- Telestroke is the use of telecommunication technology to link referring and consulting healthcare sites for real-time assessment and management of stroke patients. It is used primarily to extend access to thrombolytic treatment in healthcare facilities that do not have 24/7on-site stroke expertise. Telestroke is also a mechanism for increasing access to stroke expertise and education in the post-acute period, focusing on secondary prevention, rehabilitation, and recovery.
- Referring site is the site where the patient is physically located.
- Consulting site is the site that has the stroke expertise to support the referring site in diagnosis and treatment.
- Telestroke Network is a formally organized and continuously available integrated group of healthcare facilities that includes at least one tertiary stroke care centre, and that has appropriate telecommunication infrastructure for real time audiovisual communication and rapid transmission of radiological images between referring and consulting sites.
- Refer to Box 7.1 for Technical Components of Telestroke Delivery.
Telestroke networks should be implemented wherever acute care facilities do not have on-site stroke care expertise to provide 24/7 acute stroke assessment and treatment with tissue plasminogen activator in accordance with current treatment guidelines 533 [Evidence Level C].
7.1.1 Organization of Telestroke Delivery for Hyperacute Stroke Management
Standardized protocols should be established to ensure a coordinated and efficient approach to telestroke service delivery in the hyperacute phase of stroke to facilitate delivery of thrombolytic therapy in referring sites 533, 534[Evidence Level B].
- Telestroke consultation should be continuously available at the referring and consulting sites [Evidence Level C].
- Clearly defined criteria and protocols should be available for referring sites to determine when and how to initiate a telestroke referral [Evidence Level B].
- Two-way audiovisual communication should be in place to enable remote clinical assessment of the patient [Evidence Level A].
- The consultant should be a physician with specialized training in stroke management, and must have access to diagnostic-quality CT images during the telestroke consultation (see Technical Notes below) [Evidence Level A].
- Compared with traditional bedside evaluation and use of intravenous tissue plasminogen activator, the safety and efficacy of intravenous tissue plasminogen activator administration based solely on telephone consultation without CT interpretation via teleradiology is not well established (Evidence Level C).
- All laboratory and diagnostic results required by the consultant should be made available during the telestroke consultation [Evidence Level B].
- The most responsible physician remains the attending physician at the referring site. Decision-making is a consensus process that is achieved in consultation with the attending medical staff at the referring site, the patient and family, and the consulting physician with stroke expertise [Evidence Level C],
- A consulting physician should remain available to provide ongoing guidance to the referring site as required [Evidence Level C].
- Standardized documentation should be completed by both the referring site and the consulting site [Evidence Level C].
- At the completion of the consultation, the consulting physician should provide a consultation note to the referring site to be included in the patient medical record [Evidence Level C].
7.1.2 Organization of Telestroke Delivery for Ongoing Stroke Management
- Two-way audiovisual communication should be in place to enable post-acute stroke prevention and rehabilitation services in communities where these services do not exist [Evidence Level A].
- Clearly defined criteria and protocols or algorithms should be available for referring sites to determine when and how to access these services for stroke patients [Evidence Level B].
- The consulting healthcare provider should provide documentation to the referring site to be included in the patient medical record [Evidence Level C].
7.1.3 Staff Training and Ongoing Education
- Service providers should be trained in using the telestroke system and understand their roles and responsibilities. Telestroke training and education should be ongoing to ensure competency [Evidence Level C].
- Referring physicians should know the inclusion and exclusion criteria for thrombolytic therapy and they should be familiar with the NIH Stroke Scale (NIHSS) so that they are able to assist the telestroke consultant with the video neurological examination. Ideally referring physicians should be certified in the NIHSS [Evidence Level B].
- Consulting physicians should have expertise and experience in managing stroke patients [Evidence Level C].
- Telehealth Network/Provider
Ideally, a telestroke program should be supported by a regional telehealth provider that provides connectivity between participating hospitals and consulting physicians. The Telehealth provider would also be responsible for data privacy and security, initiating new sites, maintenance, and ensuring quality of service.
- CT imaging must be available 24/7 with a technologist on site to allow emergency department arrival to CT time to be less than 30 minutes.
- CT imaging should include axial 3 to 5 mm cuts from the foramen magnum to the vertex.
- CT angiography, CT perfusion, and MRI are not necessary for IV tPA but if these images are available they should be provided to made available to the consulting physician.
- Images should be stored and transmitted in the Digital Imaging and Communication in Medicine (DICOM) format. This format is the standard for handling, storing, printing, and transmitting medical imaging information.
