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Section 8.2

Telestroke Recommendations

4th Edition
2012-2013 UPDATE
September 30, 2013

Delivery of Stroke Care Using Telestroke Technology

8.0 Telestroke care delivery modalities should be integrated into stroke care planning and service delivery across the continuum to ensure equal access to care across geographic regions in Canada [Evidence Level C]. Telestroke is a modality that should be included as part of an organized stroke strategy within facilities and regions.

8.1 Organization of Telestroke Services for Hyperacute Stroke Management

  1. Telestroke networks should be implemented to provide access to stroke expert consultations for hyperacute and acute stroke assessment, diagnosis and treatment, including thrombolytic therapy with tissue plasminogen activator (tPA). [Evidence Level B].
    1. Consulting and referring sites should have processes in place to ensure access to stroke experts through Telestroke modalities, available 24 hours a day, seven days a week to provide equal access to stroke care across geographic regions in Canada [Evidence Level B].
  2. 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 [Evidence Level B]. Refer to Telestroke Resource Toolkit for additional details.
  3. Clearly defined criteria and protocols should be available for referring sites to determine when and how, and to whom to initiate a hyperacute Telestroke referral [Evidence Level B]. This referral system should be part of a coordinated system of stroke care within geographic regions in Canada. Refer to Telestroke Resource Toolkit for additional details and examples.
  4. The consultant should be a physician with specialized training in stroke management, and must have timely access to diagnostic-quality CT images during the Telestroke consultation [Evidence Level A]. Refer to Telestroke Resource Toolkit Technical section for additional details.
  5. Two-way audiovisual communication should be in place to enable remote clinical assessment of the patient by the consulting stroke expert [Evidence Level B].
    1. 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].
  6. All laboratory and diagnostic results required by the consultant should be made readily available during the telestroke consultation [Evidence Level B].
  7. Referring physicians should follow an algorithm agreed upon by both referring and consulting sites which describes inclusion and exclusion criteria for thrombolytic therapy [Evidence Level A].
  8. Referring physician and nursing staff who may be involved in acute Telestroke consultations should be trained in administration of the National Institute of Health Stroke Scale (NIHSS), to efficiently and competently assist the Telestroke consultant with the remote video neurological examination. Ideally referring physicians should be trained in the NIHSS [Evidence Level B].
  9. 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].
  10. A consulting physician should remain available to provide ongoing guidance to the referring site as required following initial consultation [Evidence Level C].
  11. Protocols should be in place to define criteria for patient transfer to a more advanced level of stroke care facility when clinically indicated [Evidence Level C].
  12. Standardized documentation should be completed by both the referring site and the consulting site (in accordance to hospital processes, jurisdictional legislation, and regulatory bodies) [Evidence Level C].
    1. 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].
    2. The referring site should send a discharge summary to the consulting Telestroke physician to provide feedback about the patient’s outcome [Evidence Level C].
    3. Data related to the Telestroke consultation and outcome should be captured and collected by the Telestroke Program for continuing quality improvement [Evidence Level C].

8.2 Organization of Telestroke Services for Ongoing Stroke Assessment and Management

  1. Telestroke services should be part of an integrated stroke services delivery plan that addresses hyperacute stroke care, acute stroke care, and also includes stroke prevention, rehabilitation, home-based and ambulatory care to support optimal patient recovery and family support regardless of geographic location [Evidence Level C].
  2. Two-way audiovisual communication should be in place to enable referring hospitals to request Telestroke consultations regarding:
    1. Optimal in-hospital stroke care (virtual stroke unit) [Evidence Level C].
    2. Stroke rehabilitation services, where all rehabilitation disciplines should consider the use of telemedicine technology for patient assessment and clinical therapies (example, exercise monitoring and intensity adjustments, speech therapies for aphasia) [Evidence Level C].
    3. Secondary prevention consultation and follow-up services in communities where these services do not exist [Evidence Level A].
    4. Home-based patient monitoring through web-based applications should be considered as an alternative to face-to-face clinic visits in instances where frequent patient monitoring is necessary, such as for out-patient rehabilitation services [Evidence Level C].
  3. Clearly defined criteria and protocols or algorithms should be available for referring sites to determine when and how to access these rehabilitation, prevention and ambulatory services for stroke patients [Evidence Level B].
  4. The consulting healthcare provider should provide documentation to the referring site to be included in the patient medical record, regarding patient progress, treatment plans, plans for ongoing follow-up, and discharge recommendations (in accordance with clinical care processes, organizational requirements, jurisdictional legislation, and regulatory bodies) [Evidence Level C].

