title: Post t-PA transfer to hub improves outcome of moderate to severe ischemic stroke patients.
abstract: OBJECTIVE
  Telemedicine offers rural hospitals the ability to treat acute ischemic stroke on site with intravenous tissue plasminogen activator (t-PA). Most patients are subsequently transferred to a hub hospital with a primary stroke center for post t-PA care. There is little evidence that such transfer is beneficial. The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial.
  
  
  METHODS
  We retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012. We compared the outcome of patients who were transferred to a "hub" with those who remained at the "spoke" hospital where thrombolysis took place. We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher's exact test, two-tailed, and significance was considered at p < 0.05.
  
  
  RESULTS
  Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy. The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS). However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026).
  
  
  CONCLUSIONS
  Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR shadiyaghi@yahoo.com.
authors.forename: Shadi
authors.initials: S
authors.lastname: Yaghi
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Sami I
authors.initials: SI
authors.lastname: Harik
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Archana
authors.initials: A
authors.lastname: Hinduja
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bianchi
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Debra M
authors.initials: DM
authors.lastname: Johnson
authors.affiliation: Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Salah G
authors.initials: SG
authors.lastname: Keyrouz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D017052:Hospital Mortality; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D019035:Rural Health Services / Q000458:organization & administration / Q000706:statistics & numerical data; D020521:Stroke / Q000188:drug therapy*; D017216:Telemedicine / Q000706:statistics & numerical data*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Cost-effectiveness; outcome; stroke; teleneurology; transfer