Transfer of Patients in a Telestroke Network: What Are the Relevant Factors for Making This Decision?

Considerations for the Implementation of a Telestroke Network: A Systematic Review

The application of telestroke has matured considerably since its inception in 1999. The use of telestroke is now recommended in several published guidelines. Consequently, jurisdictions without a telestroke service are seeking practical information on the best approach to implement telestroke. French et al. (2013) reviewed the challenges of implementing a telestroke network including studies between 2000 and 2010. At the time, telestroke networks were largely limited to the UK, USA, Canada and Europe and only one process evaluation had been conducted. Given the prolific expansion of telestroke services since 2010, we conducted a systematic review to determine factors associated with successful establishment, management, and sustainability of a contemporary telestroke services. A comprehensive search of telestroke studies was conducted in July 2021. Empirical studies published between 2010 and 2021 were included if they contained descriptive, evaluation or operational data on the implementation of a telestroke network. Studies were subsequently evaluated using the Consolidated Framework for Implementation Research (CFIR). The initial literature search revealed a total of 7415 potential studies; 38 of which met the inclusion criteria. The past decade of process evaluation studies has enabled a more nuanced investigations into how to implement and sustain a telestroke network. Pre-implementation planning is crucial to ensure clear telestroke processes, governance structures and stakeholder engagement. Sustainability of networks relies on securing long-term investment, providing adequate resources, and maintaining staff motivation and willingness. Recommendations are provided to overcome commonly identified barriers related to technology, staffing, planning and standardisation of processes, evaluation, and sustainability and scale-up. Further research needs to explore how new advancements in stroke care such as endovascular clot retrieval (EVT) and advanced brain imaging can be considered and planned for during the implementation of a new telestroke service.

Association of Hospital Telestroke Adoption With Changes in Initial Hospital Presentation and Transfers Among Patients With Stroke and Transient Ischemic Attacks

IMPORTANCE

It has been proposed that the implementation of telestroke services (a web-based approach to using video telecommunication to treat patients with stroke before hospital admission) changes where patients with stroke symptoms receive care, but this proposal has not been rigorously assessed.

OBJECTIVE

To assess whether the implementation of telestroke services is associated with changes in where and how patients initially present with stroke symptoms, in their decision to be transferred to another hospital, and which hospitals they are transferred to.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study compared changes in stroke systems of care between a sample of 593 US hospitals that adopted telestroke during the period from 2009 to 2016 but were not comprehensive stroke centers, major teaching hospitals, or thrombectomy-capable hospitals vs 593 matched control hospitals without telestroke based on rural location, critical access hospital status, bed size, primary stroke center status, presence of hospital alternatives in the community, hospital stroke volume, census region, and ownership. With the use of data on 100% of Medicare fee-for-service beneficiaries, all stroke and transient ischemic attack admissions from 2008 to 2018 were identified.

EXPOSURES

For each hospital pair (telestroke plus matched control), the telestroke hospital's implementation date and difference-in-differences approach were used to quantify the association between telestroke implementation and changes in care from 2 years before implementation to 2 years after implementation. Models also controlled for differences in observed patient characteristics.

MAIN OUTCOMES AND MEASURES

Hospital stroke volume, patients' ambulance transport distance to initial hospital, hospital case mix, interhospital transfer proportion, and size of the receiving hospital for transferred patients.

RESULTS

Of the 669 telestroke hospitals and 2143 potential control hospitals, 593 hospital pairs were matched; in each category, 261 hospitals (44.0%) were located in a rural area, 179 (30.2%) were primary stroke centers, and 130 (21.9%) were critical access hospitals. The changes in the preimplementation to postimplementation period were similar at telestroke and control hospitals in mean annual stroke volume (telestroke hospitals, decreased from 79.6 to 76.3 patients; control hospitals, decreased from 78.8 to 75.5 patients [-3.3 patients per year for both; difference-in-differences, 0.009; P ≥ .99]). Similarly, no differences were seen in ambulance transport distance, case mix, interhospital transfers, or bed size of receiving hospitals among transferred patients.

CONCLUSIONS AND RELEVANCE

This study suggests that, across a national sample of hospitals implementing telestroke, no association between telestroke adoption and changes in stroke systems of care were found.

The Effect of Endovascular Thrombectomy Studies on the Decision to Transfer Patients in a Telestroke Network

Background/Introduction: In 2015, five high-quality trials demonstrated the effectiveness of endovascular thrombectomy for certain patients. Patient selection for transfer to a hub hospital is mostly focused on the patient's eligibility for a potential thrombectomy. However, it remains challenging to correctly select those patients with the highest probability of undergoing a thrombectomy. Materials and Methods: In this study, we investigated which factors promote or impede the transfer of patients and whether the impact of these factors has changed since the publication of the five randomized thrombectomy studies in 2015. We analyzed 12,048 cases of telestroke consultation from the stroke telemedicine network in Thuringia (SATELIT) and compared the decision-making process related to patient transfer based on consultations that occurred before and after 2015. Results: In both time intervals, we found that the patient's age and the identification of a proximal vessel occlusion independently influenced the decision to transfer a patient. The age factor remained unchanged over time. A known proximal intracranial vessel occlusion had a strong positive influence on the decision to transfer patients. Discussion: The decision of whether to transfer a patient is currently focused on the identification of intracranial vessel occlusion. However, the age of the patient remains an unchanged but important factor that might be overemphasized. The time elapsed from symptom onset to consultation was not found to have an independent influence on the decision-making process, so it might be underemphasized. Conclusions: The decision-making process to transfer a patient within our telestroke network has been strongly affected by the publication of the endovascular thrombectomy studies, but those studies are not solely optimized for this aim.

Telehealth for Remote Stroke Management

Stroke is a leading cause of adult disability and the fourth leading cause of death in Canada. Most strokes are ischemic and functional outcome is highly time-dependent, making fast diagnosis and treatment initiation crucial. This poses a challenge in vast geographical areas where stroke neurology expertise is only available in urban centres. In this article we review the rationale for telestroke networks and their current implementation in Canada. Telestroke networks enable stroke-specific procedures to be performed by less experienced physicians under the guidance of stroke neurology experts. We also present evidence that the safety and effectiveness of intravenous alteplase in community hospitals in a telestroke network seems to be comparable with that achieved in dedicated stroke centres. It is thus a viable option to guarantee an aging population access to stroke care across large geographic regions with faster treatment and access to more advanced treatment options by means of transfer to a comprehensive centre if necessary. Although telestroke networks have an upfront implementation cost, they can lead to reduced direct and indirect costs for the health care system by reducing days spent in the hospital as well as disability with the need for long-term care. Telestroke networks can also be used for identification and enrollment of patients into emergency stroke trials and thus provide a more representative sample of the population and increase recruitment. Standardization of regional telestroke networks could lead to collaborations with larger data acquisitions for research purposes and quality control in the future.

Review. Regional Networks in Acute Cardiac Care

In acute cardiac care, the timely initiation of life-saving measures proved to be life-saving and requires many organizational and logistic measures. One of such measures is represented by the development and implementation of a regional network dedicated for the treatment of major cardiovascular emergencies, a strategy that proved to significantly reduce mortality rates on short and long term. This review aims to describe the current status in the development of regional networks in three of the main cardiovascular emergencies: acute myocardial infarction, out-of-hospital cardiac arrest, and acute stroke. The concepts demonstrating the utility of such networks, together with their results in reducing cardiac events, are presented in this paper.