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Telestroke Recommendations

2017 UPDATE
April, 2017

The Canadian Stroke Best Practice Recommendations for Telestroke, 6th Edition (2017) is published in the International Journal of Stroke (IJS) and available freely online. To access the specific recommendations for the delivery of stroke care using technology please click on this URL which will take you to the recommendations online in the IJS: http://journals.sagepub.com/doi/full/10.1177/1747493017706239

For the French version of these recommendations, open the appendix at this link : http://journals.sagepub.com/doi/suppl/10.1177/1747493017706239/suppl_file/WSO706239_supplementarey_material.pdf

All other supporting information, including performance measures, implementation resources, evidence summaries and references, remain available through www.strokebestpractices.ca, and not through the IJS. Please click on the appropriate sections on our website below for this additional content.

Rationale

Telestroke technology is a care delivery modality that is available to support equitable and timely access to optimal stroke services across the continuum of care and across geographic regions.  In many communities there are no neurologists, physicians with stroke expertise, or experts in stroke rehabilitation and recovery.  Telestroke is a cost-effective tool to support health systems in closing the urban/rural and tertiary/primary care gap.

Telestroke enables improved communication and better networking to increase access to stroke expertise, regardless of the physical location of the patient or the treating hospital (facility).  

In the hyperacute setting, the short therapeutic time window for initiating thrombolytic therapy for acute ischemic stroke patients does not allow for long distance transport to regional stroke centres. Telestroke brings an experienced stroke consultant into the local emergency department virtually (i.e., "electronically").  Patients assessed by a stroke expert through a Telestroke system who are not deemed to be candidates for tissue plasminogen activator may still benefit from the stroke specialist's assessment and recommendations for optimal investigations and treatment, e.g., early triage and management of transient ischemic attack and minor stroke patients.

In the past few years, Telestroke as a care delivery tool has expanded beyond the hyperacute phase of stroke care.  New evidence is starting to emerge of the benefits and effectiveness of Telestroke in facilitating optimal stroke recovery following the acute phase, by increasing timely access to rehabilitation specialists and therapeutic programs through remote connections in medical care facilities and patient home settings.

System Implications
  • Telestroke services should be considered as part of larger regional or provincial stroke delivery plans that "virtually" decentralize expertise to support clinical care in less well-resourced areas. Inherent in such a system are clear criteria, protocols, algorithms, and service agreements concerning the transfer and repatriation of patients when clinically indicated.
  • The human resource implications are considerable and include establishing the appropriate number of physicians to participate in on-call schedules, and right-sizing the work force taking into account the time taken away from consulting practitioners' clinical duties at their own place of work.
    • Commitment and funding for Telestroke network development is required at the facility, regional and/or provincial levels.
    • A governance structure with a clear framework of accountabilities for Telestroke services.
  • There are different models for implementing Telestroke in acute stroke management: whether referring sites manage patients post thrombolytic therapy (“drip and stay”) or transfer them to a comprehensive stroke centre (“drip and ship”) should be considered taking into account availability of resources and expertise at the referring site.
  • Involvement of administrators and providers from all parts of the continuum of care are important to ensure a coordinated Telestroke effort (e.g., EMS, emergency, radiology, laboratory, inpatient units, ICU, and rehabilitation services).
  • Patient and family education and informed consent protocols for Telestroke consultation.
  • Clear guidelines and processes for physician reimbursement established 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 teams.
  • 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 responsibilities, and be familiar with operating the technology, including regular updates to maintain competence.
  • Agreements and protocols for interprovincial consultations where appropriate.
  • Processes established for monitoring and evaluation of Telestroke services.
  • Licensing requirements for telemedicine vary between provinces and territories.  Physicians should be aware of the jurisdictional requirements where the patient is located.  Physicians may have to be licensed in multiple jurisdictions, which would include their location and the patients.  In addition, special requirements and/or conditions on the provision of services may be required in some jurisdictions. Privacy legislation should also be followed in each applicable jurisdiction.
    Telemedicine may present additional challenges with patient consent.  In addition to receiving a patient’s informed consent for proposed treatment, physicians may want to ask patients to read and accept standard terms and conditions for telemedicine services, documenting consent and discussions.
    CMPA assistance is available for telemedicine if the patient is located in Canada.  There are exceptions for assistance if the patient was located outside of Canada temporarily.
    For more information please access the CMPA website at the below link.

