Long-Term Effects of Specialized Stroke Care With Telemedicine Support in Community Hospitals on Behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS)

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Modeling optimal patient transport in a stroke network capable of remote telerobotic endovascular therapy

BACKGROUND

Telerobotic endovascular therapy (EVT) has the potential to decrease time to treatment and expand existing networks of care to more rural populations. It is currently unclear how its implementation would impact existing stroke networks.

METHODS

Conditional probability models were generated to predict the probability of excellent outcome for patients with suspected large vessel occlusion (LVO). A baseline stroke network was created for California using existing intravenous thrombolysis (IVT) centers and comprehensive stroke centers (CSCs) capable of IVT and EVT. Optimal transport decisions and catchment areas were generated for the baseline model and three hypothetical scenarios through conversion of IVT centers at various distances from a CSC into centers capable of telerobotic EVT [i.e., hospitals ≥15 and <50 miles from a CSC were converted (Scenario 1), ≥50 and <100 miles (Scenario 2), and ≥100 miles (Scenario 3)]. Procedural times and success rates were varied systematically.

RESULTS

Telerobotic EVT centers decreased median travel time for LVO patients in all three scenarios. The estimated number of robotically treated LVOs per year in Scenarios 1, 2, and 3 were 2,172, 740, and 212, respectively. Scenario 1 (15-50 miles) was the most sensitive to robotic time delay and success rate, but all three scenarios were more sensitive to decreases in procedural success rate compared to time delay.

CONCLUSIONS

Telerobotic EVT has the potential to improve care for stroke patients outside of major urban centers. Compared to procedural time delays in robotic EVT, a decrease in procedural success rate would not be well tolerated.

Recommendations for the organization of the teleconsultation service in a telestroke network

Telestroke networks aim to improve acute stroke care within their catchment area. Through a teleconsultation service, the network centers provide support to network hospitals that lack continuous neurological expertise for acute stroke management decisions. Although the importance of telemedical treatment in stroke care is steadily increasing, so far no standards exist for the organization of the teleconsultation service in networks.To ensure a high-level of quality for all processes and measures concerning telemedical stroke treatment, the commission for telemedical stroke care of the German Stroke Society (Deutsche Schlaganfall-Gesellschaft, DSG) created the following recommendations on how to organize a teleconsultation service within a telestroke network. The recommendations are the result of an adjustment process between the authors and include guidance on requirements, qualifications, processes and quality management within the teleconsultation service.

Current trends and future perspectives of stroke management through integrating health care team and nanodrug delivery strategy

Stroke is accounted as the second-most mortality and adult disability factor in worldwide, while causes the bleeding promptly and lifetime consequences. The employed functional recovery after stroke is highly variable, allowing to deliver proper interventions to the right stroke patient at a specific time. Accordingly, the multidisciplinary nursing team, and the administrated drugs are major key-building-blocks to enhance stroke treatment efficiency. Regarding the healthcare team, adequate continuum of care have been declared as an integral part of the treatment process from the pre-hospital, in-hospital, to acute post-discharge phases. As a curative perspective, drugs administration is also vital in surviving at the early step and reducing the probability of disabilities in later. In this regard, nanotechnology-based medicinal strategy is exorbitantly burgeoning. In this review, we have highlighted the effectiveness of current clinical care considered by nursing teams to treat stroke. Also, the advancement of drugs through synthesis of miniaturized nanodrug formations relating stroke treatment is remarked. Finally, the remained challenges toward standardizing the healthcare team and minimizing the nanodrugs downsides are discussed. The findings ensure that future works on normalizing the healthcare nursing teams integrated with artificial intelligence technology, as well as advancing the operative nanodrugs can provide value-based stroke cares.

Clinical Course and Recurrence in Transient Global Amnesia: A Study From the TEMPiS Telestroke Network

BACKGROUND AND PURPOSE

While the clinical hallmarks of transient global amnesia (TGA) are well defined, its pathophysiological causes are poorly understood. Specifically, risk factors for recurrences are yet to be determined.

METHODS

This retrospective study analyzed TGA cases diagnosed and treated within the TEMPiS telestroke network and a university stroke center in Germany. Demographic and clinical data were assessed and characteristics of TGA episodes were recorded, such as season of occurrence, trigger factors, duration, and concomitant symptoms. Follow-up of the potential recurrence of TGA was performed using a standardized questionnaire.

