This is a retrospective analysis of thrombolytics administered via telemedicine for acute ischemic stroke at Southern Illinois Healthcare, 07/2017-08/2024. Demographics, medical history, clinical presentation, evaluation time, stroke severity, neuroimaging, and laboratory testing were reviewed. Major technology upgrades were noted. Outcome measure was DTN. Linear regression model was fitted with ordinary least squares method to estimate the effect of sequential telemedicine encounters and preselected co-variables on DTN. A risk-adjusted cumulative chart (RA-CUSUM) was plotted to demonstrate the cumulative sum of probability of achieving DTN <60 minutes by sequence of encounters. P value was set at 0.05.

This study included 170 telemedicine-administered thrombolytics. Once adjusted for age, SBP, NIHSS, and evaluation time, the sequence of telemedicine encounters was independently associated with DTN (B: -0.086, 95%CI: -0.169, -0.03, p=0.04). RA-CUSUM demonstrated a learning curve occurring in a discrete fashion, with cycles of steep learning, followed by semi-plateau phases. Each cycle lasted approximately 40 encounters. Steep learning was irregularly associated, but not invariably, with providers newly using telemedicine, and major technology upgrades. There was no ceiling effect in learning curve. Probabilistically, every 10 encounters lowered DTN by 42 seconds. Statistically, 98 encounters were needed to predict DTN to <60 minutes.

We identified a learning effect on DTN in telemedicine-administered thrombolytics. The learning curve occurred at three levels: system level of the network, provider experience, and improvement in the technology. Our experience supports expansion of telemedicine in underserved areas and may guide rural hospitals approaching telemedicine technology in the acute stroke care for the first time.