https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/telemedicine-challenges-and-obligations

Performance Measures

Jurisdictions may consider using one or some of the following indicators for monitoring telestroke services:

  1. Proportion of patients who arrive at a designated referring hospital with stroke symptoms who receive a Telestroke consult 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, 4 and 5  hours of symptom .
  2. Proportion of Telestroke cases where an urgent follow-up is required with the stroke specialist due to complications or unexpected events.
  3. Time to initiation of Telestroke consult from: (note: add local benchmarks)
    1. stroke symptom onset (last time patient was known to be normal)
    2. arrival in emergency department
    3. completion of the CT scan
  4. Number of Telestroke referrals where stroke specialists were inaccessible or access was delayed due to
    1. multiple conflicting calls (Telestroke and other)
    2. technical difficulties preventing video-transmission
  5. Proportion of Telestroke patient consults who are treated with tPA.
  6. Proportion of Telestroke patient consults who are transferred to a comprehensive stroke centre for acute endovascular treatment.
  7. Proportion of stroke patients managed with Telestroke who received tPA, who (a) had a symptomatic secondary intracerebral hemorrhage, (b) systemic hemorrhage, (c) died in hospital, or (d) were discharged to long-term care, home or to inpatient rehabilitation.
  8. Proportion of patients managed with Telestroke where the Telestroke consultant’s note is found in the patient’s chart.
  9. Median number of scheduled rehabilitation appointments for stroke patients accessing rehabilitation services through Telestroke modalities (report values separately for each service accessed – e.g., physiotherapy, speech therapy).
  10. Median duration per scheduled rehabilitation appointment for stroke patients accessing rehabilitation services through Telestroke modalities (report values separately for each service accessed – e.g., physiotherapy, speech therapy).
  11. Proportion of stroke patients discharged from an emergency department in a location without a prevention clinic who receive a scheduled prevention appointment through Telestroke modalities.

Measurement Notes

  • Refer to the Canadian Stroke Best Practices Performance Measurement Manual for detailed indicator definitions, numerators and denominators, and additional analysis considerations.
  • 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.
  • For indicators related to actual therapies, please refer to the appropriate section regarding the therapy in the Recommendations.
Implementation Resources and Knowledge Transfer Tools

Refer to Telestroke Implementation Resource Toolkit for comprehensive implementation tools for developing a business case, and planning for a Telestroke program, including implementation, technological considerations, and evaluation approaches.

Summary of the Evidence

Telestroke Evidence Table and Reference list

Traditionally, telestroke has been regarded as a means to enhance decision-making and management of thrombolysis treatment for patients with ischemic stroke. More recently, its application has been expanded further along the stroke continuum to include provision of secondary prevention counseling, rehabilitation therapies and patient education.

In its most common form, telestroke is used to increase access to thrombolytic treatment at facilities that lack 24 hour, 7 days a week onsite stroke expertise, using 2-way audiovisual equipment to carry out a detailed stroke examination, combined with a system to reliably transmit CT scan results. The safety, feasibility and efficacy of the “spoke and hub” model, which connects a tertiary stroke center to one or more distant primary care centers, has been established in many studies conducted in Europe and North America (LaMonte et al. 2003, Wiborg et al. 2003, Schwamm et al. 2004, Audebert et al. 2005, Waite et al. 2006, Vaishnav et al. 2008, Legris et al. 2016).  In some of these studies, although minor technical difficulties were reported, the number of patients treated with t-PA increased at the spoke sites where telestroke systems were implemented and the symptom onset, to treatment time decreased. Choi et al. (2006) reported that a significantly greater percentage of patients received treatment with t-PA during the implementation of the telestroke system compared with the 13-month period prior (4.3% vs. 0.81%, p<0.001).  Following the implementation, Pedragoasa et al. (2009) reported a significant decrease in the mean time from symptom onset to treatment (210 min vs. 162 min; p=0.05) and an increase in the percentage of patients treated within the 3-hour window (30% vs. 68%, p=0.04). Sanders et al. (2016) reported that as their telestroke system grew over time from 7 to 20 participating centres, there were significant reductions in key process times (door-to-needle, call-to-needle and door-to-call). However, large variations in t-PA use have been noted in regions with several spoke hospitals. Switzer et al. (2014) reported that among a telestroke network with two hub hospitals and 15 and 17 spoke hospitals, the rate of t-PA use varied from 0.85-8.74/10,000 emergency department visits/year.

