Care of rural stroke patients improves with telephone support

The care of rural stroke patients was improved when an urban stroke center offered telephone assistance in treatment, according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology.

The stroke center doctors helped decide when and how to treat patients with the clot-busting drug tissue plasminogen activator, called tPA. The drug can reduce disability and save lives, but its use is complicated. The treatment carries risks, is only appropriate for certain patients, and must be given within three hours of the start of stroke symptoms. In some rural areas, there is a lack of staff experienced in the treatment. As a result, the treatment is often not given when it could be beneficial.

In the past, many stroke centers have required that patients be transported to the urban hospital to receive tPA, in part due to liability and safety concerns. For this study, patients were treated at small rural hospitals with telephone support from the stroke center, and then transported to the stroke center for care.

The study compared those who were treated in the rural hospitals and transported to those who were treated at the stroke center. “Overall, the results were equivalent for those treated by telephone and those treated on-site,” said neurologist James L. Frey, MD, study author and director of the Stroke Program at Barrow Neurological Institute in Phoenix, Ariz. “The most important result was that 53 people received tPA who otherwise would not have received it.”

The time from the start of symptoms to when the drug was administered was almost the same for the two groups. Those in the rural areas got to the emergency room sooner, but then the time before they received treatment was longer, so the differences evened out.

Those in the rural areas were as a group older and had more severe strokes. Because of this, their outcomes were not as positive as the other group. However, both groups had improvement in their amount of disability from when they were admitted to when they were discharged.

Patients were taken to the urban stroke center by emergency air transportation, from as far as 277 miles away. They received tPA intravenously during the flights, with an average flight time of 30 minutes. There were no in-flight complications or subsequent problems that could be attributed to the air transportation, Frey said.

Frey said major factors in the success of this study include the willingness of the emergency department doctors and staff at 43 community hospitals to quickly evaluate and treat eligible patients and the availability of emergency air transport and willingness of paramedics to provide the care needed.