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October 2008 | Back to Table of Contents

Clinical and Health Affairs

Implementing a Stroke System of Care in a Rural Hospital

A Case Report from Granite Falls

By Dan Hoody, M.D., Sandra Hanson, M.D., Darrell Carter, M.D., and Therese Zink, M.D., M.P.H.

Abstract
Acute stroke is a leading cause of morbidity and mortality. Both time-sensitive treatment and telemedicine are being used to improve the care of stroke patients in rural areas. This article highlights the case of a 62-year-old male patient with sudden onset of right-sided hemiparesis and a family history of vascular disease and how he was treated at a rural hospital that was connected by telemedicine technology to an urban tertiary care center. It also reviews protocols for acute treatment of stroke and systems of stroke care in rural areas.

Stroke is a major cause of morbidity and mortality in the United States, with approximately 700,000 cases diagnosed annually.1 In particular, stroke is a major cause of long-term disability and reductions in quality of life. Intravenous thrombolytic (fibrinolytic) therapy has emerged in recent years as an effective treatment for selected patients presenting with acute ischemic stroke. Administration of alteplase for ischemic stroke has been linked to an increase in favorable outcomes.1 However, the window for administering these “clot-busting” drugs by a peripheral IV route closes after 3 hours, so timely transportation to an emergency department and assessment are essential.1 This can be especially challenging in rural areas.

This article illustrates how use of a telemedicine system connecting a hospital in rural southwestern Minnesota with a tertiary care center in the Twin Cities led to a positive outcome for a patient as a result of receiving thrombolytic therapy soon after onset of symptoms.

Case Report
P.H., a 62-year-old male, presented to the emergency department (ED) at Granite Falls Municipal Hospital, a critical access hospital in Granite Falls, Minnesota, with a sudden inability to speak and paralysis on the right side of his body. He woke that morning at his usual time, walked to get the newspaper, and was having coffee when he suddenly was unable to move the right side of his body and speak. His wife immediately called 911 at 8:06 a.m. The local ambulance service delivered him to the ED at 8:20 a.m., an estimated 15 minutes after the onset of symptoms. The patient had no significant medical or surgical history but was a smoker and consumed alcohol. He also had a family history of stroke, coronary artery disease, and abdominal aortic aneurysm. P.H. had no history of transient ischemic attacks or stroke symptoms and was taking no medications.

Upon initial examination, P.H.’s vital signs were normal; his blood pressure was 135/80 mmHg. He was afebrile and alert. The initial neurological exam showed a significant expressive and receptive aphasia with no speech output. Cranial nerves II through XII were intact, with the exception of facial drooping on the right side. His midline tongue showed minimal protrusion. No visual field loss was noted. Both his right upper and lower extremities were totally flaccid with marked hyperreflexia when compared with the left upper and lower extremities. Babinski sign was present on the right side and absent on the left. No other strength, sensory, or focal deficits were noted. Findings on examination of the head, eyes, ears, nose, and throat were unremarkable, with no fundal papilledema noted. Cardiovascular, respiratory, and abdominal exams were grossly unremarkable, with the patient noted to be in normal sinus rhythm on electrocardiogram. Because of their high suspicion of stroke, the hospital staff initiated the telestroke program.

Lessons from the Granite Falls Case

Key American Stroke Association Recommendations for Emergency Medical Services

  • Arrive at the patient’s location as quickly as possible;
  • Use diagnostic algorithms and protocols that reflect the most current stroke treatment recommendations to ensure initial response;
  • Evaluate patients for hyperacute interventions such as thrombolytic therapy.