RESULTS

Overall 109 patients were included (age 64±8 years [mean±SD], 59.6% female). The most common vascular risk factor was arterial hypertension (60.6%), and other concomitant conditions included migraine (11.9%), hypothyroidism (22.9%), and atrial fibrillation (4.6%). The most frequent concomitant clinical feature accompanying the TGA episode at admission was elevated blood pressure (48.6%). Nineteen patients experienced at least one recurrent TGA episode. Migraine and hypothyroidism were only observed in subjects with a single TGA episode without recurrence (migraine: 14.4% without recurrence vs. none in the recurrence group, p=0.02; hypothyroidism: 27.8% without recurrence vs. none in the recurrence group, p=0.009). In contrast, atrial fibrillation was more common in subjects with TGA recurrence (p<0.001).

CONCLUSIONS

Arterial hypertension is prevalent in TGA patients, with elevated blood pressure being the most-frequent concomitant condition. In our cohort, recurrence of TGA occurred in approximately one-fifth of patients. Concomitant conditions such as migraine, hypothyroidism, and atrial fibrillation occurred at different frequencies in the two groups.

The impact of telemedicine enabled pre-hospital triage in acute stroke - a protocol for a mixed methods systematic review

Introduction

Increasing access to thrombolysis and thrombectomy through improved pathway organisation remains a health service challenge that requires contextualisation to the geographic, demographic and resourcing status of any regional stroke service. Pre-hospital delays or delays during inter-hospital transfers can result in patients being outside the window for one or both interventions. Pre-hospital triage using technology-enabled interdisciplinary communication networks may facilitate rapid individualized care decisions, permitting streamlined care pathways to hospital sites most appropriate to their clinical presentation and history in the first instance. Understanding the experience of those involved in efforts to improve or reorganise care may help to explain the impact observed.

Objectives

1. To review the impact of pre-hospital telemedicine enabled workflow intervention strategies on patient outcomes and on service process metrics in hyper-acute stroke care2. To examine how the experience of those involved in providing or receiving such interventions might identify key characteristics of effective interventions.

Inclusion criteria

Quantitative, qualitative and primary mixed methods studies will be included. Quantitative studies will assess effectiveness of telemedicine-enabled interventions that facilitate pre-hospital acute stroke triage. Intervention effects on functional outcomes of patients, on intervention rates and on key time metrics in hyperacute stroke care will be assessed. Qualitative studies will explore the experiences of people involved in or impacted by these interventions.

Methods and analysis

A convergent segregated mixed methods systematic review will synthesise and integrate primary qualitative, quantitative and mixed methods studies using the Joanna Briggs Institute methodology. Database searches will include OVID (MEDLINE), EMBASE, The Cochrane Library, CINAHL and Web of Science. Critical appraisal will include the Mixed Methods Assessment Tool. Results of quantitative studies and findings of qualitative studies will be integrated and configured to explore and contextualize each single method synthesis.

Systematic review registration

This protocol has been submitted for registration with PROSPERO.

A Managed Care System with Telemedicine Support for Neurological Emergencies

OBJECTIVES

Telemedicine is frequently used to provide remote neurological expertise for acute stroke workup and was associated with better functional outcomes when combined with a stroke unit system-of-care. We investigated whether such system-of-care yields additional benefits when implemented on top of neurological competence already available onsite.

METHODS

Quality improvement measures were implemented within a "hub-and-spoke" teleneurology network in 11 hospitals already provided with onsite or telestroke expertise. Measures included dedicated units for neurological emergencies, standardization of procedures, multiprofessional training, and quality-of-care monitoring. Intervention effects were investigated in a controlled study enrolling patients insured at 3 participating statutory health insurances diagnosed with acute stroke or other neurological emergencies. Outcomes during the intervention period between November 2017 and February 2020 were compared with those pre-intervention between October 2014 and March 2017. To control for temporal trends, we compared outcomes of patients with respective diagnoses in 11 hospitals of the same region. Primary outcome was the composite of up-to-90-day death, new disability with the need of ambulatory or nursing home care, expressed by adjusted hazard ratio (aHR).

