Emergency Physician Versus Telemedicine Neurologist Assessment for Thrombolytic Indication in the Treatment of Acute Ischemic Stroke ( AIS )

BACKGROUND AND OBJECTIVES: Through the advent of telemedicine, ED patients in many smaller and rural hospitals have gained access to input from neurologists for the decision to provide thrombolytics (tPA) for AISCVA. We evaluated the interrater agreement between teleneurologists and emergency physicians (EP) for the indication to give thrombolytic tPA to ED patients with symptoms suggestive of AISCVA. METHODS: This was a prospective, observational study conducted at an urban, community teaching hospital. A convenience sample of adult ED patient encounters for possible AISCVA symptoms < 4.5 h duration was included for analysis. Immediately following bedside evaluations, EPs filled out a structured form regarding their history, exam, and assessment of indications for thrombolytic tPA therapy. Subsequently, each patient was evaluated by a teleneurologist, and their assessment was recorded. Multivariate logistic regression was performed. Interrater agreement was assessed by 𝜅. RESULTS: A total of 92 patients were enrolled; mean age 61 ± 15 years, 47% female, mean NIHSS 7 ± 6, 11% prior AISCVA past 3 months, intracranial hemorrhage on CT 5%, 8% discharged home from ED, 10% neurointerventional procedure. Thrombolytic tPA was received by 18 patients (20%). Agreement between EPs and teleneurologist for ± thrombolytic tPA indicated was moderate (86% agreement; 𝜅 = 0.58) and the reason for thrombolytic tPA ineligibility substantial (83% agreement; 𝜅 = 0.77). In five (5.4%) cases, the EP determined that thrombolytic tPA was indicated, the teleneurologist disagreed and the patient did not receive thrombolytic tPA. On the other hand, in nine (9.8%) cases, the EP felt thrombolytic tPA was not indicated and the teleneurologist assessed that it should be administered. For three cases, patients did not receive thrombolytic tPA despite the + teleneurologist impression that it was indicated, including one where the EP dissented. CONCLUSION: Within our study group of patients evaluated for possible AISCVA, agreement between EP and teleneurologists for thrombolytic tPA indication was moderate and their agreement for thrombolytic tPA ineligibility reasons was substantial.