8.3 Staff Training and Ongoing Education

  1. Referring and consulting service providers should be trained in using the Telestroke system and understand their roles and responsibilities for technical aspects of a Telestroke consultation [Evidence Level C].
  2. Training should include physicians, nurses, therapists and any support staff (such as members of technology department), who may be involved in any Telestroke consultation or therapy appointment [Evidence Level C].
  3. Telestroke training and education should be ongoing with a regular update cycle to ensure competency [Evidence Level C]. Refer to Telestroke Resource Toolkit Technical section for additional information and resources for staff training.
  4. Consulting physicians and other healthcare professionals involved in Telestroke consults should have expertise and experience in managing stroke patients [Evidence Level C].
  5. Education should be made available in online format as well as standard face to face teaching in order to ensure that remote based practitioners have access to ongoing education [Evidence Level C].
Rationale

Telestroke technology is a care delivery modality that is available to support equal and timely access to optimal stroke services across the continuum of care and across geographic regions.  In many communities there are no neurologists, other physicians with expertise in stroke care 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 treating hospital (facility) and the patient’s location.  In the hyperacute setting, 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 virtually (i.e., "electronically"). Patients assessed by a stroke expert through the 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. This includes 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, and new evidence is starting to emerge for 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
  • Commitment and funding for Telestroke network development is required at the facility, regional and/or provincial funder levels.
  • A governance structure with a clear framework of accountabilities for Telestroke services
  • Telestroke must be included 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.  Signed services agreements should be in place and include recognition of possible transfer of patients to appropriate sites with more advanced stroke services if clinically indicated.
  • Involvement of providers from all parts of the continuum of care are important to ensure a coordinated Telestroke effort (e.g., EMS, emergency, radiology, inpatient units, ICU, and rehabilitation services).
  • Human, technological, and financial resources to establish Telestroke networks and appropriate training.
  • Patient and family education, and informed consent 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 are familiar with operating the technology, including regular updates to maintain competence
  • Agreements and protocols for interprovincial consultations where appropriate.
Performance Measures
  1. 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.
  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
    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. Percentage of telestroke patient consults who are treated with tPA.
  6. Proportion of stroke patients managed with telestroke who received tPA, who had a symptomatic secondary intracerebral hemorrhage, systemic hemorrhage, died in hospital, and were discharged to long-term care vs. home or to rehabilitation.
  7. Percentage of patients managed with Telestroke where the Telestroke consultant’s note is found in the patient’s chart.
  8. 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).
  9. Median duration per 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. 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.

 

Implementation Resources and Knowledge Transfer Tools
  • Refer to Telestroke Implementation Resource Toolkit for comprehensive implementation tools for developing a business case, to planning for a Telestroke program, implementation, technological considerations, and evaluation approaches.
Summary of the Evidence, Evidence Tables and References

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).  In some of these studies, although minor technical difficulties were reported, the number of patients treated with tPA 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 tPA during the implementation of the telestroke system compared with the 13-month period prior to its implementation (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).

The outcomes of patients treated at “spoke” hospitals were similar to those of patients treated at the “hub” sites. In one of the larger studies (n=6,610), although a higher percentage of eligible patients at 2 academic stroke centres were treated with tPA over a one-year period as compared with those admitted to 12 regional hospitals offering telestroke services, there were no differences in the rates 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) (Audebert et al. 2005). Schwab et al. (2007) compared 170 patients who received tPA following telestroke consultation and 132 consecutive patients who had been treated in one of the two stroke centres and received tPA over the same time period. Mean time from stroke onset to administration of tPA 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 tPA (Pervez et al. 2010). Treatment with tPA 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.

Evidence 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 tPA treatment. Consultations were provided by staff at a single hub institution to patients located at 4 remote sites. The number of patients treated with tPA was similar between groups (28% vs. 23%, p=0.425). Mean times from stroke onset to tPA 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 outcome, 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.  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 tPA 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”. An 8-week therapy program designed to improve strength and balance and to provide social support and education 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 (Lai et al. 2004). In another 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).  In this RCT, 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 1 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.

Evidence Table 8.0 (Telestroke) and Reference List