RESULTS

We included 1,418 patients post-implementation (55% female, mean age 76.7 ± 12.8 year) and 2,306 patients pre-implementation (56%, 75.8 ± 13.0 year, respectively). The primary outcome occurred in 479/1,418 (33.8%) patients post-implementation and in 829/2,306 (35.9%) pre-implementation. The aHR for the primary outcome was 0.89 (95% confidence interval [CI]: 0.79-0.99, p = 0.04) with no improvement seen in non-participating hospitals between post- versus pre-implementation periods (aHR 1.04; 95% CI: 0.95-1.15).

INTERPRETATION

Implementation of a multicomponent system-of-care was associated with a lower risk of poor outcomes. ANN NEUROL 2023;93:511-521.

Economic Evaluation of a Mobile Stroke Unit Service in Germany

BACKGROUND

Lower global disability and higher quality of life among ischemic stroke patients was found to be associated with the dispatch of mobile stroke units (MSUs) among patients eligible for recanalizing treatments in the Berlin_Prehospital Or Usual Delivery of stroke care (B_PROUD) study. The current study assessed the cost-utility and cost-effectiveness of additional MSU dispatch using data from this prospective, controlled, intervention study.

METHODS

Outcomes considered in the economic evaluation included quality-adjusted life years (QALYs) derived from the 3-level version of EQ-5D (EQ-5D-3L) and modified Rankin Scale (mRS) scores for functional outcomes 3-months after stroke. Costs were prospectively collected during the study by the MSU provider (Berlin Fire Brigade) and the B_PROUD research team. We focus our results on the societal perspective. As we aimed to determine the economic consequences of the intervention beyond the study's follow-up period, both care costs and QALYs were extrapolated over 5 years.

RESULTS

The additional MSU dispatch resulted in an incremental €40,984 per QALY. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €24,470.76 and €61,690.88 per QALY. In the cost-effectiveness analysis, MSU dispatch resulted in incremental costs of €81,491 per survival without disability. The best-case scenario and the worst-case scenario yielded additional costs of, respectively, €44,455.30 and €116,491.15 per survival without disability.

INTERPRETATION

Among patients eligible for recanalizing treatments in ischemic stroke, MSU dispatch was associated with both higher QALYs and higher costs and is cost-effective when considering internationally accepted thresholds ranging from an additional €40,000 to €80,000 per QALY. ANN NEUROL 2023.

Telestroke Infrastructure, Processes, and Support Needs: A Survey of Hospitals in Five States

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs.

The impact of telemedicine enabled pre-hospital triage in acute stroke – a protocol for a mixed methods systematic review

Introduction Increasing access to thrombolysis and thrombectomy through improved pathway organisation remains a health service challenge that requires contextualisation to the geographic, demographic and resourcing status of any regional stroke service. Pre-hospital delays or delays during inter-hospital transfers can result in patients being outside the window for one or both interventions. Pre-hospital triage using technology-enabled interdisciplinary communication networks may facilitate rapid individualized care decisions, permitting streamlined care pathways to hospital sites most appropriate to their clinical presentation and history in the first instance. Understanding the experience of those involved in efforts to improve or reorganise care may help to explain the impact observed. Objectives 1. To review the impact of pre-hospital telemedicine enabled workflow intervention strategies on patient outcomes and on service process metrics in hyper-acute stroke care 2. To examine how the experience of those involved in providing or receiving such interventions might identify key characteristics of effective interventions Inclusion criteria Quantitative, qualitative and primary mixed methods studies will be included. Quantitative studies will assess effectiveness of telemedicine-enabled interventions that facilitate pre-hospital acute stroke triage. Intervention effects on functional outcomes of patients, on intervention rates and on key time metrics in hyperacute stroke care will be assessed. Qualitative studies will explore the experiences of people involved in or impacted by these interventions. Methods and analysis A convergent segregated mixed methods systematic review will synthesise and integrate primary qualitative, quantitative and mixed methods studies using the Joanna Briggs Institute  methodology. Database searches will include OVID (MEDLINE), EMBASE, The Cochrane Library, CINAHL and Web of Science. Critical appraisal will include the Mixed Methods Assessment Tool. Results of quantitative studies and findings of qualitative studies will be integrated and configured to explore and contextualize each single method synthesis. Systematic review registration This protocol has been submitted for registration with PROSPERO.

