Quality and safety of Telemedicine in acute ischemic stroke: Early experience in Taiwan.

BACKGROUND: Telemedicine helps to provide the safe management of stroke patients in the emergency department (ED) and has been used worldwide. However, we had limited experience of telestroke in Taiwan. We aimed to identify the quality of telestroke and compare it with the original face-to-face consultation model. METHODS: Among 178 consecutive acute ischemic stroke patients treated with intravenous tissue plasminogen activator (IVtPA) from January 1, 2018, to December 31, 2019, we compared two different consultation methods: face-to-face consultation and telestroke consultation. We collected data on demographics, the National Institutes of Health Stroke Scale (NIHSS) scores, Modified Rankin Scale (mRS) scores, time measurements (onset-to-arrival time, onset-to-telestroke activation time, and time of IVtPA administration (Door-to-Needle; DTN)). RESULTS: The mean age to receive a telestroke consultation was 66.6 years, 36% were female, and the median NIHSS score was 9. The median time from patient arrival to telestroke consult activation was 40 min, and the median DTN time was 11 min longer than for face-to-face consults (62 min versus 51 min, p = .01). Telestroke consultation, similar to a face-to-face consultation, resulted in safe IVtPA eligibility assessments and administration with post-thrombolysis ICH in 4% overall (4% telestroke, 3% face-to-face consultation; p = .851). The 90-day outcomes were not different for mRS score, dichotomized 0-2 (60% telestroke 59% face-to-face consultation; p = .961), or for mortality (16% telestroke, 9% face-to-face consultation; p = .292). CONCLUSION: In the ED, consultation via the telestroke program provides equal quality to the original face-to-face consultation model to manage ischemic stroke.

Time cost of a nonclosing intravenous thrombolysis service for acute ischemic stroke.

BACKGROUND/PURPOSE: Intravenous thrombolysis for ischemic stroke saves societal costs. The aim of this study was to investigate the cost burden that hospitals may shoulder. METHODS: Stroke code activations between May 2009 and April 2011 were recorded and divided into groups based on work and duty time, as well as the period of the day or season. "Time cost of nonclosing service" (TCNS) per stroke code activation or intravenous thrombolysis treatment was calculated by dividing the time by the number of activations or thrombolysis treatments during that period. Comparisons were made among groups. RESULTS: There were a total of 634 stroke code activations in a period of 2 years, and intravenous thrombolysis was used in 132 (20.8%) of these cases. The rates of thrombolysis were not statistically different between the groups. Overall, the average TCNS for the stroke team was 27.6 hours per code activation and 132.7 hours per thrombolysis treatment. The TCNS during duty time was 1.38 times that during work time per stroke code activation and 1.46 times per thrombolysis treatment. In summer, the TCNS was 1.6 times that in winter per code activation and 2.2 times per thrombolysis treatment. During the late night hours, the TCNS was four times that of early night hours per code activation and 9.8 times per thrombolysis treatment. CONCLUSION: Our results demonstrate a large variation in the time cost of a nonclosing service for intravenous thrombolysis. Payment based on piece-rate compensation may not be appropriate and requires improvement.

In-hospital case management to increase anticoagulation therapy for stroke patients with atrial fibrillation: a hospital-based registry.

BACKGROUND/PURPOSE: Anticoagulation is underused for stroke patients with atrial fibrillation in Taiwan. An effective preventive measure is in great need of improvement. METHODS: In-hospital case management was implemented to monitor the diagnosis of atrial fibrillation and the use of warfarin. Timely feedback to treating physicians was made. Change in performance after the implementation was analyzed. RESULTS: A total of 2754 patients hospitalized for acute ischemic stroke or transient ischemic attack were included, 1216 before and 1538 after the intervention. The percentage of patients without electrocardiography examination decreased from 8.7% to 2.9% (p < 0.001). The diagnosis of atrial fibrillation increased from 11.5% (n = 140) to 15.9% (n = 244) (p = 0.001). The use of warfarin at discharge increased from 36.9% to 54.7% (p = 0.001). In-hospital case management was significantly related to the use of warfarin (odds ratio = 2.47, p < 0.001). The percentage of warfarin use was still significantly higher in the intervention group at 3 months of follow-up (45.9% vs. 27.8%, p = 0.002) and at 6 months of follow up (49.2% vs. 28.6%, p = 0.004). More patients' international normalized ratio was within the recommended range in the intervention group at 6 months' follow-up (30.5% vs. 9.1%, p = 0.039). CONCLUSION: Our study indicates that in-hospital case management may be an effective strategy to improve anticoagulation for eligible stroke patients.