80 km20 km80 km45 km40 km40004000150070017005001200140655‡1660130‡60582660‡17011‡616500 kB–2 MB760 kB–2 MBUMTS/ISDNGPRS2 Mb10 MB/s2 MB/s2-way2-way2-wayNot yet2-way2-way2-wayYesYesYesNo(Yes)1 out of 3YesYesYesYesNoYesNoYesYesYesYesYesYesNoNoB, C, DB, C, DDA, BACA, C, DA via CAADDAwww.tempis.dehttp://steno-netz.de/www.strokeangel.dewww.helios-neuronet.dehttp://www.neuro.med.tu-dresden.de/sos-net/Although the most-studied encounters in telestroke have been those that involve thrombolysis eligibility for patients presenting within the first few hours of stroke onset, telestroke may offer substantial benefits to many patients presenting with stroke symptoms regardless of the timing in relation to stroke onset or the phase of care they require at the time of consultation. These benefits are explored in the context of each domain of the SSCM, preceded by an overview of the relevant barriers and potential solutions offered by telestroke.Burden of StrokeStroke is a major public health problem worldwide.16 A major challenge will be to increase access to appropriate interventions for stroke among patients in more remote or underserved regions. The United States has approximately 4.0 neurologists per 100 000 persons, caring for more than 700 000 acute strokes per year,17 although many parts of the United States are without access to acute stroke services entirely.18 Across the United States, a growing number of neurologists are opting out of call coverage for acute stroke and other neurological emergencies, thereby increasing the number of patients who could be described as neurologically underserved. State and local regulations requiring hospitals to provide this emergency call coverage if they wish to be licensed or recognized as acute stroke–capable facilities or primary stroke centers are further exacerbating this gap between supply and demand for on-site acute stroke expertise. Direct and indirect costs of stroke are estimated to be $62.7 billion annually in the United States, with 15% to 30% of stroke survivors being permanently disabled and 20% requiring institutional care at 3 months after stroke.Rapid recognition and accurate diagnosis are critical to optimize outcomes in patients with acute stroke. A variety of conditions can mimic acute stroke,19 and the ability to rapidly and accurately differentiate among these can be challenging for physicians without neurological expertise. The misdiagnosis rate by primary care and emergency physicians is substantial and may be as high as 30% when preimaging initial diagnoses by primary care and emergency physicians are compared with stroke team final diagnoses.20 Delays in diagnosis, misdiagnosis, and complete failure to diagnose acute stroke limit the use of proven therapies such as thrombolysis that improve outcomes and substantially lower the long-term costs of stroke.21,22Barriers to Improved Stroke Outcomes and Proposed Telestroke Solutions Within the Stroke Systems of Care FrameworkPrimary or Primordial Prevention and Community EducationIn geographically remote areas, lack of access to specialty care may hinder timely assessment and receipt of primary or secondary prevention. Community education is vital to the achievement of improved outcomes for acute stroke patients. Community outreach may be less frequent or effective in small or remote communities that have fewer resources. Remote clinical assessment has the potential to be of use in primary prevention of stroke. Currently, risk factors for stroke such as obesity, diabetes mellitus, and hypertension are increasing,23–26 and fewer patients in rural areas receive preventive services such as cholesterol testing.27For example, the Indian Health Service addresses the health needs of more than 1.6 million American Indians and Alaskan Natives in a network of 48 hospitals, more than 230 clinics, and a system of tribal and urban programs across the United States. Acute stroke services are limited in Indian Health Service hospitals because of the geographically remote regions in which they are located. The establishment of a telestroke network for these hospital systems would provide them the opportunity to be a provider of primary stroke services for their American Indian and Alaskan Native patients. Concurrent emphasis on outreach to the tribal communities with health promotion and stroke prevention education is of paramount importance.Telemedicine infrastructure may help experts provide up-to-date medical education about best practices for primary prevention of stroke to patients, primary care providers, and emergency physicians. In addition, access to subspecialty expertise via teleconsultation might be beneficial for challenging cerebrovascular cases, such as patients with asymptomatic carotid disease and several comorbid features, refractory hypertension, atrial fibrillation (in a patient with fall risk), or cerebral venous thrombosis presenting as pseudotumor cerebri. There is currently not enough evidence to provide any concrete recommendation for telemedicine implementation in this area. Research is needed to evaluate whether telemedicine is safe and effective in supporting stroke prevention clinics and enhancing patient/provider stroke