Stroke care networks and the impact on quality of care

Lack of rapidly available neurological expertise, especially in rural areas, is one of the key obstacles in stroke care. Stroke care networks attempt to address this challenge by connecting hospitals with specialized stroke centers, stroke units, and hospitals of lower levels of care. While the benefits of stroke care networks are well-documented, travel distances are likely to increase when patients are transferred almost exclusively between members of the same network. This is particularly important for patients who require mechanical thrombectomy, an increasingly employed treatment method that requires equipment and expertise available in specialized stroke centers. This study aims to analyze the performance of the current design of stroke care networks in Bavaria, Germany, and to evaluate the improvement potential when the networks are redesigned to minimize travel distances. To this end, we define three fundamental criteria for assessing network design performance: 1) average travel distances, 2) the populace in the catchment area relative to the number of stroke units, and 3) the ratio of stroke units to lower-care hospitals. We generate several alternative stroke network designs using an analytical approach based on mathematical programming and clustering. Finally, we evaluate the performance of the existing networks in Bavaria via simulation. The results show that the current network design could be significantly improved concerning the average travel distances. Moreover, the existing networks are unnecessarily imbalanced when it comes to their number of stroke units per capita and the ratio of stroke units to lower-care hospitals.

Tele-EMS physicians improve life-threatening conditions during prehospital emergency missions

Almost seven years ago, a telemedicine system was established as an additional component of the city of Aachen's emergency medical service (EMS). It allows paramedics to engage in an immediate consultation with an EMS physician at any time. The system is not meant to replace the EMS physician on the scene during life-threatening emergencies. The aim of this study was to analyze teleconsultations during life-threatening missions and evaluate whether they improve patient care. Telemedical EMS (tele-EMS) physician consultations that occurred over the course of four years were evaluated. Missions were classified as involving potentially life-threatening conditions based on at least one of the following criteria: documented patient severity score, life-threatening vital signs, the judgement of the onsite EMS physician involved in the mission, or definite life-threatening diagnoses. The proportion of vital signs indicating that the patient was in a life-threatening condition was analyzed as the primary outcome at the start and end of the tele-EMS consultation. The secondary outcome parameters were the administered drug doses, tracer diagnoses made by the onsite EMS physicians during the missions, and quality of the documentation of the missions. From January 2015 to December 2018, a total of 10,362 tele-EMS consultations occurred; in 4,293 (41.4%) of the missions, the patient was initially in a potentially life-threatening condition. Out of those, a total of 3,441 (80.2%) missions were performed without an EMS physician at the scene. Records of 2,007 patients revealed 2,234 life-threatening vital signs of which 1,465 (65.6%) were remedied during the teleconsultation. Significant improvement was detected for oxygen saturation, hypotonia, tachy- and bradycardia, vigilance states, and hypoglycemia. Teleconsultation during missions involving patients with life-threatening conditions can significantly improve those patients' vital signs. Many potentially life-threatening cases could be handled by a tele-EMS physician as they did not require any invasive interventions that needed to be performed by an onsite EMS physician. Diagnoses of myocardial infarction, cardiac pulmonary edema, or malignant dysrhythmias necessitate the presence of onsite EMS physicians. Even during missions involving patients with life-threatening conditions, teleconsultation was feasible and often accessed by the paramedics.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

TeleNeurological evaluation and Support for the Emergency Department (TeleNS-ED): protocol for an open-label clinical trial

INTRODUCTION

The COVID-19 pandemic compelled health systems to protect patients and medical personnel during transit in hospitals by minimising transfers, prompting the use of telehealth systems. In the field of neurology, telemedicine has been used in emergency settings for acute stroke management between spoke and hub hospital networks, where good outcomes have been achieved. However, data on the use of telemedicine in non-stroke acute neurological conditions accessing the emergency department (ED) are currently missing.

METHODS AND ANALYSES

This is an interventional, open-label trial on the use of teleconsultation in the ED for neurological diseases other than stroke. The study aims to develop a remote consultancy system (TeleNeurological Evaluation and Support, TeleNS) for patients with acute neurological symptoms referred to hospital facilities without a 24-hour availability of a neurologist consultant (spoke hospitals). The study population will include 100 ED patients referred to two spoke hospitals in 6 months, who will be asked to perform teleconsultation instead of inperson visits. As a control group, retrospectively available data from patients admitted to the ED of spoke hospitals during the same time period over the last 2 years will be evaluated. The primary objective is to assess whether a TeleNS for the ED guarantees a faster but qualitatively non-inferior diagnostic/therapeutic work-up if compared with inperson examination, assuring the availability of all the necessary examinations and treatments with consistent time-saving.

