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Section 8.1

Telestroke Overview

4th Edition
2012-2013 UPDATE
September, 2013

1.1 Introduction – Taking Action towards Optimal Stroke Care

Improved quality and availability of technology has made the delivery of cross-continuum services possible within a variety of facilities and practice settings throughout Canada. This technology has been a major driver and opportunity for bridging the gap in access to equitable stroke services regardless of geographic location. The challenge we are now presented with is that this known and available technology is significantly under-utilized in the management of patients who have experienced a stroke, and their family members.

The Canadian Telestroke Action Collaborative is led by an expert group within the Canadian Best Practice Recommendations for Stroke Care (CTAC) initiative. The CTAC group is mandated to update current evidence-based recommendations for Telestroke and to gather together the knowledge and experience of Telestroke experts across Canada and assemble this implementation toolkit to support uptake of best practices. CTAC’s goal is to increase access to stroke specialists through Telestroke care delivery models for hyperacute stroke care, stroke rehabilitation, prevention services and to support patients in returning to the community.

The guiding principles for CTAC in the update of the best practices for Telestroke and the development of a comprehensive Implementation Toolkit include:

  • Telestroke programs should be established within coordinated systems of stroke care, and not as stand-alone isolated projects whenever possible. This will increase the benefits of a Telestroke investment and enhance sustainability, with it firmly embedded within a broader stroke services model of care;
  • Telestroke programs should be established across the continuum of stroke care, and be expanded beyond the hyperacute phase, especially given the shortage of stroke rehabilitation experts in many smaller communities, and the increased burden on families and the stroke care system when stroke patients are not able to access services to assist them in achieving optimal recovery;
  • Healthcare providers involved in Telestroke programs should be involved in ongoing education to maintain competency in stroke care and in the efficient use of the technology;
  • Telestroke initiatives should follow a quality improvement model and could start out on a small scale with minimal technology investment, then continue to be developed and enhanced as capacity increases.

The documents included in this toolkit are intended to support both consulting and referring sites with the implementation of Telestroke services in their facility. The information provided should be considered a starting place – examples and templates provided for use by all sites to review, adopt or adapt as appropriate to meet their own needs and best reflect the site-specific technology and resources with the goal of furthering development and implementation of a Telestroke program to support care delivery across the stroke continuum.

The information included here should also be considered dynamic – it will change and evolve as new evidence emerges, and we encourage all users to share their own materials with the broader Telestroke community through this resource. All submissions can be sent to the Stroke Best Practices Office at the following email: strokebestpractices@hsf.ca

1.2 Telemedicine and Telestroke Definitions

There is considerable variation in the literature and in practice regarding the terminology used to describe Telemedicine and Telestroke services. For the purposes of the information contained throughout the CTAC Telestroke implementation Toolkit, the following definitions have been accepted and operationalized.

  • Telehealth is the use of information and communication technology to deliver health services, expertise and information over distance. It includes telephone, internet or web-based e-health and video-based applications, and can be delivered real-time (live) or through store-and-forward (record now, view later) mode (University of Calgary).
  • Telemedicine is the provision of medical expertise for the purpose of diagnosis and patient care by means of telecommunications and information technology where the patient and the provider are separated by distance. Telemedicine may include, but is not limited to, the provision of pathology, medical imaging and patient consultative services (Federation of Medical Regulatory Authorities of Canada). Sometimes telehealth may be used synonymously and for the purposes of this document we use telemedicine. Telehealth is biggest and broader concept of using technology in healthcare.

For the purposes of this toolkit, the following are the operational definitions for Telestroke:

  • Telestroke is the use of telecommunication technology to link referring and consulting healthcare sites together for real-time assessment and management of stroke patients. Presently, it is used primarily to extend access to thrombolytic treatment in healthcare facilities that do not have 24/7 on-site stroke expertise. However, Telestroke is also a mechanism for increasing access to stroke expertise and education in the acute, 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.
  • On-Demand Telestroke is defined as an unplanned, often urgent, Telestroke consultation; access to unplanned Telestroke services requires 24 hour per day, 7 days per week access, and usually occurs in the emergency department.

1.3 The Canadian Telestroke Action Collaborative Framework

The CTAC writing group has developed a comprehensive framework that encompasses the major components of Telestroke as a care delivery mechanism (policy and advocacy, readiness and models of delivery, best practices and implementation, technology and evaluation) embedded within the Donabedian quality domains of structure, process and outcomes of Telestroke implementation. Inherent to the framework is an emphasis on patient-centred care, with the patient and their family, represented by the red ‘dots’, included in every component.