Key American Stroke Association Recommendations for AcuteTreatment

  • Make acute stroke treatment capabilities available to providers, EMS, and the public;
  • Incorporate all hospitals in a stroke system of care, regardless of their stroke center status (any hospital can have a plan in place for rapid assessment and management); 
  • Properly identify “acute stroke capable” hospitals;
  • Consistently follow clinical pathways related to acute interventions; and
  • Properly identify the roles and responsibilities of each hospital within the system.
Source: Schwamm LH, Panciolo A, Acker JE 3rd, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Stroke. 2005;36(3);690-703.
The telestroke program is a collaboration between rural hospitals including Granite Falls Municipal Hospital in Granite Falls, a town of 3,000 in southwestern Minnesota, and Park Nicollet Methodist Hospital, a tertiary care center and a Joint Commission-certified stroke center 120 miles away in suburban Minneapolis. It is designed to provide the outstate facilities with access to an on-call neurologist experienced in administering alteplase using telemedicine technology. The program protocol consists of a list of tasks to be completed in chronological order by the emergency department physician, nurses, pharmacists, computed tomography (CT) technician, social services staff, ward secretary, and consulting neurologist in order to make a stroke diagnosis as quickly as possible. It allows for the identification of acute stroke patients who are candidates for thrombolytic therapy and the administration of thrombolytics in a timely manner.

A closed-circuit television system allows the on-call neurologist to perform a neurologic exam on the patient using live, remote-control video and audio feeds. Although this case occurred approximately 5 weeks prior to the official January 1, 2007, start date of the Granite Falls Telestroke Program, the necessary audio/visual equipment was on hand and some of the staff had been trained to use it and implement the protocol. Thus, the physician in the Granite Falls ED activated the program.

Following the stroke protocol, a peripheral intravenous line was placed. Blood work was ordered at 8:35 a.m., and blood was drawn at 8:39 a.m. The patient was then sent to radiology for a CT scan of his brain. The on-call neurologist at Methodist Hospital was paged and responded on closed-circuit television at 8:50 a.m. The attending physician in Granite Falls discussed the case with the neurologist. When the patient returned from radiology several minutes later, the neurologist examined him via closed-circuit television.

At 8:55 a.m., the physician in Granite Falls and the neurologist at Methodist Hospital examined the digital CT images on computer monitors located at both sites. They found an acute thrombus in the left middle cerebral artery with no evidence of intracranial hemorrhage, mass effect, midline shift, or abnormal fluid collection. Laboratory results were received at 9 a.m., and the patient’s complete blood count, basic metabolic profile, prothrombin time, and partial thromboplastin time were all within normal limits. This information allowed the physicians to make a working diagnosis of cerebral infarct of the left middle cerebral artery territory. The patient’s history, physical exam, and laboratory and imaging results indicated that he was a candidate for acute thrombolytic treatment. At 9:03 a.m., intravenous alteplase was started, and the patient was prepared for air transport to Methodist Hospital.

At 9:15 a.m., the neurologist at Methodist assisted by the attending physician in Granite Falls completed a neurologic assessment via telemedicine. P.H.’s NIH Stroke Scale score was 11.2

During the course of thrombolytic treatment, P.H. regained some motor strength in his right upper and lower extremities as well as some speech. At 9:45 a.m., the flight crew arrived, and P.H. was transported to Methodist Hospital for further observation and treatment. During the trip, he continued to tolerate the alteplase well and showed no signs of adverse side effects.

P.H. was hospitalized at Methodist Hospital for 4 days. Magnetic resonance angiography and arteriography with 4-vessel runoff performed after admission showed a high-grade critical left internal carotid artery stenosis with persistent thrombus of the proximal aspect of the left internal carotid artery. The patient underwent a left carotid endarterectomy on day 3 of his hospitalization with no complications. P.H. was discharged home on day 4 with only mild to moderate aphasia and some right upper extremity weakness. Eight weeks after the initial episode, P.H. returned to the clinic in Granite Falls for follow-up. He had minimal residual symptoms that consisted of slight numbness in the 3rd and 4th fingers of his right hand, mild intermittent right upper extremity ataxia, and mild intermittent expressive aphasia (occasional word-searching). He required no assistance with activities of daily living and resumed his job as a heavy equipment operator.