ETHICS AND DISSEMINATION

The trial was designed following the national guidelines on clinical investigation on telemedicine provided by the Italian Ministry of Health and according to the Standard Protocol Items for Randomized Trials statement guidelines. This research protocol was approved by Comitato Etico Area Vasta Emilia Nord in September 2020 (number/identification: 942/2020/DISP/AOUMO SIRER ID 805) and was written without patient involvement. Patients' associations will be involved in the dissemination of study design and results. The results of the study will be presented during scientific symposia or published in scientific journals.

TRIAL REGISTRATION NUMBER

NCT04611295.

A Review of Robotic Interventional Neuroradiology

Robotic interventional neuroradiology is an emerging field with the potential to enhance patient safety, reduce occupational hazards, and expand systems of care. Endovascular robots allow the operator to precisely control guidewires and catheters from a lead-shielded cockpit located several feet (or potentially hundreds of miles) from the patient. This has opened up the possibility of expanding telestroke networks to patients without access to life-saving procedures such as stroke thrombectomy and cerebral aneurysm occlusion by highly-experienced physicians. The prototype machines, first developed in the early 2000s, have evolved into machines capable of a broad range of techniques, while incorporating newly automated maneuvers and safety algorithms. In recent years, preliminary clinical research has been published demonstrating the safety and feasibility of the technology in cerebral angiography and intracranial intervention. The next step is to conduct larger, multisite, prospective studies to assess generalizability and, ultimately, improve patient outcomes in neurovascular disease.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis

BACKGROUND

The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas.

METHODS

Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I²  = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I²  = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I²  = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I²  = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I²  = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences.

CONCLUSION

Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.

Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study

Background

Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions.

Methods

A “hub-and-spoke” network structure was implemented connecting three academic neurological centres (“hubs”) and rural hospitals (“spokes”) caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission.

Discussion

Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed.

Study registration

German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS00013068

Two years' experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke)

Background

Telemedicine improves the quality of acute stroke care in rural regions with limited access to specialized stroke care. We report the first 2 years’ experience of implementing a comprehensive telemedical stroke network comprising all levels of stroke care in a defined region.

Methods

The TRANSIT-Stroke network covers a mainly rural region in north-western Bavaria (Germany). All hospitals providing acute stroke care in this region participate in TRANSIT-Stroke, including four hospitals with a supra-regional certified stroke unit (SU) care (level III), three of those providing teleconsultation to two hospitals with a regional certified SU (level II) and five hospitals without specialized SU care (level I). For a two-year-period (01/2015 to 12/2016), data of eight of these hospitals were available; 13 evidence-based quality indicators (QIs) related to processes during hospitalisation were evaluated quarterly and compared according to predefined target values between level-I- and level-II/III-hospitals.

Results

Overall, 7881 patients were included (mean age 74.6 years ±12.8; 48.4% female). In level-II/III-hospitals adherence of all QIs to predefined targets was high ab initio. In level-I-hospitals, three patterns of QI-development were observed: a) high adherence ab initio (31%), mainly in secondary stroke prevention; b) improvement over time (44%), predominantly related to stroke specific diagnosis and in-hospital organization; c) no clear time trends (25%). Overall, 10 out of 13 QIs reached predefined target values of quality of care at the end of the observation period.

Conclusion

The implementation of the comprehensive TRANSIT-Stroke network resulted in an improvement of quality of care in level-I-hospitals.

Establishment of an internationally agreed minimum data set for acute telestroke

INTRODUCTION

Globally, the use of telestroke programmes for acute care is expanding. Currently, a standardised set of variables for enabling reliable international comparisons of telestroke programmes does not exist. The aim of the study was to establish a consensus-based, minimum dataset for acute telestroke to enable the reliable comparison of programmes, clinical management and patient outcomes.

METHODS

An initial scoping review of variables was conducted, supplemented by reaching out to colleagues leading some of these programmes in different countries. An international expert panel of clinicians, researchers and managers (n = 20) from the Australasia Pacific region, USA, UK and Europe was convened. A modified-Delphi technique was used to achieve consensus via online questionnaires, teleconferences and email.

