When Telestroke Programs Work, Hospital Size Really Does Not Matter

Background  There are still marked disparities in stroke care between rural and urban communities including difference in stroke-related mortality. We analyzed the efficiency of tissue plasminogen activator (tPA) delivery in the spoke sites in our telestroke network to assess impact of telecare in bridging these disparities. Methods  We analyzed critical time targets in our telestroke network. These included door-to-needle (DTN) time, door-to-CT (D2CT) time, door-to-call center, door-to-neurocall, and total consult time. We compared these time targets between the larger and smaller spoke hospitals. Results  Across all the 52 spokes sites, a total of 825 stroke consults received intravenous tPA. When compared with larger hospitals (>200 beds), the smaller hospital groups with 0 to 25 and 51 to 100 beds had significantly lower D2CT time ( p -value 0.01 and 0.005, respectively) and the ones with 26 to 50 and 151 to 200 beds had significantly lower consult time ( p -value 0.009 and 0.001, respectively). There was no significant difference in the overall DTN time when all the smaller hospital groups were compared with larger hospitals. Conclusion  In our telestroke network, DTN times were not significantly affected by the hospital bed size. This shows that a protocol-driven telestroke network with frequent mock codes can ensure timely administration of tPA even in rural communities regardless of the hospital size and availability of local neurologists.

Abstract TP179: No Need to 'Card' Here; Cocaine/Opioid Use in Middle Age and Stroke

Background: Drug overdose from 1999 to 2017 in the US has continued to increase. Rural America has seen an increase in methamphetamine (Meth) users. Meth usage in Arkansas and its effects on stroke incidence and treatment are all largely unknown. Drug abuse can cause an immediate stroke or increase the risk of stroke either by damage to the cerebrovasculature, hypertension, or by affecting vital organs. Here we retrospectively examined strokes from 57 rural communities that self-reported positive for drug use from a large telestroke program for age, thrombolysis, alcohol and smoking use, gender, race, deficit level and symptom to door time.

Hypothesis: Incidence of drug use is greater among younger age groups and increases the incidence of stroke in younger age categories.

Methods: We analyzed consult prospective data from 2015 to 2018 of the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program for consults who self-reported as positive for drug use. We included all stroke assessed consults for age (ranged by decade), thrombolysis (alteplase use), alcohol and smoking use, consult gender, race, initial deficit level at presentation using the national institutes of health stroke scale (NIHSS) and symptom to door time (minutes).

Results: In 2015 to 2018 the number of consults positive for drug use per person were 2,349, 1,747, 1,910 and 1,137 per 100,000, respectively. Sixty-two percent of drug users were in their 40’s and 50’s (p<0.0001) with hypertension (p<0.0001). Drug users were most frequently smokers (73%) and consumed alcohol (39%) at p < 0.0001. Significantly fewer received alteplase (20%, p=0.039). There was no difference of gender in drug use (p=0.08). Almost half of the drug users were consulted for stroke but were not confirmed as stroke (46%, p=0.045). Symptom to door time average was lower in drug users, though not significant at 56.4±10 vs. 68.9±1.9 minutes, p=0.37. There was no effect of race in incidence of drug use, or deficits.

Conclusion: While the incidence of drug use does persist in the rural communities, demographics suggest it is more common in the middle age group than younger patients.

Validation of Newly Developed Surveys to Evaluate Patients' and Providers' Satisfaction with Telehealth Obstetric Services

Background: Patient and/or provider satisfaction and experience are among the most important indicators for quality assurance of health care services, including telehealth. Validated surveys should be used for this purpose to provide reliable information for a program evaluation. Objective: To validate the newly developed satisfaction surveys, report patient, and provider satisfaction with Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS) telehealth services. Methods: Two self-administered paper surveys were developed by a multidisciplinary team. The surveys were validated among obstetric patients who received telehealth services in 2016 and providers in Arkansas from July to August 2017. Psychometric testing was performed to establish reliability and validity of both the surveys. Descriptive statistics was performed to describe patient and provider satisfaction. Results: A total of 89 patient- and 66 provider surveys were analyzed. Construct validity and internal consistency reliability (Cronbach's α >0.7) were confirmed on both the surveys. The majority of patients were highly satisfied with telehealth services and reported positive perceptions toward future use of services. In the past 12 months, telehealth (78.6%) was the most used ANGELS service by providers. Finally, >90% of the providers reported high satisfaction and rated telehealth services as "excellent." Conclusions: The newly developed patient and provider telehealth surveys were reliable and valid. The surveys also demonstrated that the telehealth services were well-accepted and highly valued in a sample of obstetric patients and providers. As both surveys are short, they can be used in routine evaluation of patient and provider satisfaction with similar telehealth programs in the country.

