Rural areas face barriers to timely acute stroke intervention. Neurology trainees are a resource to support rural areas.

A neurology resident implemented a rural telestroke site initiative focused on a rural ED acute stroke protocols. Areas of focus were: activation; image acquisition, image transfer/read times; and management approach. Protocols were iteratively developed by local stroke coordinator and neurologist as well as academic Stroke Center resident, faculty, and staff. Data was collected from 3 periods: pre-intervention (1/1/18- 12/31/21), intra- (1/1/22-5/22/22) and post- (5/23/22-10/14/22) protocol changes. Door to imaging (DTI), door to thrombolysis (DTN), and door-in-door-out (DIDO) times were compared using a non-parametric ANOVA test. CTA use was categorized as 1) no CTA, 2) CTA simultaneous to HCT, or 3) CTA after HCT, and were compared using Fisher’s exact test. 

Of 180 code strokes (144 pre- , 17 intra-, and 19 post-intervention), mean age was 67.7 years (SD 16.4, range 18-95), 46% female, with median NIHSS 3 (IQR 1, 7). The majority (97%) underwent HCT, 23 (12.8%) received thrombolysis, and 43 (23.9%) transferred to another facility. There was no difference in DTI, DTN, or DIDO among the three groups. However, both overall CTA and CTA simultaneous with HCT increased: 33% and 9% pre- to 83% and 50% post-intervention, respectively (p<0.05 each). 

In this initiative, a trainee drove implementation of protocols for acute stroke management. While there was no change in time-based metrics, there was change in use of CTA, critical for LVO detection. Trainees can be resources to underserved areas and are more prepared for practice in resource deficient areas. Next steps include iterative process improvement and data collection of LVO detection and treatment.