The VA Brings to Bear a POC App for Improved Stroke Outcomes

Acute stroke is frequently a terrifying and devastating disease process for patients. Currently, acute stroke remains the fifth leading cause of death in the United States and nearly 800,000 patients per year suffer a stroke. Stroke is both preventable via treatment of hypertension and tobacco cessation for example and treatable via the use of thrombolytics and endovascular treatments. However, stroke frequently goes unrecognized by either the patient and/or family members resulting in these patients missing critical time windows for specific treatments. For example, current AHA guidance (new guidelines in 2019) for the use of t-PA in stroke recommends use no greater than 4.5 hrs from the “last known well.” Newer techniques including intra-arterial therapy (MR CLEAN trial 2015), endovascular thrombectomy (DAWN trial 2018) have extended these treatment windows while providing positive outcomes, but are still not widely available/require transport to specialty centers. 

The Department of Veterans Affairs (VA) has been a leader in the development of telestroke protocols. Launched in 2017, the VA telestroke program involves over 30 medical centers and more than 20 neurologists. This enables rapid point-of-care decision making from the primary care team in consultation with the VA specialists via a video telehealth system. To date they have successfully performed over 10,00 consultations. They now have launched a “companion app” that provides POC decision support called Stroke Code. The app permits the primary treatment team to rapidly collect the relevant information necessary for a proper treatment determination in consultation with a stroke neurologist. The app includes the relevant times including the “last known well”, NIHSS calculator, t-PA dosing calculator, etc. The app can be used by anyone who cares for acute stroke patients. The app includes all of the relevant indications/contraindications for t-PA and endovascular treatments, information for patient records, activity reminders, etc. 

Evidence-based medicine

The VA Stroke Code app is geared for rapid telehealth consultation with a stroke expert/neurologist to aid in the use of t-PA or endovascular treatments of acute stroke. The app follows current NIH/AHA guidelines and includes the current t-PA dosing and NIHSS calculators. The app does not contain any links to the corresponding publications or CPGs however. 

 What providers would benefit from this app?

Students, residents, mid-levels, emergency medicine, family medicine, internal medicine, neurologists, hospitalists/critical care, and any provider who cares for acute stroke patients.

Price

o Free

 Likes

  • Contains latest protocol for Code Stroke from NIH/AHA built into POC app
  • Includes calculators for NIHSS and tPA, data collected can be used for patient records
  • Walks through the process to decide between tPA vs. endovascular procedures

 

Dislikes

  • No “overall” directions included in app or overview; no information about VA app team
  • No links to any relevant guidelines, protocols
  • Not available for Android

 

Overall

The VA Stroke Code app is a very useful telehealth/bedside stroke protocol app. Designed for VA providers to collect data for video telehealth with neurology stroke experts, the app could easily be used by any provider who cares for these critical patients in conjunction with their own neurology service. The app provides the latest NIH/AHA guidance and some handy built in calculators. The app would be improved with some better overview/directions, links to relevant literature/CPGs, and an Android version. Recommended.

 

Overall Score

o 4.0

 User Interface

o 4.0

Needs an overview screen and/or more comprehensive instructions. Otherwise, the calculators and data input sections work fine.

Multimedia Usage

o 4.0 stars

The app contains a mostly intuitive clinical decision pathway with a built-in NIHSS calculator, tPA dosing calculator, and prompts to decide between tPA and endovascular procedures. However, it contains no links to online resources such as relevant publications, CPGs, etc. 

Price

o 5 stars

App is free.

 Real-World Applicability

o 4.5 stars

A useful app for those working in the VA Emergency/Urgent Care centers, but really any civilian ER/urgent care could benefit as well as those on inpatient services, neurology, etc. The app handles scenarios for both tPA and endovascular procedures with useful built-in NIHSS calculator. 

 Device Used For Review

o iPhone 11 Pro running iOS 13.6.

Available for Download for iPhone and iPad. Not available for Android at this time.