The framework also demonstrates the concept that stroke care provided through Telestroke technology can occur at any stage along the care continuum, and for a range of intended goals from hyperacute care to support tPA administration, through to rehabilitation and access to speech therapy, and on to community reintegration and home monitoring of activities of daily living. Telestroke should enable effective patient-centred care regardless of patient location, ensure that patients have access to the best, optimal stroke care, the care they receive is timely, and where possible, cost efficient (bring the specialist to the patient via Telestroke).

Figure 1: Telestroke Action Framework

Fig 1. Telestroke Action Framework

Heart and Stroke Foundation and Canadian Stroke Network, 2013

Taking Action in Telestroke

Taking Action is an imperative within stroke care and recovery, and applies to systems of care, healthcare providers, patients and the broader community. Results from the Quality of Stroke Care in Canada Report (Canadian Stroke Network, 2011) indicate that many Canadians are not receiving optimal stroke services, and there are significant geographic variations in care. Telestroke is a care delivery modality that has emerged to bridge the geographic gap between patient and expertise. Many healthcare facilities already have some elements of telemedicine in place within their institution, yet there is only a small number of sites actively using established telemedicine technology for hyperacute stroke care – focused on rapid assessment and decision-making with respect to acute thrombolysis, or to access rehabilitation and prevention experts who can help patients reach optimal recovery potential and reduce risk of stroke recurrence.

Taking Action in Telestroke involves healthcare providers, policy makers, patients and the public. Telestroke is a tool or care delivery modality. A critical component of Telestroke is development of ‘on-demand’ (urgent, unplanned) and ‘scheduled’ access to specialized stroke services, ideally provided by dedicated stroke providers in acute care, prevention, rehabilitation and the community. In order to be successful, Telestroke has to be implemented within an established and coordinated stroke system, where stroke experts and referring sites can be connected in an efficient and organized manner. Issues such as increased workload, scheduling challenges, equipment cost and functioning, and physician reimbursement have all been posed as barriers and road-blocks to Telestroke implementation. Healthcare systems need to Take Action to address the specific barriers and reservations within their jurisdiction and find workable solutions. In 2011, Krueger et al found that implementation of Telestroke results in significant cost-avoidance and is one of four major cost-avoidance drivers in stroke management (along with stroke unit care, tPA administration and early supported discharge)(Stroke, 2011). Further, Telestroke committees are urged to Take Action to follow the Telestroke roadmap (Figure 2) developed by the CTAC group to provide with a high-level overview of the components and considerations to be addressed in creating a Telestroke program.

Taking Action in Telestroke also means that providers need to start thinking beyond the utility of Telestroke just in the hyperacute phase for tPA decision-making and administration. There is an emerging set of demonstration projects and research initiatives where Telestroke is used as the care delivery model for prevention and rehabilitation services. These applications enable people access to expertise to manage risk factors which reduces recurrence rates for stroke, and therefore reduces burden on the healthcare system. Similarly, applications within the rehabilitation realm enable access to physiotherapy, occupational therapy and speech therapy to help further the gains made post stroke (positive patient-related outcomes) and, again, decrease the burden on the healthcare system.

Key messages for 2013 and significant changes to previous recommendations include:

  • Telestroke as a care delivery modality is under-utilized in Canada
  • Telestroke should be implemented within established stroke systems of care to maximize effectiveness
  • Telestroke applications should include hyperacute care to increase access to acute thrombolysis, and also expand beyond this setting to implementation for rehabilitation, prevention and community support.

1.4 Telestroke Program Development Roadmap (CTAC 2013)

This roadmap provides an overview of critical elements, stages and stakeholders to be considered in the development of a Telestroke program. It has been developed to assist Telestroke project teams in planning all aspects of Telestroke initiation and implementation and may be applied across the continuum of care and for on demand (emergency) and scheduled healthcare encounters using telestroke technology. Since Telestroke is a care delivery modality, it is imperative to have coordinated supporting structures in place to ensure successful implementation and sustainability. This roadmap identifies high-level key elements to be addressed throughout Telestroke development and implementation.

Figure 2: Telestroke Program Roadmap (CTAC, 2013)

Fig 2. Telestroke Roadmap

1.5 About the Canadian Best Practice Recommendations for Stroke Care

The Canadian Best Practice Recommendations for Stroke Care provides up-to-date evidence-based guidelines for the prevention and management of stroke. The goal of disseminating and implementing these recommendations is to reduce practice variations in the care of stroke patients across Canada, and to reduce the gap between knowledge and practice. Recommendations are updated on a rotating cycle every two years to ensure they continue to reflect contemporary stroke research evidence and leading expert opinion. Each update involves critical review of the current medical literature, which informs decisions regarding modification of the recommendations and the performance measures used to assess their impact. Ongoing monitoring of the literature for new evidence ensures recommendations are current and reliable. All sets of recommendations are accompanied by implementation resources to guide end users through effective integration of recommendations to clinical practice. These resources are developed in collaboration with stroke experts and implementation specialists across Canada and internationally.