- Picture Archiving Communication System (PACS)
- Images are stored and made available to the consulting physician using a PACS system.
- The communication protocol TCP/IP is used to communicate between systems.
- Consulting Site: Physician Access to Images and Video Conferencing
- The consulting site physician should have access within 15 minutes or less to a computer and video conferencing system to review the patient’s brain images and to connect for video conferencing.
- Ideally, to shorten the delay in obtaining the consulting physician’s opinion, access should be provided both at the consulting site physician’s home and office/hospital.
- Referring Site: Audio Video Conferencing
- Requires high definition video conferencing system with 1.5 Mb bandwidth per call of voice quality such as Tandberg, PolyCom technologies.
- Local Area Network on 100 Mbps which must support voice quality of service (QOS) with maximum 150 Mbps or less delay end to end in both directions.
- Video Conferencing Gateway L. 323 (protective firewall)
- Consulting Site: Audio Video Conferencing
- Wide Area Network (WAN) which supports the Local Area Network at 1.5 Mbps bandwidth per call of Voice Quality Service (QOS) with full duplex capability.
- Video Conferencing Gateway L. 323, which is the protective firewall.
- Local Area Network (LAN): Defining characteristics of a LAN are high data-transfer rates, small geographic area. LAN connectivity must be 100Mbps or greater and be a full duplex system.
- High definition video conferencing screen with 1.5 mb bandwidth per call of voice quality such as Tandberg, PolyCom technologies.
- System reliability
- Must maintain best practice and follow Information Technology standards.
- System reliability depends on process formation and requires collaborative change management protocols from both referring and consulting sites.
- All points on the network should be continuously monitored to ensure sites and workstations are up 24/7.
- Technical support
- 24/7 IT support on call for PACS servicing.
- 24/7 IT support on call for video systems.
- Monitoring Network to ensure 24/7 connectivity.
- Local and or remote system service contract arrangement.
Telestroke enables improved communication and better networking to increase access to and distribution of optimal stroke care. It assists in closing the urban/rural and tertiary/primary care gap. In many communities there are no neurologists or physicians with expertise in stroke care, and the short therapeutic time window for initiating thrombolytic therapy for acute ischemic stroke patients does not allow them to be transported long distances to regional stroke centres. Telestroke brings an experienced stroke consultant into the local emergency department "electronically". Patients assessed by a telestroke system who are not deemed to be candidates for tissue plasminogen activator still benefit from the stroke specialist's assessment and recommendations for optimal investigations and treatment.
Telestroke networks can also be used to facilitate early triage and management of transient ischemic attack and minor stroke, and may play a valuable role in post-acute rehabilitation and support. 198, 203, 533
- Telestroke network development as part of larger regional or provincial stroke delivery plans, to ensure adequate clinical stroke services within communities that lack physicians with special expertise in stroke care.
- Human, technological, and financial resources to establish telestroke networks.
- Patient and family education, and informed consent for telestroke consultation
- Establishing physician reimbursement at the outset of a telestroke program
- Appropriate emergency and intensive care services at referring sites, especially to manage patients who receive tissue plasminogen activator, such as 24-hour per day CT imaging, protocols for using intravenous tissue plasminogen activator, and intensive care beds.
- Service agreements that address the availability of maintenance and technical support, to ensure the clinical requirements of telestroke are met. (For hyperacute applications, these supports should be available 24 hours a day, 7 days a week).
- The need for all users of a telestroke system to be aware of their roles and familiar with operating the technology, including regular updates to maintain competence
- Agreements and protocols for interprovincial consultations where appropriate.
- Percentage of patients who arrive at a designated referring hospital with stroke symptoms who receive access to stroke expertise through telestroke as (a) the proportion of total stroke cases treated at the referring site and (b) the proportion of patients with acute ischemic stroke arriving at the hospital within 3.5 hours.
- Proportion of telestroke cases where an urgent follow-up is required with the stroke specialist due to complications or unexpected events.
- Time to initiation of Telestroke consult from
- stroke symptom onset (last time patient was known to be normal)
- arrival in emergency department
- completion of the CT scan
- Number of Telestroke referrals where stroke specialists were inaccessible or access was delayed due to
- multiple conflicting calls (telestroke and other)
- technical difficulties preventing video-transmission
- Percentage of telestroke consults who are treated with tPA.
- Proportion of stroke patients managed with telestroke who received tPA, who had a symptomatic secondary intracerebral hemorrhage, systemic hemorrhage, died in hospital, were discharged to long-term care vs. home or to rehabilitation.