RESULTS

Overall, 533 variables were initially identified and harmonised into 159 variables for the expert panel to review. The final dataset included 110 variables covering three themes (service configuration, consultations, patient information) and 12 categories: (1) details about telestroke network/programme (n = 12), (2) details about initiating hospital (n = 10), (3) telestroke consultation (n = 17), (4) patient characteristics (n = 7), (5) presentation to hospital (n = 5), (6) general clinical care within first 24 hours (n = 10), (7) thrombolysis treatment (n = 10), (8) endovascular treatment (n = 13), (9) neurosurgery treatment (n = 8), (10) processes of care beyond 24 hours (n = 7), (11) discharge information (n = 5), (12) post-discharge and follow-up data (n = 6).

DISCUSSION

The acute telestroke minimum dataset provides a recommended set of variables to systematically evaluate acute telestroke programmes in different countries. Adoption is recommended for new and existing services.

[Telemedicine projects in rural areas of Germany. A systematic evaluation with the "Model for Assessment of Telemedicine"]

BACKGROUND

The term telemedicine describes the delivery of healthcare services through the use of information and communication technologies in a situation where the actors are at different locations. While telemedical applications are piloted in research projects in Germany, they have rarely become part of everyday care. In order to find indications as to why the transfer of knowledge into practice has so far been slow, it is necessary to examine telemedical projects for aspects of implementation science.

METHODS

A systematic search looking for telemedical projects in Germany was conducted in the electronic databases PubMed, Web of Science and ACM Digital Library using a complex search strategy. The criteria and domains of the Model for Assessment of Telemedicine (MAST) were used to evaluate the publications.

RESULTS

A total of 336 publications were identified, 16 of which were ultimately included in the analysis. Much of the work deals with stroke and the implementation of telemedicine networks. The analysis according to MAST shows that most publications omit essential considerations.

CONCLUSION

Publications on telemedical projects are often characterized by unsystematic approaches. The MAST instrument identifies areas where the approaches to telemedical projects could be extended in the future to ensure the sustainability and feasibility of these prototypical telemedical applications.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.

Action Plan for Stroke in Europe 2018-2030

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

Sustainable implementation of innovative, technology-based health care practices: A qualitative case study from stroke telemedicine

INTRODUCTION

Technology-based innovation requires long-term changes to workforce routines, otherwise practices will not be sustained. The aim of this study was to identify influential factors in the ongoing use of an acute stroke telemedicine programme.

METHODS

A new acute stroke telemedicine programme in a regional hospital receiving 375 patients with stroke or transient ischaemic attack per year was used as an exploratory case study. Semi-structured interviews with acute care and emergency department clinicians (n = 25) were conducted at two time-points: after a six-month pilot and then after a further 12-month implementation phase. Interviews (between 12-60 min) were recorded, transcribed and analysed inductively using descriptive thematic analysis. Reported barriers and facilitators were compared with those previously reported pre-implementation (deductive analysis) to identify changes over time. Using an implementation framework and a behaviour change taxonomy, strategies were developed to address influential factors on sustainability.

RESULTS

New facilitators were identified including hospital system changes, benefits to clinicians and telemedicine becoming standard practice. New and ongoing barriers included infrequent use, competing demands and the continued resistance to a specific treatment.

DISCUSSION

Understanding the factors supporting a health service in successfully implementing change can accelerate population benefits. The innovation itself may include barriers to be addressed, and barriers and facilitators can change over time. Individual attitudes remain critical to initial and ongoing success. Strategies proposed included promoting benefits across the organisation and allaying uncertainties with site-specific evidence. The effectiveness of these strategies, however, needs to be evaluated. Strategies sustaining change post-implementation should be considered.

Impact of simulation training on a telestroke network

Background

Stroke is a leading cause of morbidity and mortality in Brazil, where there are significant imbalances in access to specialized stroke care. Telemedicine networks allow patients to receive neurological evaluation and intravenous thrombolysis in underserved areas, where performance measures are challenging.

Aims

To describe the impact caused by adequate stroke care training, using realistic simulation, in a developing country telestroke network.

Methods

Retrospective observational study comparing the number of all stroke diagnoses, thrombolysis rate, door-to-needle time and symptomatic intracranial hemorrhage after intravenous thrombolysis, during one year providing just algorithms and orientation in stroke care to spoke facilities (phase 1), with the results achieved along one year after the beginning of ongoing live training sessions (phase 2).