The results from several studies indicate the outcomes of patients treated with t-PA through telemedicine vs. traditional in-hospital care, are similar. Zhai et al. (2015) conducted a systematic review & meta-analysis including the results of 8 studies that compared the outcomes of patients treated with t-PA through telemedicine vs. traditional in-hospital care. Telestroke systems were not associated with increased odds of symptomatic ICH (OR=1.08, 95% CI 0.47-2.5, p=0.85) or mortality (OR=0.95, 95% CI 0.82-1.11, p=0.51. In one of the larger studies (n=6,610), although a higher percentage of eligible patients at two academic stroke centres were treated with t-PA over a one-year period, there were no differences in the incidence of ICH (2.7% vs. 7.8%, p=0.14), 7-day mortality (0.9% vs. 3.5%, p=0.37) or in-hospital mortality (4.5% vs. 3.5%, p=0.74), compared with those admitted to 12 regional hospitals offering telestroke services (Audebert et al. 2005). Schwab et al. (2007) compared 170 patients who received t-PA following telestroke consultation and 132 consecutive patients who had been treated in one of the two stroke centres and received t-PA over the same time period. Mean time from stroke onset to administration of t-PA was similar (141 vs. 144 min).  There were no statistically significant differences in mortality between groups at either 3 months (11.2% vs. 11.5%, p=0.55) or 6 months (14.2%, vs. 13%, p=0.45), nor were there differences in the proportion of patients who experienced a good outcome (mRS score ≥1) at 3 months (38.2% vs. 33.7%, p=0.26) or 6 months (39.5% vs. 30.9%, p=0.10). In one study, both videoconferencing and telephone consultations were used to provide telestroke services at 33 spoke hospitals. Patients were subsequently transferred to the regional stroke centre (RSC) following treatment with t-PA (Pervez et al. 2010). Treatment with t-PA was initiated in 181 (16.1%) cases at the spoke hospitals and in 115 (38.9%) at the RSC. There were no significant differences in the distribution of patients in each mRS category or deaths between the spoke and hub hospitals at 3, 6 or 12 months following treatment.

Perhaps the most recent innovation in telestroke services is the use of mobile stroke units, referring to ambulances which are equipped with specialized equipment, such as on-site laboratories and CT scanners, and are staffed with additional personnel with stroke expertise. These vehicles have been shown to be both feasible and effective. Kunz et al. (2016) compared the outcomes of patients who received thrombolysis therapy using the mobile stroke unit, STEMO from 2011-2015 with patients who received thrombolysis, but arrived to hospital via traditional emergency medical services. A significantly higher proportion of patients in the STEMO group were treated ≤ 90 minutes of stroke (62% vs. 35%, p<0.0005) and were living without severe disability at 3 months (83% vs. 74%, p=0.004). The 3-month mortality was also significantly lower in the STEMO group (6% vs. 10%, p=0.022). However, there was no significant difference in the primary outcome, the number of patients who achieved an excellent outcome (mRS 0-1) at 3 months (53% STEMO vs. 47% conventional, p=0.14). There were no significant differences in the safety outcomes between the 2 groups (sICH 3% vs. 5%, p=0.27 and 7-day mortality 2% vs. 4%, p=0.23). Adjusting for baseline characteristics, STEMO was an independent predictor of living without severe disability at 3 months (OR=1.86, 95% CI 1.20-2.88, p=0.006), but not for the primary outcome (OR=1.40, 95% CI 1.00-1.97, p=0.052). For patients treated with t-PA, mobile ambulances were associated with shorter mean process times, including door-to-needle, last known well to needle, and alarm to treatment decision, compared with non-telestroke treated patients (Belt et al. 2016, Itrat et al. 2016, Ebinger et al. 2014).