This is the fourth edition of the Canadian Best Practice Recommendations for Stroke Care, which was first released in 2006. The theme of the 2012 – 2013 update is Taking Action, and stresses the critical role and responsibility of healthcare providers at every stage of the continuum of care to ensure that best practice recommendations are implemented and adhered to. Taking Action will lead to optimal outcomes for each stroke patient by providing the best care within the most appropriate setting. This includes rapid and efficient access to diagnostic services, stroke expertise and medical and surgical interventions, rehabilitation and support for ongoing recovery and community reintegration.

Taking Action requires a committed team approach and strong coordination of care across regions and networks, with pre-hospital, acute care, rehabilitation and community-based healthcare providers working together to ensure optimal outcomes for patients and their families, regardless of geographic location.

Taking Action also applies to patients who have experienced a stroke, their families and informal caregivers. Stroke patients and their families need to actively participate in their recovery and openly communicate with their healthcare team. Patients and families must participate in setting the goals they want to achieve during recovery from a stroke, and share concerns, as well as physical, mood and cognitive issues with their team, which will lead to the care required for optimal recovery in all aspects of health.

Telestroke Update 2013 Resource Package Includes:

  1. Stroke Best Practice Recommendations for Telestroke
  2. Evidence summary and evidence table for all topics addressed in the recommendations
  3. Canadian Telestroke Action Collaboration Implementation Toolkit, with educational information, resources checklists and roadmaps for hyperacute ‘on-demand’ Telestroke use and ‘scheduled’ planned appointments across the continuum. This toolkit addresses all aspects from decision-making to develop a Telestroke program, to preparing for Telestroke, implementation and evaluation.
  4. Contact information for Telestroke leaders and telehealth supporting organizations nationally and within provinces.

Development of the Canadian Best Practice Recommendations for Stroke Care

For detailed methodology on the development and dissemination of the Canadian Best Practice Recommendations for Stroke Care please refer to the stroke best practices website at http://www.strokebestpractices.ca/index.php/overview/methods/.

Acknowledgements

The Canadian Stroke Best Practices Team, Heart and Stroke Foundation and the Canadian Stroke Network gratefully acknowledge the writing group leaders and members, members of the stroke best practices advisory committee, and the external reviewers, all of whom have volunteered their time and expertise to this update. We thank the Canadian Stroke Quality and Performance Advisory Group for their work in updating and confirming the performance measures that accompany each recommendation. We are grateful to Norine Foley and her team at workHORSE Consulting Group for their diligent work on the evidence review and the evidence summaries, implementation tool development, and providing ongoing information and support to the writing group. Special acknowledgement is given to the Heart and Stroke Foundation of New Brunswick, Vitalité, and Horizon Health, along with their respective teams, for jointly sponsoring and hosting a National Telestroke Summit in May 2013. This summit was a pivotal activity to inform the development of these guidelines and the supporting implementation toolkit. French translation of this chapter has been provided by (TBA).

Funding

The development of these Canadian Best Practice Recommendations for Stroke Care is funded in its entirety by the Canadian Stroke Network and the Heart and Stroke Foundation. No funds for the development of these guidelines come from commercial interests, including pharmaceutical companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, dissemination or implementation.

Conflict of Interest

All participants in the development, writing, and review of these recommendations completed a Conflict of Interest form which was reviewed by the CSN privacy officer for risk assessment. No significant conflicts of interest were noted, that would impact these recommendations. A broad consensus process minimized any potential biases.

Citing the Telestroke Best Practices Update and Implementation Toolkit 2013

Lindsay MP, Taralson C, McClure A, Foley N, and Silver F, on behalf of the Canadian Telestroke Action Collaborative Writing Group. Chapter 8: Telestroke.

In Lindsay MP, Gubitz G, Bayley M, and Phillips S (Editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Heart and Stroke Foundation and the Canadian Stroke Network.

Comments

We invite comments, suggestions, and inquiries on the development and application of the Canadian Best Practice Recommendations for Stroke Care and ongoing updates.

Please forward comments to the Heart and Stroke Foundation Stroke Best Practices and Performance team at strokebestpractices@hsf.ca

1.7 Telestroke Report 2012 – Executive Summary

1.8 Telestroke Report 2012 Slides

1.9 Taking Action for Telestroke Slides (Blacquiere)