- Percentage of patients managed with Telestroke where the Telestroke consultant’s note is found in the patient’s chart.
- An attempt should be made to document information about all consecutive patients with stroke at the hospital using Telestroke for the denominator.
- Documentation for Telestroke consultations is often not standardized, making it harder to gather performance measure information.
Given the vast geographic size of Canada there is an insufficient number of hospitals with the resources to manage patient with acute stroke. Acute stroke assessment and decision making for thrombolysis is complicated. Given the relative shortage of stroke specialists, most of whom are located in tertiary care hospitals, the most effective solution to this problem to date has been the use of established telecommunication technology to develop “Telestroke networks” for real time audio-visual assessment of acute stroke patients at a distance. The “spoke and hub” model of a tertiary stroke center connected to a number of distant primary care centers has been employed effectively in a growing number of telestroke networks throughout Europe and North America many of which have now been operating successfully for over a decade.533, 535
The term “Telestroke” was first used by Levine and Gorman referring to real time audio and video connection allowing two way communication usually between a tertiary center with a stroke specialist providing an emergent stroke consultation to a stroke patient and attending medical staff at a distant site that lacks 24 hours per day, 7 days a week onsite stroke expertise.536 This is accomplished with mobile or fixed compact telemedicine units located in the acute care ED environment that transmit high fidelity audio and video signals over high band width, secure, reliable cable and/or wireless networks to a viewing terminal at the distant tertiary site. Critical to a properly functioning telestroke system is the transmission of DICOM format images of the patient's CT scan of the head (with or without vascular imaging studies) to the tertiary center for review by the on call stroke specialist. Current technology is user friendly, robust and provides high quality two-way images more than adequate to carry out a detailed stroke examination and discussion with the patient, family and on site medical team. Technology is not a limiting factor.
With a functioning telestroke system, as outlined above, the stroke specialist in the tertiary center is provided all the necessary components required for acute treatment decision making. From the clinical assessment done with the assistance of medical staff at the distant site information is acquired regarding the nature of the clinical stroke syndrome, time frame involved, location and severity of the deficit, presumed arterial territory involved, and presence or absence of significant clinical contraindications to thrombolysis and reperfusion. High quality CT images allow elimination of hemorrhagic stroke syndromes and determination of the extent and severity of ischemic damage. The stroke expert can then discuss with the attending team, patient and family at the distant site the nature of the stroke process, general prognosis and potential treatment options and their relative risks and benefits. The patient and medical team at the distant site receive essentially the same access to emergency stroke consultation as is available in the tertiary stroke center. This assessment and decision making process can take less time with a Telestroke system as compared to waiting for a local on call neurologist to arrive.537 Current evidence suggests that decision making is more accurate when all components of the evaluation are used (audio-visual assessment and PACS images) than when limited evaluation is performed as with phone with or without PACS. 538
In summary, Telestroke systems extend the effective distribution of stroke expertise and increases access of the population at large to standardized evidence based stroke care under the direction of a stroke specialist. In a disease process with a very limited time window for treatment, telestroke systems counter the effect of geography and transport times and increase the number of stroke victims who have an opportunity for reperfusion in a time frame that offers potential for improved clinical outcome. The emergency projection of stroke expertise to the patient bedside increase the number of patients with potential for treatment with r-tPA, reduces the risk of protocol violations and complications, and increases the number of stroke patients who can be treated locally in their own communities. Although difficult to quantify, telestroke consultations are also an excellent example of subspecialty input at the teachable moment and represent a critical component of skill transfer from tertiary to primary center.
In Ontario 75 percent of acute stroke patients assessed by a telestroke system are not treated with r-tPA however they receive the benefit of subspecialty advice regarding other aspects of treatment and investigation which impacts on all types of stroke. Early triage of TIAs and minor stroke is another example of the potential impact of telestroke networks.198, 203, 533 Just as an acute stroke rapid triage system represents only one component of the larger system of the stroke care continuum in a tertiary stroke center, a telestroke system in a primary stroke center is just one component of general stroke care improvement that comes with membership in a stroke care network. Telestroke networks and systems should be viewed as a facilitator of improved communication and better networking to increase access to and distribution of optimal stroke care. It assists in closing the urban-rural and tertiary-primary care gap.
The success of telestroke programs has been documented in numerous reports from centers in Europe and North America and the development and use of telestroke networks is supported by national and international guidelines. 537A number of factors will influence the practicality and feasibility of implementing telestroke networks including financial resources, population size, physician willingness and availability, access to CT, and distances and transport times.