Veterans Administration National Telestroke Program: A Distributed Hub System of Acute Stroke Care

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Purpose: Access to acute stroke expertise is a challenge for rural communities. The Department of Veterans Affairs (VA) emphasizes access to care throughout its network of 170 medical centers, many of which serve rural communities.

Methods: To increase access to acute stroke expertise for rural veterans, we designed and implemented a nationwide system of emergency stroke care within the VA. Unique aspects of the program include (1) its “distributed hub”—a network of stroke neurologists that remain in their current job and location while dedicating a portion of their time to VA NTSP; (2) the nationwide distribution of “spoke” sites; (3) use of “off the shelf” mobile technologies; (4) interprofessional training curriculum utilizing whole-hospital simulations to inform iterative rapid-cycle process improvement; (5) consultant curriculum emphasizing the “tele” aspects of telestroke care; (6) monthly SCAN-ECHO educational conferences; and (7) a dedicated research team that evaluates process measures and outcomes through chart review of all ischemic strokes and all telestroke consults at participating facilities, as well as surveys/interviews with veterans, site staff, and NTSP neurologists.

Results: VA NTSP is currently live at 12 sites. Our team has performed over 250 telestroke consults, 58% for rural veterans. We have trained 20 consultants and 18 sites. Although most of our initial 8 sites had never treated acute stroke, veterans with acute ischemic stroke who received telestroke consults during the first 2 quarters had mean a “door to CT” time of 16 minutes, 63.5% received CT within 25 minutes; and 92.3% of eligible patients were treated with alteplase. Median door to needle (DTN) time was 62 minutes, and 41.7% had DTN times < 60 minutes. Satisfaction is high for veterans (6.5/7) as well as site staff (8.8/10). Additional data from 3rd and 4th quarters will be provided.

Conclusions: Our “distributed hub” model of nationwide stroke care has been effective in bringing acute stroke expertise to rural as well as urban VAs. Partnering with sites to develop and test local processes that address unique barriers while maintaining high standards of acute stroke care is a key factor in this success.