Women on Hormone Therapy with Ischemic Stroke, Effects on Deficits and Recovery

Background:

Hormone replacement therapy (HT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program.

Hypothesis:

The age of women who acknowledged HT use will negatively impact stroke severity and outcomes.

Methods:

We analyzed consult data from two consecutive years for all women and included HT use, current age, and baseline and 24 h NIHSS’s. We included all women consults regardless of IV Alteplase treatment. 24 h NIHSS and three month modified Rankin scale (mRS) were included from women given IV Alteplase.

Results:

Strokes were identified in 523 women and 244 women received Alteplase therapy. Women without HT use numbered 459 and 64 women listed HT use. Mean NIHSS scores regardless of HT use significantly improved 24 h NIHSS vs. baseline NIHSS (p<0.0001). Baseline NIHSS scores were significantly improved in women on HT vs. non-HT users (p=0.01) in women age 50 to 79 years. Although mean NIHSS scores at 24h was not different from HT to no HT use (4.9 ± 1.6 vs. 7.8 ± 0.6, p=0.08) a trend was present for lower NIHSS scores for women 50–79 years. The mRS scores at three months indicated significant improvements among HT users vs. non-HT use (1.46 ± 0.4 vs. 2.51 ± 0.2, p=0.05).

Conclusion:

While cautions persist on the use, route and dosage of HT for risks of ischemic stroke, the HT moderation of AIS deficits and outcomes in women <80 years of age warrants further investigation.

Abstract TP270: When Telestroke Programs Work, Bed Size Really Doesn’t Matter

Background: Telestroke rural networks are comprised of micro>small>medium>large sized hospitals without specialized neurology support. Many times the micro hospitals are < 25 beds. In an examination of spoke hospitals in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program, we determined program efficacy correlating bed number. Efficacy was determined by the mean Door-to-ED physician (D2MD) time and door-to-needle (D2N) Alteplase time, and numbers of Alteplase administrations (#Alteplase), mock scenario sessions (#Mocks) and consults (#Consults).

Hypothesis: All hospitals would perform equally well with the larger hospitals with slight tendencies to outperform the smaller hospital sites in the #Consults and #Alteplase.

Methods: We retrospectively reviewed 2015-2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The #Mocks and #beds were comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase. Spoke sites were categorized by bed numbers; 0-25, 26-50, 51-100, 101-150, 151-200 and > 200.

Results: Data from 53 spokes encompassing 2,555 consults over three years indicated that sites > 151 beds were significantly higher in #Alteplase (p < 0.01) and #Consults (p < 0.002). Although the #Mocks were not different among the smaller vs. larger hospitals (p > 0.19), nor was the D2MD time (p=0.82). However, the hospitals < 50 beds had significantly shorter D2N mean time (p < 0.03). The micro (0-25 beds) vs the largest hospitals ( > 200 beds) D2N mean times, were significantly less (76.0±2.5 vs 87.5±4.0 min, p=0.01, respectively).

Conclusions: Although the smaller hospitals receive less volume of consults and #Alteplase, with training they perform equally if not better than their larger counterparts.

Abstract 169: Rural Hospitals in Telestroke: How Effective are On-Site Mock Drills and Community Education on Stroke Awareness?

Background: Mock drills of stroke triage care is an essential training component of most telestroke programs. Another potential component for telestroke programs is community stroke awareness education. While stroke-mocks improve the timeliness and care in rural spoke emergency departments (ED), community stroke awareness education may also improve treatment. Mocks and community education information was evaluated in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program. Correlations were made with mean Door to ED physician (D2MD) time and door-to-needle (D2N) Alteplase time and administration numbers (#Alteplase) and consult numbers (#Consults).

Hypothesis: Total number of mocks (#Mocks) and community education events (#Community-events) will independently increase #Consults and #Alteplase, and improve the D2MD and D2N time.

Methods: We retrospectively reviewed 2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The total number of #Mocks, #Community-Events was comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase.

Results: Data from 51 spoke sites and 1,002 consults, indicated #Mocks were positively correlated to the D2MD time (R=0.31; p=0.03) and the #Alteplase (R=0.28; p=0.04); however, increasing the #Mock sessions did not influence the D2N time or the #Consults (p=NS). Community-Events were significantly associated with #Consults (R=0.48; p=0.0004) and #Alteplase (R=0.47; p=0.0006); however not to D2MD time or D2N time (p=NS).

