title: Safe and Effective Implementation of Telestroke in a US Community Hospital Setting.
abstract: There is substantial hospital-level variation in use of tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Telestroke services can bring neurologic expertise to hospitals with fewer resources.
  
  
  
  To determine whether implementation of a telestroke intervention in a large integrated health system would lead to increased tPA utilization and would change rates of hemorrhagic complications.
  
  
  
  A stepped-wedge cluster randomized trial of 11 community hospitals connected to 2 tertiary care centers via telestroke, implemented at each hospital incrementally during a 1-year period. We examined pre- and postimplementation data from July 2013 through January 2015. A 2-level mixed-effects logistic regression model accounted for the staggered rollout.
  
  
  
  Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications.
  
  
  
  Of the 2657 patients, demographic and clinical characteristics were similar in pre- and postintervention cohorts. Utilization of tPA increased from 6.3% before the intervention to 10.9% after the intervention, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients (odds ratio = 2.0; 95% confidence interval = 1.2-3.4). Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of the 10 were at least as likely to administer tPA as the highest-volume center.
  
  
  
  Telestroke implementation in a regional integrated health system was safe and effective. Community hospitals' rates of tPA utilization quickly increased and were similar to the largest-volume tertiary care center.
authors.affiliation: Assistant Professor in the Department of Emergency Medicine at Massachusetts General Hospital and Harvard Medical School in Boston. ksauser@mgh.harvard.edu.
authors.forename: Kori
authors.initials: K
authors.lastname: Sauser-Zachrison
authors.affiliation: Biostatistician in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. ernest.shen@kp.org.
authors.forename: Ernest
authors.initials: E
authors.lastname: Shen
authors.affiliation: Neurologist at the Los Angeles Medical Center in CA. navdeep.x.sangha@kp.org.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Sangha
authors.affiliation: Neurologist at the Los Angeles Medical Center in CA. zahra.a.ajani@kp.org.
authors.forename: Zahra
authors.initials: Z
authors.lastname: Ajani
authors.affiliation: Neurologist at the San Diego Medical Center in CA. william.p.neil@kp.org.
authors.forename: William P
authors.initials: WP
authors.lastname: Neil
authors.affiliation: Research Scientist in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. michael.k.gould@kp.org.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.affiliation: Emergency Physician at the San Rafael Medical Center in CA. dustin.ballard@kp.org.
authors.forename: Dustin
authors.initials: D
authors.lastname: Ballard
authors.affiliation: Physician in the Department of Research and Evaluation for Kaiser Permanente in Pasadena, CA. adam.l.sharp@kp.org.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Sharp
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006764:Hospitals, Community; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000150:complications / Q000188:drug therapy*; D017216:Telemedicine / Q000706:statistics & numerical data*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014481:United States
chemical_list: C067262:PLAT protein, human; D010959:Tissue Plasminogen Activator