Discussion
During the past decade, Twin Cities hospitals have created high-speed systems for managing stroke. The next step has been to extend those systems to rural areas so that physicians in greater Minnesota can receive assistance in making rapid decisions about which patients would benefit from thrombolytic treatment and arrange for immediate transport of those patients to stroke centers. The first Minnesota telestroke partnership was established between Methodist Hospital and Glencoe Regional Health Services in 2006. Soon after, hospitals in Granite Falls, Shakopee, and Redwood Falls began the process of becoming telestroke partners. That 3-month process involves setting up the necessary computer, video, and audio equipment; developing a stroke team and a plan for maintaining their skills; and committing to quarterly videoconferences with neurologists at Methodist in order to review data for quality-improvement purposes. Similar programs are emerging throughout the United States. But technology is only part of the reason for P.H.’s good outcome. That the Granite Falls hospital had a stroke system of care may have played a bigger role in his successful recovery.

In 2005, the American Stroke Association (ASA), a division of the American Heart Association, published its recommendations for the development and establishment of stroke systems of care.1 The recommendations were designed to minimize fragmentation in the delivery of stroke care, which had been identified as a barrier to effective treatment, and apply up-to-date science-based standards and guidelines for caring for stroke patients. The systems approach for stroke care proposed by the ASA consisted of the following components: primordial and primary prevention; community education about the symptoms of stroke and the importance of calling 911 immediately; notification and timely response of emergency medical services (EMS); availability of acute stroke treatment (delivery of intravenous thrombolytic therapy to carefully selected patients within 3 hours of onset of symptoms, according to the American Heart Association’s stroke algorithm); availability of subacute stroke treatment and secondary prevention; rehabilitation; and continuous quality-improvement activities.1

Alteplase administration for ischemic stroke, a key element in a stroke system of care, has been linked to a 30% increase in favorable patient outcomes when used appropriately; the number needed to treat (NNT) for clinical benefit is as few as 3 patients.3,4 Yet, a significant portion of eligible stroke patients do not receive alteplase treatment.5,6 A 2004 review of 54 studies involving a total of 39,030 acute stroke patients identified the following reasons why patients did not receive acute thrombolytic treatment: 1) lack of patient awareness about the symptoms of stroke and the importance of immediately calling 911 when they experience symptoms, 2) nonurgent triage by paramedics and EMS providers, 3) delays in neuroimaging, 4) inefficient in-hospital emergency stroke care, 4) difficulty obtaining consent for thrombolysis, and 5) uncertainty among physicians about thrombolytic administration.7 Patients in rural areas are often likely to experience delays in treatment because they may be taken to facilities that lack an acute stroke protocol or standard practices and neuroimaging technology, and must be transported to the nearest stroke center for treatment.8-13 In addition, lack of readily available neurology consult and physician discomfort with administering thrombolytic therapy affect the care of acute stroke patients in rural settings.11,13-15

Establishing a stroke system of care based on ASA recommendations may allow for more appropriate acute stroke care at any hospital, urban or rural. For rural hospitals in particular, the addition of a telestroke system such as the one used by Granite Falls Municipal Hospital and Methodist Hospital may help decrease the time needed to make a diagnosis and begin administration of thrombolytics. Having a CT scanner and high-speed electronic neuroimaging transfer capabilities allows for a neurological consult that would otherwise not be available in a rural setting. The establishment of a telestroke system at a rural hospital may result in review or initiation of a stroke protocol that will help physicians identify patients who may be candidates for intravenous thrombolytic therapy and get them treatment faster and encourage efforts to educate the public about the importance of recognizing the signs of stroke and immediately calling 911.