education and whether it is comparable or superior to alternative methods.Notification and Response of Emergency Medical ServicesOnly two thirds of stroke patients arrive by emergency medical services, and those who do receive faster evaluation and treatment than those arriving by private transportation.28,29 In rural areas with limited emergency medical services vehicles, prehospital provider uncertainty about stroke diagnosis for patients at the initial receiving hospital can lead to delays or reluctance to dispatch limited ground or aeromedical resources for interfacility transport. Telemedicine has been used in pilot studies of prehospital diagnosis and scoring of symptom severity and has the potential to increase prehospital diagnostic accuracy in acute stroke and support the deployment of advanced resources (eg, aeromedical evacuation) directly at the scene.30 Although telemedicine may be useful for early recognition of stroke symptoms, on-the-scene triage of stroke patients for referral to adequate treatment facilities, and prearrival notification of emergency departments about transport of suspected stroke patients, there is not yet sufficient evidence for a specific recommendation.Acute Stroke Treatment, Including the Hyperacute and Emergency Department PhasesThe most effective treatment for acute ischemic stroke is rapid reperfusion. Current recommendations and drug labeling limit the use of intravenous tissue plasminogen activator (tPA) in the United States to within 3 hours of the time the patient was last seen well (or had witnessed onset of symptoms). Although a large, risk-adjusted pooled analysis of intravenous tPA–treated patients has suggested that intravenous tPA may be effective up to 5 hours after onset,31 current practice generally adheres to this 3-hour limit. It has also been convincingly shown that the benefit from intravenous tPA decreases as a function of time from onset to treatment and that systems should strive to deliver tPA within 60 minutes of hospital arrival. The main barrier to increasing treatment among those patients arriving within 3 hours is physician reluctance to deliver the therapy in the absence of available acute stroke expertise around the clock.Much of the reluctance to use intravenous tPA in acute stroke has been related to physician fears of side effects and liability.32 In one survey, 40% of emergency physicians indicated they would not use intravenous tPA, most citing the risk of intracerebral hemorrhage as the reason.33 Reluctance to administer tPA at hospitals that have not made an institutional commitment to acute stroke care, including the rapid provision of neurological and radiological expertise on demand, is reasonable, because several reports suggested that complication rates may be higher in inexperienced facilities.34,35 Reassuringly, studies have shown that with training and implementation of stroke teams, complication rates return to expected and acceptable levels.36 National guidelines from the American College of Emergency Physicians recommend that hospitals alert local emergency medical systems regarding their stroke treatment readiness so that optimal routing of patients with suspected stroke to appropriate facilities may be implemented.Ironically, the available evidence concerning litigation involving stroke therapy with tPA indicates liability is predominantly associated with failure to provide tPA rather than with adverse events associated with its use. The greatest risk of malpractice litigation for providers comes not from adverse outcomes after tPA administration but rather from failure to document appropriate reasons as to why the therapy was either withheld or not mentioned. In 29 (88%) of the cases reviewed in this report, patient injury was claimed to have resulted from failure to treat with tPA. Emergency physicians were the most common physician defendants. Defendants prevailed in 21 cases (64%), and among the 12 with results favorable to the plaintiff, 10 (83%) involved failure to treat, whereas 2 (17%) claimed injury from treatment with tPA.37Catheter-based reperfusion (eg, chemical thrombolysis, thromborrhexis, clot retrieval, angioplasty, and/or stenting) may confer benefit in carefully selected patients with acute ischemic stroke who are not eligible for intravenous tPA thrombolysis or who have failed to respond to it. Although the window for initiation of catheter-based mechanical clot retrieval may be up to 8 or 9 hours after symptom onset, there are currently only 385 interventional neuroradiologists in the United States, practicing in 238 hospitals in 45 states.38 The ability to increase the proportion of ischemic stroke patients who are transported to centers that can provide reperfusion therapy will rely on increased training of appropriate specialists, although it might result in significant cost savings for the healthcare system that could potentially offset the initial capital costs associated with improved diagnostics or interfacility transport.39A growing number of centers in the United States and abroad have initiated telestroke programs to support rapid evaluation of patients for intraven
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