Improving Stroke Care in Rural Settings

Mark J. Alberts, MD


December 20, 2013

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Hello, and welcome to this Medscape stroke update. I am Dr. Mark Alberts, Vice Chair of Neurology at UT Southwestern in Dallas.

Today I want to talk about a recent report, "Formation and Function of Acute Stroke-Ready Hospitals Within a Stroke System of Care," by me and my colleagues at the Brain Attack Coalition.[1] This was published online in the journal Stroke and should be available in the print version of Stroke in the very near future.

Acute stroke-ready hospitals, which we call ASRHs, are meant to be relatively small hospitals that are in settings away from large urban or metropolitan areas. The concept is that within a rural environment, hundreds of miles, there may be scattered hospitals that do a better job with stroke patients than others. The Brain Attack Coalition posits that if certain hospitals are designated as ASRHs, patients and emergency services in these remote areas would know where to go when someone is having an acute stroke.

What would these ASRHs need to have on site and readily available? As detailed in this publication, they would have to have an acute stroke team that could be at the bedside within 15 minutes; rapid imaging and laboratory tests; the ability to give IV tPA (tissue plasminogen activator) with a door-to-needle time of 60 minutes, which can be a challenge for many of us in many settings; and then typically a telemedicine or telestroke link to neurologists in a larger facility, unless there was neurology expertise available and on the ground at or near that hospital.

The overall concept is that patients will go to the ASRH to be stabilized and receive any acute therapy that might be needed and appropriate, such as IV tPA for ischemic stroke or a reversal agent for a hemorrhagic stroke. Folks at this ASRH could tap into the expertise of a larger primary or comprehensive stroke center (PSC/CSC) via a telemedicine link; figure out what is going on; and then in most cases, if the patient really did have a stroke, send the patient to a larger facility, typically a PSC or CSC, that could be hours away, either by ambulance or helicopter.

In the Stroke article, we discuss various treatment paradigms and time epochs for getting testing done. In addition, we propose some metrics of care, such as how long it takes to set up a telemedicine or telestroke link, how long it takes to transfer the patient, how closely various protocols are followed, and the like.


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