Conclusions: Mocks and Community stroke awareness education played crucial roles in the AR SAVES program improving #Consults and #Alteplase administrations. Both education components are warranted for telestroke programs.

Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt

Background

Studying critical time interval requirements can enhance thrombolytic treatment for stroke patients in telestroke networks. We retrospectively examined 12 concurrent months of targeted time interval information in the South Central US telemedicine programme, Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES).Hypothesis: We hypothesised that consult data analysis would highlight areas for improvement to shorten overall door to Intra venous (IV) tissue plasminogen activator (tPA) administration time.

Methods

We analysed critical time targets for 238 consecutive telestroke neurology consults obtained over 12 months from AR SAVES spoke sites when tPA was administered. The following time intervals were analysed: emergency department (ED) door to Computed Tomography (D-CT); ED door to call centre (D-CC) for initiation of consult; ED door to neurology call (D-NC); neurology call to camera (NC-Cam); tele consult time (Con); ED door to tissue plasminogen activator (tPA)/needle (DTN).

Results

The median times of D-CT (13 min, inter quartile range (IQR) 6–22 min), D-CC (34 min, IQR 20–45 min), D-NC (40 min, IQR 21–71 min), NC-Cam (4 min, IQR 2–8 min), and Con (25 min, IQR 17–37 min) all contributed to a DTN median time of 71 min (IQR 50–104 min). A total of 238 patients received tPA with a 29.4% treatment rate and a DTN time of ≤60 min was achieved in 25.2% of patients.

Conclusions

Focusing on reducing D-CC and Con times may help to achieve the DTN time of < 60 min for the majority of patients. Having ideal time targets for telestroke patients akin to traditional patients will help identify and improve the overall goal of a DTN time < 60 min.

Abstract TP233: An Analysis of Thrombolysis in a Large Telestroke Program in the Stroke Belt

Background: Thrombolytic treatment of stroke patients in telestroke can be enhanced by studying critical time interval requirements. We retrospectively examined 12 concurrent months of targeted time interval information from 2016 in a large 48 site telemedicine program. Telemedicine programs with new spoke sites added throughout the year must continually evaluate where improvements can be made to decrease the arrival to treatment time.

Hypothesis: We hypothesized that referral data analysis would highlight areas for improvement to shorten time to treatment.

Methods: We analyzed critical time targeted information during 12 months of 247 consecutive telestroke neurology referrals from AR SAVES spoke sites when tissue plasminogen activator (tPA) was given. Measured time intervals of: emergency department (ED) door to CT (ED2CT), ED door to call center (ED2CC) for initiation of consult and ED door to neurology call (ED2NeuroCall), neurology call to camera (NeuroCall2Cam), total consult (Con), ED door to tPA (ED2tPA) were studied.

Results: Reported median times of door to CT [ED2CT, 8 min, IQR 4-15 min], door to call center [ED2CC, 37 min, IQR 26-53 min], door to neurology call time [ED2NeuroCall, 42 min, IQR 33-57 min], neurology call response time [NeuroCall2Cam, 3 min, IQR 2-5 min], and total time spent in consult [Con, 24 min, IQR 19-32 min] all contributed to a ED2tPA median time of 73 min [IQR 60-90]. Twenty-six percent of referral patients received tPA ≤ 60 min and an overall tPA treatment rate of 33.2% was reported. The largest delay in time were: arrival to neurology call time and in consult time, 27 minutes and 13 minutes respectively. Totaling 40 minutes in variation.

Conclusion: Focus in either ED2NeuroCall or Con of these time areas, may produce the largest improvements and reduce the door to treatment time. A 20 minute reduction in time would dramatically reduce the door to treatment time and increase the percentage of tPA administration to well within the goal of 60 minutes or less.

Abstract WP149: Women on Hrt With Ischemic Stroke, a Positive Effect on Deficits and Recovery?

Background: Hormone replacement therapy (HRT) for post-menopausal women is associated with increased incidence of ischemic stroke risk. Effects of HRT on stroke related deficits and functional outcomes in acute ischemic stroke (AIS) are uncertain. We retrospectively examined female consult data for HRT use and National Institutes of Health Stroke Score (NIHSS) at baseline and recovery for 2015 and 2016 in a large stroke telemedicine program.

Hypothesis: The age of women on HRT will affect stroke severity and outcomes.