These measures may save precious time in ischemic stroke diagnosis and/or transport from a rural hospital to the nearest stroke center. Time is especially important, as recent studies have indicated that patients who are diagnosed and receive alteplase within 90 minutes of symptom onset have better outcomes.16 Studies of existing telestroke systems being used in Germany, Georgia, and Ontario, Canada, have highlighted some of these benefits. They also have shown that telestroke systems are technologically feasible, provide for a higher incidence of thrombolytic usage, and result in similar safety profiles for thrombolytic therapy administered in urban and rural hospitals.12,13,15

The cost and economic benefits of telestroke systems and thrombolytic usage have been discussed in several recent publications, but more detailed assessments are needed.14,17 Historically low reimbursement has been detrimental to the sustainability of telemedicine programs.18 However, Medicare recently recognized treatment of acute ischemic stroke with thrombolytics and the use of telemedicine consults in its diagnosis and reimbursement schemes.11,19

Conclusion
There were a number of reasons for the positive outcome in the case of P.H. Undoubtedly, the acute stroke response at Granite Falls Municipal Hospital, which was developed around the ASA’s recommendations for stroke systems of care, played a big part in the patient’s recovery. Other factors contributing to his good outcome include the fact that P.H. and his wife knew the signs of stroke and called for help immediately, the EMS providers were readily dispatched to his residence and made the initial assessment of a potential stroke based on his symptoms, the hospital used a streamlined acute stroke protocol, which allowed the staff to gather the necessary clinical, laboratory, and neuroimaging data, the consulting neurologist at Methodist Hospital was able to quickly read the images using the telestroke system and make an accurate diagnosis of ischemic stroke, and the physician in the ED administered thrombolytic treatment prior to the patient’s transport to a stroke center 120 miles away. As a result, P.H. was started on intravenous alteplase approximately 57 minutes after initial onset of stroke symptoms, giving him the highest chance of a successful outcome.

Since P.H. was seen in the ED, the Granite Falls hospital staff has seen good results in other cases as well. During a 20-month period from November 2006 through June 2008, they evaluated 26 patients who met the criteria for activation of the hospital’s stroke protocol. Twenty-two were assessed as having ischemic stroke. Seven of those patients (27%) received thrombolytic therapy. Critical time intervals were monitored during quarterly quality assurance reviews for the patients who received thrombolytic therapy. Results for these patients are as follows:

  • The average time from onset of the patient’s symptoms until arrival at the emergency department was 72 minutes.
  • The average time from the patient’s arrival at the emergency department until the beginning of the CT scan was 7 minutes.
  • The average time from ED arrival to the administration of thrombolytic therapy (door to drug) was 48 minutes.
  • The average time from the onset of the patient’s symptoms until the beginning of the thrombolytic therapy was 127 minutes.

About a third of the ischemic stroke patients (7/22) received thrombolytic treatment during the study period; this compares with the national average of less than 5% of ischemic stroke patients receiving thrombolytic treatment.20 Of the 19 patients who were not offered thrombolytic therapy, 9 were excluded because they were outside the 180-minute time window from the onset of symptoms to the start of thrombolytic therapy, 3 were excluded because of the presence of hemorrhage, and the other 7 were not strokes. Although the number of patients treated was too small to suggest a trend, 5 of the 7 who received thrombolytics had good results. Of the 2 who did not have good outcomes, 1 presented with a massive stroke and expired in spite of the thrombolytic treatment and the other developed a post-thrombolytic treatment CNS hemorrhage.

As the case of P.H. illustrates, rural hospitals that have a protocol for stroke care and neuroimaging and telemedicine capabilities can safely provide thrombolytic therapy. A telestroke system can remove some of the traditional barriers to acute stroke care in rural settings and improve patients’ chances of suffering minimal damage and disability. MM

Dan Hoody is a first-year resident in internal medicine at the University of Colorado in Denver; during the presentation of P.H., he was a student in the University of Minnesota’s Rural Physician Associate Program (RPAP) in Granite Falls. Sandra Hanson is director of the Methodist Hospital/Park Nicollet Stroke Program. Darrell Carter practices with Affiliated Community Medical Center in Granite Falls. Therese Zink is a professor of family medicine at the University of Minnesota Medical School and faculty with the RPAP program.
 
References
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19. The Medicare Learning Network. Medicare guide to rural health services information for providers, suppliers, and physicians. Available at: www.cms.hhs.gov/MLNProducts/Downloads/MedicareRuralHealthGuide.pdf. Accessed September 12, 2008.
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