Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

BACKGROUND: The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. OBJECTIVE: To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. METHODS: We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. RESULTS: Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. CONCLUSIONS: Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

The Association between Presentation by EMS and EMS Prenotification with Receipt of Intravenous Tissue-Type Plasminogen Activator in a State Implementing Stroke Systems of Care.

Introduction: Collaboration between emergency medical services (EMS) and hospitals receiving stroke patients is critical to ensure prompt, effective treatment, and is a key component of the stroke systems of care (SSoC). The goal of our study was to evaluate the association between presentation by EMS and EMS prenotification with odds of receiving Tissue-type Plasminogen Activator (IV-tPA) in a state implementing SSoC while rigorously accounting for missing data. Methods: We utilized data from the Massachusetts Paul Coverdell Stroke Registry for this study, and analyzed adult patients presenting with ischemic stroke to Massachusetts Coverdell hospitals between 2016 and 2018. Patients with contraindications to IV-tPA were excluded. We used generalized estimating equations to assess associations between presentation by EMS, EMS prenotification, and receipt of IV-tPA. We also performed a sensitivity analysis using multiple imputation to assess the sensitivity of our findings to missing data. Results: We identified 9,230 eligible patients with ischemic stroke during the study period. In multivariate complete case regressions, presentation by EMS and EMS prenotification were associated with statistically significant increased odds of receiving IV-tPA (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.28-1.80, p-value < 0.01; OR 1.75, 95% CI 1.36-2.24, p-value < 0.01, respectively). Analysis of imputed data indicated level or stronger associations. Conlcusion: Our analysis indicates that presentation by EMS and EMS prenotification are associated with increased odds of receiving IV-tPA in a state implementing the SSoC. Our results lend importance to the critical role of EMS in the SSoC. Future interventions should work to increase rates of prenotification by EMS and assess inequities in receipt of IV-tPA.

Resource utilisation among patients transferred for intracerebral haemorrhage.

Background: Patients with intracerebral haemorrhage (ICH) are frequently transferred between hospitals for higher level of care. We aimed to identify factors associated with resource utilisation among patients with ICH admitted to a single academic hospital. Methods: We used a prospectively collected registry of consecutive patients with primary ICH at an urban academic hospital between 1 January 2005 and 31 December 2015. The primary outcome was use of either intensive care unit (ICU) admission or surgical intervention. Logistic regression examined factors associated with the outcome, controlling for age, sex, Glasgow coma score (GCS) and ICH score. Results: Of the 2008 patients included, 887 (44.2%) received ICU stay or surgical intervention. These patients were younger (71 vs 74 years, p<0.001), less often white (83.9% vs 89.3%, p<0.001), had lower baseline GCS (12 vs 14, p<0.001) and more frequently had intraventricular haemorrhage (58.6% vs 43.4%, p<0.001). Factors independently associated with ICU stay or surgical intervention were age >65 years (OR 0.38, 95% CI 0.21 to 0.69), GCS <15 (1.23, 95% CI 1.01 to 1.52) and ICH score >0 (OR 2.23, 95% CI 1.70 to 2.91). Conclusion: Among this cohort of primary patients with ICH, GCS of 15 and ICH score of 0 were associated with less frequent use of ICU or intervention. These results should be validated in a larger sample but may be valuable for hospitals considering which patients with ICH could safely remain at the referring facility.

Delays in the Air or Ground Transfer of Patients for Endovascular Thrombectomy.

BACKGROUND AND PURPOSE: For suspected large vessel occlusion patients efficient transfer to centers that provide endovascular therapy (ET) is critical to maximizing treatment opportunity. Our objective was to examine associations between transfer time, modes of transfer, ET, and outcomes within a hub-and-spoke telestroke network. METHODS: Patients with ischemic stroke were included if transferred to a single hub hospital between January 2011 and October 2015 with National Institutes of Health Stroke Scale>6, onset<12 hours from hub arrival with complete clinical, imaging, and transfer data. Transfer time was the interval between initiation of telestroke consult and arrival at the hub. Algorithms were created for ideal transfer times; ideal time was subtracted from actual time to calculate delay. We examined bivariate relationships between transfer time and several clinical outcomes and used multivariable regression modeling to explore possible predictors of delay. RESULTS: Of 234 patients that met inclusion criteria, 51% were transferred by ambulance and 49% by helicopter; 27% underwent ET (36% achieved modified Rankin Scale score of 0-2 at 90 days). Median actual transfer time was 132 minutes (interquartile range, 103-165), compared with median ideal transfer time at 102 minutes (interquartile range, 96-123). Longer transfer time was associated with decreased likelihood of undergoing ET (odds ratio, 0.990; P=0.003). Nocturnal transfer (18:00 to 06:00 hours) was associated with significantly longer delay (ß=20.5; P<0.0005), whereas intravenous tissue-type plasminogen activator (tPA) delivery at spoke hospital was not. The median delay for nocturnal transfer was 31 minutes (interquartile range, 11-51), compared with daytime at 14 minutes (interquartile range, -9 to 36). CONCLUSIONS: Within a large telestroke network, there was an association between longer transfer time and decreased likelihood of undergoing ET. Nocturnal transfers were associated with a substantial delay relative to daytime transfers. In contrast, delivery of tPA was not associated with delays, underscoring the impact of effective protocols at spoke hospitals. More efficient transfer may enable higher ET treatment rates. Metrics and protocols for transfer, especially at night, may improve transfer times.

Frequent Hub-Spoke Contact Is Associated with Improved Spoke Hospital Performance: Results from the Massachusetts General Hospital Telestroke Network.

BACKGROUND: For acute ischemic stroke patients, shorter time to thrombolytic (tissue plasminogen activator [tPA]) is associated with improved outcomes. INTRODUCTION: Telestroke increases tPA use at spoke hospitals, yet its effect on door-to-needle (DTN) times for tPA administration is unknown. We hypothesize that spoke hospitals with more frequent contact to a hub hospital will have shorter DTN times than those with less frequent contact. MATERIALS AND METHODS: We identified 375 patients treated with tPA by conventional or telestroke methods in an academic hub-and-spoke telestroke network for whom date and time data were available. Strength of the spoke-hub connection was the primary predictor variable, defined as the number of all telestroke consults (tPA and non-tPA) done at each spoke hospital during the year of the patient's presentation. Patient-level regression analyses examined the relationship between DTN time and spoke-hub connection during the year of the patient's presentation, controlling for temporal trends and clustering within hospitals. RESULTS: Sixteen spoke hospitals contributed data on 375 tPA-treated patients from 2006-2015. Hospitals treated a median of 13.5 patients with tPA per year; median hospital-level DTN was 78.8 min (interquartile range [IQR] 71.3-85). Median number of telestroke consults per year was 34 (range 3-137). Among all 375 patients, median DTN was 76 min (IQR 60-97). Strength of spoke-hub connection was significantly associated with faster DTN time for patients (1.3 min gain per 10 additional consults, p = 0.048). CONCLUSIONS: More frequent contact between a telestroke spoke and its hub was associated with faster tPA delivery for patients, even after accounting for secular trends in DTN improvements.