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ONLINE EXCLUSIVE: Hub and Spoke For Stroke


Given the varying access to acute-stroke expertise and the roles hospitalists play in treatment (see “Spotlight on Stroke,” p. 1), stroke protocol differs from hospital to hospital throughout the U.S. One response is known as “drip and ship.” Physicians at remote hospitals consult experts at a tertiary-care medical center by phone or video before initiating clot-busting intravenous recombinant tissue plasminogen activator (t-PA) within its three- to 4.5-hour therapeutic window. Once t-PA is administered, the patient is transferred to the medical center for ongoing care.

This is not a game to play casually. It’s about developing new healthcare delivery models, with lots of complicating factors.

—Lee Schwamm, MD, director of acute-stroke services, Massachusetts General Hospital, Boston

“But what is the best way to provide that expertise at the bedside to support the first-responding physician who is not a stroke expert?” asks Lee Schwamm, MD, director of acute-stroke services at Massachusetts General Hospital (MGH) in Boston. While the goal is to disseminate stroke treatment expertise as widely as possible, there are other benefits to the arrangement, from the quality of the infrastructure, ongoing education, and a growing relationship that is more than just “transactional” telemedicine.

MGH and Brigham and Women’s Hospital are the hubs for the relationship-building Partners TeleStroke Network. It connects 27 participating hospitals across three states with an escalating chain of access to stroke resources. Spoke hospitals transmit, through a secure link, such clinical data as noncontrast head CT scans to the hub, where a stroke expert “examines” the patient via live video feed and shares in the responsibility for deciding whether to initiate t-PA. The network’s resources include clinical and information technology advocates at the hub and spokes; managers of business processes, contracts, licensure, and credentialing; consultation recording for quality purposes; regular telemedicine grand rounds; and the network’s leadership in an alliance of hub-and-spokes stroke networks at other academic medical centers. “This is not a game to play casually. It’s about developing new healthcare delivery models, with lots of complicating factors,” Dr. Schwamm says.

Hospitalists should not only note that stroke care is coming under greater regulatory scrutiny, but also that stroke information increasingly is available on the Web, Dr. Schwamm says. He also urges hospitals to participate in one of the national quality programs for stroke care, including the American Stroke Association’s Get with the Guidelines: Stroke, the Joint Commission’s primary stroke center accreditation, or the CDC’s Paul Coverdell National Acute Stroke Registry. “Each of these provides a structure for improving the quality of stroke care,” Dr. Schwamm explains, “and is money well spent by the hospital.”

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