The outcomes of patients treated with t-PA at spoke hospitals (drip and stays model) appear to be worse compared with those of patients treated at hub hospitals (drip and ship model). Heffner et al. (2015) reported that the drip and stay patients had higher odds of in-hospital mortality (OR=6.8, 95% CI 2.2-21.7) and hospital stays > 6 days (OR=4.3, 95% CI 2.4-7.8) compared with patients treated at the hub (i.e, without telestroke) compared with patients treated with t-PA at a spoke hospital (drip and ship patients). Thy also reported the odds of long-term survival (2,500 days) were significantly higher in the combined drip and ship and hub groups treated with t-PA. Yaghi et al. (2015) reported similar results, among patients with moderate to severe stroke. Patients with NIHSS scores ≥8 in the spoke group were significantly more likely to experience a poor outcome (mRS ≥3 at 3 months: 76% vs. 50%, p=0.026). Among patients with mild stroke (NIHSS score <8), there was no difference in the numbers of patients with a poor outcome, or 30-day mortality, whose treatment after t-PA was located at the hub or stroke hospital. The elements of care associated with specialized stroke units (dedicated staff, core interdisciplinary team), which may be lacking at spoke hospitals, have been well-established and may account for the differences in outcomes between these groups, notwithstanding similar treatment with t-PA.

The results from several RCTs, also suggests that outcomes and indicators associated with telestroke services provided by videoconferencing and telephone only, are similar.  In the Stroke Team Remote Evaluation using a Digital Observation Camera (Stroke DOC) trial, Meyer et al. (2008) randomized patients to receive telestroke (n=111) using real-time, 2-way audio/video or telephone (n=111) consultations, to assess the patient’s candidacy for t-PA treatment. Consultations were provided by staff at a single hub institution to patients located at 4 remote sites. The number of patients treated with t-PA was similar between groups (28% vs. 23%, p=0.425). Mean times from stroke onset to t-PA were 157 and 143 min in the telemedicine and telephone groups, respectively (p=0.137). There were no differences between groups (telemedicine vs. telephone) in the occurrence of ICH (7% vs. 8%, p=1.00), good outcome at 90 days, defined as a mRS score of 0-1 (30% vs. 32%, p=1.00), or 90-day mortality after adjustment for baseline NIHSS score (OR=3.4, 95% CI 0.6-19, p=0.168). However, correct treatment decisions were made more often using videoconferencing (98% vs. 82%, p=0.0009). In a follow-up study (Meyer et al. 2012), which assessed 6 and 12-month outcomes, there were no differences between groups in mortality or the proportion experiencing a good outcome at either assessment point.

The cost-effectiveness of telestroke services is difficult to determine. Few studies have been conducted and all models were very sensitive to assumptions related to the number of spoke and hub hospitals, the number of patients treated and the number of subsequent transfers. However, it appears that if evaluated over the lifetime horizon, telestroke services are cost-effective. For example, Nelson et al. (2011) used a decision analytic model to compare the costs and outcomes associated with patients presenting with acute ischemic stroke to spoke hospitals with and without telestroke access. Lifetime costs for usual care and telestroke were $130,343 vs. $133,527, resulting in an incremental cost-effectiveness ratio of $2,449/QALY, which was well below the $50,000/QALY usually used to establish a willingness-to-pay threshold. Using a base case of a 90-day time horizon, the ICER increased to $108K/QALY.  More recently, Nelson et al. (2016) compared in-hospital costs prior to the implementation of the telestroke system (up to 2 years prior) and up to 3 years after the start date of the telestroke system. A decision analytic model was used to estimate the probabilities of the consequences of treatment decisions at critical points (e.g. t-PA vs. no t-PA), from both the hub, and spoke perspectives. From the spoke perspective, if the hospitals assumed 50% and 100% of the implementation costs, the ICERs were ~26,000 and 51,000, respectively. From the hub perspective, if the hospitals assumed 50% and 100% of the implementation costs, the ICERs were ~47,000 and 22,363, respectively. From both perspectives, more severe strokes were associated with lower ICERs. A decision analytic model developed by Switzer et al. (2012) predicted that 114 fewer ischemic stroke patients would present to the hub hospital each year, and 16 more patients would present to one of the spoke hospitals, leading to an overall costs savings of $358,435 during the first 5 years, from the network perspective. The model also predicted that 45 additional patients could be treated with t-PA and 20 more could receive endovascular therapy if a telestroke system were in place. This would also result in an additional 6.1 patients being discharged home each year, with an equal number of decreases in admissions to rehab and nursing homes. With cost sharing arrangements between spoke and hub hospitals, the model predicted that each hospital could save $45K over 5 years.

