Safe and Effective Implementation of Telestroke in a US Community Hospital Setting

Perm J. Fall 2016;20(4):15-217. doi: 10.7812/TPP/15-217. Epub 2016 Jul 25.


Context: 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.

Objective: 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.

Design: 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.

Main outcome measures: Receipt of tPA. Secondary outcome was the rate of significant hemorrhagic complications.

Results: 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.

Conclusion: 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.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Aged, 80 and over
  • Delivery of Health Care / methods*
  • Female
  • Hemorrhage / etiology
  • Hospitals, Community*
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Stroke / complications
  • Stroke / drug therapy*
  • Telemedicine / statistics & numerical data*
  • Tissue Plasminogen Activator / therapeutic use*
  • United States


  • PLAT protein, human
  • Tissue Plasminogen Activator