Stroke patients who receive a remote evaluation through telemedicine are more likely to get treatment, but they face significant delays that could reduce the effectiveness of the care they receive. A new study reveals that while telestroke consultations increase the odds of a patient receiving crucial clot-busting medication, the time it takes to administer that treatment is longer compared to in-person evaluations. This paradox is a critical concern for stroke care, as the mantra “time is brain” underscores the urgency of intervention to prevent irreversible neurological damage.
The research, published in JAMA Network Open, analyzed over 3,000 ischemic stroke patients across 42 Michigan hospitals and found that telestroke patients were 1.6 times more likely to receive thrombolysis, a time-sensitive medication that dissolves blood clots. However, these same patients experienced a “door-to-needle” time that was nearly seven minutes longer than those assessed in person. This delay resulted in telestroke patients having 44% lower odds of receiving treatment within the 60-minute window recommended by national guidelines. The study highlights a crucial opportunity to improve telestroke systems to ensure that the benefits of increased access to care are not undermined by treatment delays.
The Double-Edged Sword of Telestroke
Telestroke has emerged as a vital tool for expanding access to specialized stroke care, particularly in rural and underserved areas where neurologists may not be readily available. By connecting emergency department staff with stroke specialists via videoconferencing, telestroke systems facilitate expert evaluation and treatment recommendations. The new study confirms the success of telestroke in one of its primary goals: increasing the administration of thrombolysis. Patients evaluated remotely had a 61% higher odds of receiving this critical clot-busting medication, a finding that underscores the value of telestroke in making advanced stroke care more accessible.
However, the study also uncovers a significant downside to the current implementation of telestroke. The delays in treatment, even if they seem small, can have a profound impact on patient outcomes. For every minute that a large vessel ischemic stroke goes untreated, a patient can lose nearly 2 million neurons. The finding that telestroke patients had a longer door-to-needle time is therefore a serious concern. The study’s lead author, Dr. Brian Stamm of the University of Michigan Medical School, emphasized that these findings reveal “clear gaps in the ability to promptly treat these patients after they are evaluated.”
Delays in Treatment and Transfers
Door-to-Needle Time
The 60-minute door-to-needle time is a key benchmark in stroke care, established by the American Heart Association to promote efficient and effective treatment. The study found that only 60% of telestroke patients who received thrombolysis were treated within this one-hour window. In contrast, the American Heart Association’s Target: Stroke program aims for 85% of ischemic stroke patients to be treated within 60 minutes of hospital arrival. The nearly seven-minute average delay for telestroke patients is a significant hurdle to meeting this goal.
Hospital Transfer Delays
The study also identified even more substantial delays for patients who needed to be transferred to another hospital for more advanced treatment, such as endovascular thrombectomy. This minimally invasive surgical procedure is used to remove large blood clots and is a critical intervention for many stroke patients. Telestroke patients who required a transfer experienced a delay of 47 minutes longer than those who were evaluated in person. This is a particularly alarming statistic, as national guidelines recommend that patients who are candidates for endovascular therapy should spend less than 90 minutes in the initial transferring emergency department. Previous research has already shown that a majority of stroke patients who require a transfer wait longer than two hours, and this new study suggests that telestroke may exacerbate this problem.
Challenges and Opportunities for Improvement
The reasons for these delays are multifaceted and may be inherent to the telestroke process itself. The need for remote consultation, coordination between the local and remote medical teams, and the technical aspects of telemedicine can all contribute to a longer workflow. Additionally, telestroke is more frequently used in rural hospitals, which may face other systemic challenges, such as limited EMS availability and difficulties in finding an accepting facility for transfers. Dr. Deborah Levine, the senior author of the study, noted that “several barriers exist for timely transfer to comprehensive stroke centers.”
Despite these challenges, the study’s authors emphasize that telestroke is an essential component of modern stroke care systems. The goal is not to discourage the use of telestroke, but rather to identify and address the factors that contribute to treatment delays. Quality improvement initiatives are needed to streamline the telestroke workflow, improve communication between facilities, and ensure that patients can receive the full benefits of this life-saving technology. Dr. Mollie McDermott, another co-author of the study, stated that “there is considerable room to ‘move the needle’ on timely stroke treatment for patients evaluated by telestroke.”
The Importance of Timely Stroke Care
The urgency of stroke treatment is difficult to overstate. Ischemic strokes, the most common type, occur when a blood clot blocks an artery that supplies blood to the brain. Without a steady supply of oxygen-rich blood, brain cells begin to die, leading to a range of neurological and functional deficits. The effectiveness of treatments like thrombolysis is highly dependent on how quickly they are administered. The earlier the intervention, the better the chances of a good outcome for the patient.
The American Heart Association’s Target: Stroke program was launched in 2010 to address the need for more efficient stroke treatment. A study conducted four years after its launch found that participating hospitals had successfully reduced their average door-to-needle times from 74 minutes to 59 minutes, demonstrating that focused efforts can lead to significant improvements. The findings of the current study suggest that a similar focus on quality improvement is now needed for telestroke systems to ensure that all patients, regardless of how they are evaluated, receive the timely care they need.