Methods: We analyzed consult data from two consecutive years for women HRT use, age, and baseline and 24 hour NIHSS’s. We included all treated with IV Activase.

Results: In two years 235 women received Activase therapy. Women without HRT use numbered 208 and 27 women listed HRT use. All 235 consults regardless of HRT use had significantly improved 24 h NIHSS vs. baseline (7.5 +/- 0.5 vs. 11.2 +/- 0.5, p<0.0001). Women on HRT had significantly improved 24 h NIHSS vs. baseline, (4.9 +/- 1.6 vs. 8.4 +/- 1.2, p=0.0084). Composite NIHSS’s at 24 h for ‘No HRT’ was not different from ‘Yes HRT’ (7.8 +/- 0.6 vs. 4.9 +/- 1.6, p=0.084) when groups included all women regardless of age. The baseline NIHSS’s when divided into specific age ranges showed decreased values when on HRT from 50s through 70s ( figure A ) p=0.028. Women placed in decade age ranges showed that 24 h NIHSS’s (40-80 years) with HRT use were lower vs. women >80 years ( figure B ). p=0.084.

Conclusion: While controversy persists on the use, route and dosage of HRT for risks of ischemic stroke, positive HRT benefits could include moderation of AIS deficits and improved outcomes in women <80 years of age. Further study is needed.

Abstract TMP60: Validation of an Education Gauge for Measuring Stroke Outreach Efforts

Background: To improve rural population access to telestroke sites for referral and treatment, hospitals are required to fulfill monthly educational outreach. Telehealth sites that provide stroke outreach through awareness educational campaigns remain unaware of the efficacy of their outreach efforts. This study sought to apply a measurable scale to their outreach efforts and determine if the values correlated to the sites referral and treatment rates.

Hypothesis: Measurable differences of outreach efforts in rural populations positively correlate to referral and treatment rates at telestroke hospital sites.

Methods: A large telestroke network (n=48 spoke sites) had 12 consecutive months during 2016 of community outreach efforts evaluated on an educational gauge scale. Events were categorized as active or passive depending on the type of event. All events were assigned a value based on the type of event, audience size and the crowd’s level of attention/participation. Total monthly values for all spoke sites were calculated and compared by month and category. Regression analysis was used to determine significance of correlative analysis of education vs. number of referrals and vs. number of tissue plasminogen activase (tPA) treatments.

Results: Outreach efforts promoting stroke awareness from all 48 sites totaled 2,625 educational points. There was a temporal trend of active events occurring in the spring (April through June) and in the fall (October). In regression analysis there was a positive correlation in the number of referrals vs. educational gauge (R=0.23; P=0.0013) and in the number of tPA treatments (R=0.20; P=0.0055). One spoke site was evaluated for their community events due to their high referral rate in the first quarter of the year. Outreach efforts during these months included stroke awareness events at local high schools, a sporting race event and to apartment residents.

Conclusion: Targeted outreach efforts can now be measured for efficacy of reaching diverse populations with direct effects on referral and treatment rates.

Abstract 226: Strokes Worse in Women at 24 hours but Severity Reduced in Younger Women With Hormone Therapy

Background: Gender related differences in stroke incidence hallmark the increased observation of women experiencing strokes later in life. Complications of women longevity has accounted for their increased risk of cardiovascular and cerebrovascular diseases. However, the severity of acute ischemic stroke (AIS) outcomes in women remains problematic. Previous studies have reported that women experience more disabilities and have poorer outcomes at three month follow-ups and may be related back to age at the time of stroke. We retrospectively examined 12 months of neurology consults in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telemedicine program.

Objective: To investigate whether gender influenced recovery at 24 hours following therapy for AIS.

Methods: During 12 consecutive months 809 patients received neurology acute stroke consults and 238 (29%) received tissue plasminogen activator (tPA). Outcome data at 24 hours was available on 216 tPA-consults. Patient demographics, age, and gender, were analyzed along with baseline and 24 hour outcome National Institutes of Health Stroke Scale (NIHSS), onset to tPA, smoking, alcoholism, and hormone replacement therapy (HRT). Co-morbidity information collected included previous transient ischemic attacks (TIA), atrial fib (AF), diabetes, chronic obstructive pulmonary disease (COPD), hypertension (HT), hyperglycemia and coronary artery disease (CAD).

