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Decreasing door-to-needle time with telehealth

Lessons learned from implementation of a telestroke program

By Lori Hendrickx, RN, EdD, CCRN, CNL; and Chelsey Kuznia, RN, BSN, SCRN

Patients living in rural areas who experience stroke-like symptoms may experience a delay in diagnosis and subsequent intervention due to the distance to specialized neurologic care. Rural areas often do not have neurologic teams readily available in smaller hospitals, and transport to larger facilities may be problematic due to distance, weather issues or a shortage of emergency medical transport teams. One solution has been the use of telemedicine through the implementation of telestroke programs.

Telestroke consultation pairs the patient with a teleneurologist at a remote location using a telemedicine network for consultation and discussion regarding treatment options, while the patient remains at the rural healthcare facility. This allows rapid assessment using the National Institutes of Health Stroke Scale (NIHSS) and timely determination of treatment needs, including time-sensitive options such as the administration of thrombolytic drugs or endovascular intervention.

In the upper Midwest, the Essentia Health Comprehensive Stroke Center, in Fargo, North Dakota, and five acute stroke-ready rural hospitals implemented a telestroke program to serve patients.

Over the 5-year period since the inception of the telestroke program, the percentage of patients receiving thrombolytic drugs in less than 60 minutes increased and door-to-needle time decreased.

Our team learned several lessons that can be considered when a telestroke program is developed.

1. Education

Education must be provided for all personnel involved in the program and should include use of the technology, setup and connection procedures, use of the NIHSS and procedures for troubleshooting issues.

Our team developed a tiered stroke algorithm and a telestroke workflow chart to help healthcare professionals at the remote sites complete the processes and determine eligibility for a telestroke consultation. These charts were connected to the telestroke equipment for easy access. Contact phone numbers were also provided with the equipment should problems arise.

At least annual education or demonstration of the telestroke process and technology is ideal to ensure staff’s confidence with its use. This is especially applicable to rural sites that may only use this technology a few times a year. Repeated review of the process through orientation programs and subsequent educational review sessions is important for newly hired personnel and those who are new to the equipment.

2. Technology

When initiating a telestroke program, working with a team that specializes in project management for initiating telehealth may be beneficial to ensure a comprehensive review of all parts of the telestroke process that will need to be implemented. Access to information technology (IT) experts is imperative for both the rural facility and the stroke center.

In our program, connectivity problems arose, particularly after a software update, and having an IT representative who is trained in the telestroke equipment and its usage allows for prompt resolution of issues when quick decisions need to be made regarding a potential stroke diagnosis and treatment.

Updates in the equipment also need to be communicated to all outlying stroke-ready centers so that procedures continue to be performed in a timely and skilled manner.

3. Staff participation

Personnel at either site may be reluctant to use new technology that they are not familiar with or don’t use on a regular basis.

Designation of a super-user at each rural site and someone coordinating the process at the comprehensive stroke center is an excellent way to provide a resource for those nurses or providers who may not use the telestroke option regularly. This also allows for in-time resolution of any difficulties that may arise when a telestroke consult is deemed appropriate, rather than relying on connecting to someone remotely who might not be able to assess the situation and offer timely assistance.

Prompt follow-up by the telestroke team on issues with the use of the telestroke (whether it be the technology itself or the process) is essential to encourage the staff’s use of the technology.

Implications for prehospital providers

The shortage of EMTs and paramedics in rural areas poses a threat to rapid stroke diagnosis and timely transport to treatment, which increases the risk of death or disability.

Ensuring that prehospital providers are aware of telestroke options in rural locations allows patients to gain access to evaluation and treatment sooner than if the patients had to be transported to a larger facility at a greater distance. Shorter transport time allows for greater potential that a patient with stroke-like symptoms will obtain a timelier CT scan, have more rapid access to thrombolytic drugs or receive endovascular intervention within the recommended time frames (door-to-needle time).

Improvement in care

For the year prior to implementation of the telestroke program, 73% of eligible patients received thrombolytic therapy in less than 60 minutes, with a mean door-to-needle time of 61 minutes. In the year following implementation, the results improved to 92% of eligible patients receiving thrombolytic therapy in less than 60 minutes, with the mean door-to-needle time decreasing to 38 minutes.

The ability to receive expert consultation with a specialized neurologic team through care at a rural facility has shown to be a successful way to achieve timely diagnosis of stroke, followed by treatment recommendations and intervention.


About the authors
Lori Hendrickx is a professor in the College of Nursing at South Dakota State University, and a staff nurse in the emergency department of Essentia Health St. Mary’s in Detroit Lakes, Minnesota.

Chelsey Kuznia is the stroke program manager at Essentia Health, Fargo, North Dakota.

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