The feasibility and effectiveness of telestroke has also been evaluated in the context of rehabilitation therapy, where it is often referred to as “telerehabilitation” or “telerehab”. The results of these studies have been ambiguous. Chen et al. (2016) included the results of 7 RCTs that included patients who received rehab therapies through telemedicine systems for a minimum of 4 weeks in duration via virtual reality based training, telephone, or the internet. There was no additional benefit associated with telerehab, compared to usual care. The mean Barthel Index scores, Berg Balance Scale scores and Fugl-Meyer (Upper Extremity) scores were similar between groups. A Cochrane review (Laver et al. 2013) included the results of 10 RCTs examining telerehabilitation. The number of trials, which could be pooled were limited as the treatment contrasts and outcomes assessed were highly variable.  Although the authors reported no significant differences between groups in upper-limb function or performance in ADL, they concluded that there was insufficient evidence to support or refute the effectiveness of telerehabilitation following stroke. Chumbler et al. (2012, 2015) evaluated the effectiveness of a Stroke Telerehabilitation program (STeleR) among 52 veterans who had suffered a stroke within the previous two years. The intervention, which focused on improvement of functional mobility, included 3 components: 3x 1 hour televisits to the participant’s home, 5 telephone calls and an in-home messaging device system to instruct patients on functional exercises and adaptive strategies. At 6 months, there were no significant differences in the primary outcomes, the Telephone Version of FIM, the Late-Life Function and Disability Instrument or Falls Efficacy Scale, between groups. There was a significant difference between groups, from baseline to 6 months, in the mean Stroke-specific Patient Satisfaction with Care Scale (hospital care sub score) at 6 months, favouring the STeleR group, but not in the home care sub scale.

Lai et al. (2004) conducted an 8-week therapy program designed to improve strength and balance and to provide social support and education, which was delivered by a physiotherapist located off site to patients at a community centre for seniors, via videoconferencing. There was significant improvement at the end of the intervention in all outcomes assessed including the Berg Balance Scale, State Self-Esteem Scale, SF-36, and a 10-item stroke knowledge test. In addition, 63% and 37% of participants rated the clinical effectiveness of the program as good and excellent, respectively. In another positive trial, telerehab was used to provide in-home therapy to patients with moderate upper-extremity motor impairment one year following stroke (Piron et al. 2009).  Patients in the intervention group performed exercises using a PC-based virtual reality system, where a therapist provided feedback remotely. Patients in the control group received conventional physical therapy.  The duration of the program for patients in both groups was one month. At the end of the program, although minor problems with the quality of the broadband transmission were reported, patients in the tele-rehab group had significantly higher Fugl-Meyer Assessment (upper-extremity) scores compared with patients in the control group (53.6 vs. 49.5, p<0.05). The gains achieved were maintained at 1-month follow-up.

The use of telestroke to support secondary stroke prevention has gained some momentum.  Across Canada and in some other jurisdictions, telestroke is being used to support stroke prevention for people with stroke living in geographic areas that are more rural and/or lack local access to stroke expertise. Currently, there is a lack of research evidence to quantify the benefits and differences in outcomes compared to areas not using telestroke.  This knowledge gap should drive future research agendas.