Results: A total of 108 men and 108 women tPA treated patients showed no significant differences in age for male vs. female (mean±se 67.5±1.3 vs. 70±1.5, p=0.79). However, the men had twice the number of women in the 70-79 age range and women had twice the number of men at >80 years of age ( χ 2 p=0.0096 for all age ranges for both sexes). While baseline NIHSS was not significant in men vs. women (10.8±0.6 and 11.8±0.7, p=0.32, respectively), the women’s 24 hour NIHSS was significantly greater (5.9±0.7 vs. 9.1±0.9, p=0.0047, respectively). The incidence of HRT use in n=11 women < 80 years of age was associated with lower NIHSS’s at 24 hours vs. women without HRT (2.3±0.8 vs. 8.7±1.4, p=0.03, respectively). Males had a higher incidence of smoking ( χ 2 p=0.007). All other co-morbidities occurred equally between sexes.

Conclusion: Women in this study had more severe 24 hour AIS outcomes than men but this improved with HRT use in women younger than 80 years. This cannot be fully explained by age differences as there could be other underlying factors. Improving 24 hour NIHSS may correctly predict later outcomes following AIS. Further study of HRT use in AIS outcomes is justified.

Immune changes in alcohol-dependent patients without medical disorders

INTRODUCTION

We examined a battery of in vitro immune measures in inner city alcohol-dependent (as determined by the Structured Clinical Interview for DSM-III-R (SCID) persons who were without liver or other medical disorders and free of other substance abuse. These subjects were seeking treatment at an ambulatory alcohol treatment center.

METHODS

Alcohol-dependent subjects (n = 44) were compared with healthy, nonabusing community subjects (n = 34). Subjects, both male and female, had a mean age of 41 years and were primarily African American. Many were homeless. An extended battery of enumerative and functional immune measures was obtained, as well as information about alcohol consumption.

RESULTS

CONTROLLING for age and gender, ANCOVA revealed no differences (p > 0.1) between alcohol-dependent and control subjects in leukocyte and lymphocyte subsets or in circulating CD56+ (natural killer) cells. There were also no significant differences in responses to the mitogens phytohemagglutinin, concanavalin A, or pokeweed mitogen ( > 0.1) or in natural killer cell activity (p > 0.1). There was, however, altered granulocyte function in the alcohol-dependent sample, with decreased phagocytic activity in the alcohol-dependent males (p < 0.04) and gender and age dependent differences in the number of circulating granulocytes (p < 0.01). Granulocyte killing of Staphylococcus aureus, however, did not differ between the groups.

CONCLUSIONS

The findings suggest that although males with chronic alcohol dependence have compromised phagocytic function, chronic alcohol-dependent subjects who are free of medical disorders do not have substantial abnormalities in many immune system functions.

Survival of parasite eggs upon storage in sludge

Destruction rates of parasite eggs in stored sludge were examined to help understand the fate of these agents of enteric diseases in sludge lagoons. Eggs from the roundworms, Ascaris spp., Toxocara spp., Trichuris spp., and the tapeworm, Hymenolepis spp., were treated with domestic sludges by aerobic or anaerobic processes. Sludge samples seeded with eggs were stored at 4 or 25 degrees C or in a container inserted into the ground to simulate lagoon conditions. The number of eggs recovered from the samples decreased with storage time. The viability and infectivity of eggs recovered were related to the storage temperature; i.e., the eggs stored at 4 degrees C remained viable longer than those stored at 25 degrees C. After 25 months at 4 degrees C, the Toxocara eggs and some Ascaris eggs remained both viable and infective, whereas most of these eggs stored at 25 degrees C were rendered nonviable after 10 to 16 months of storage in sludge. Although storage temperature was found to be the most important factor affecting the destruction and viability of these eggs, other factors, such as the type of sludge digestion, whether or not the eggs were digested along with the sludge or added later, storage in the soil versus sludge, pH, and egg species also exhibited some minor effects. These controlled laboratory studies suggest that lagooning of sludge can be an effective method for the elimination of parasite eggs, particularly in warmer geographical locations.

Changes in urine polyamines in childhood leukemias

Urine polyamine:creatinine ratios (nm per mg) measured in eight children with active hematologic cancers were compared with those of age-matched controls and children with hematologic cancer in remission. Polyamine:creatinine ratios in the children with active disease were significantly higher than those of the controls (p less than 0.0025) and of the children in remission (p less than 0.0025). Putrescine:creatinine ratios were, in general, higher in children with hematologic tumors than in those with solid tumors. Urinary polyamines are thought to reflect variations in bone marrow polyamine content and have been postulated to be an indicator of clinical status.