Results

The mean number of patients diagnosed with stroke increased from 7.5 to 16.58 per month ( P = 0.019) rising from 90 patients during phase 1 to 199 in phase 2. There was a reduction in the mean door-to-needle time from 137.1 to 95.5 min (−41.58; 95% CI −62.77 to −20.40). The thrombolysis and symptomatic intracranial hemorrhage rates had a non-significant decrease from 21.31% to 18.18% (OR 0.82; 95% CI 0.39 to 1.71) and 12.5% to 7.69% (OR 0.58; 95% CI 0.046 to 7.425), respectively.

Conclusions

Realistic simulation stroke care training provided by stroke centers to spoke facilities seems to significantly reduce door-to-needle time and enhance adherence in a telestroke network.

Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System

Supplemental Digital Content is available in the text.

Background and Purpose—

Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California’s Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates.

Methods—

The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge.

Results—

This study included 310 patients treated with alteplase in the pre–EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29).

Conclusions—

Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.

[Telemedicine in stroke care]

Telemedicine is already widely used in many telestroke networks and ensures stroke treatment close to the patient's home in rural and medically underserved areas. This is particularly effective when telemedicine is integrated into a stroke unit concept. While telemedically based thrombolysis therapy has become routine practice for many years, practical implementation of comprehensive mechanical thrombectomy and the related processes remains challenging. The main tasks for the future further include development of a structured stroke aftercare system in neurologically underserved areas and permanent assurance of high-quality stroke care in telemedically connected sites.

Exploring the benefits of a stroke telemedicine programme: An organisational and societal perspective

We undertook a qualitative analysis to identify the broader benefits of a state-wide acute stroke telemedicine service beyond the patient-clinician consultation. Since 2010, the Victorian Stroke Telemedicine (VST) programme has provided a clinical service for regional hospitals in Victoria, Australia. The benefits of the Victorian Stroke Telemedicine programme were identified through document analysis of governance activities, including communications logs and reports from hospital co-ordinators of the programme. Discussions with the Victorian Stroke Telemedicine management were undertaken and field notes were also reviewed. Several benefits of telemedicine were identified within and across participating hospitals, as well as for the state government and community. For hospitals, standardisation of clinical processes was reported, including improved stroke care co-ordination. Capacity building occurred through professional development and educational workshops. Enhanced networking, and resource sharing across hospitals was achieved between hospitals and organisations. Governments leveraged the Victorian Stroke Telemedicine programme infrastructure to provide immediate access to new treatments for acute stroke care in regional areas. Standardised data collection allowed routine quality of care monitoring. Community awareness of stroke symptoms occurred with media reports on the novel technology and improved patient outcomes. The value of telemedicine services extends beyond those involved in the clinical consultation to healthcare funders and the community.

Telemedical strategies for the improvement of secondary prevention in patients with cerebrovascular events—A systematic review and meta-analysis

Background

Data from European countries consistently show that guideline-conform secondary prevention after stroke/transient ischemic attack is being realized in only 50–80% of patients. Use of telemedicine to support long-term secondary prevention has been effective in other cardiovascular diseases.

Aims

We reviewed current evidence for telemedical-supported strategies for the improvement of secondary prevention after stroke/transient ischemic attack. A systematic review was performed in accordance with the PRISMA statement searching MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 18 May 2016. Randomized controlled trials and observational studies were included if they analyzed the effect of a telemedical strategy for supporting secondary prevention after stroke/transient ischemic attack compared to usual care and reported primary (behavior according to guidelines, e.g., medication adherence) or surrogate outcomes (consequences of primary outcome, e.g., blood pressure).

Summary of review

The review included 13 of 100 identified studies involving 2672 patients. Telemedical support mainly comprised telephone interventions, predominantly done by nurses. Outcomes were heterogeneous: medication adherence did not differ in one randomized controlled trial (p = 0.089). Mortality was reported in one study and was significantly (p < 0.001) higher in patients non-participating in a web-based intervention. Four studies assessed blood pressure in a comparable way that allowed calculation of a meta-analysis. In that, telemedical intervention had a significant blood-pressure lowering effect compared to the control group (mean difference −6.14 (95% confidence interval −10.41, −1.87), p = 0.005).

Conclusions

Telemedical-supported secondary prevention in cerebrovascular diseases might be effective but larger trials with standardized interventions and outcome measures including clinical endpoints are needed.

Telemedical support for prehospital Emergency Medical Service (TEMS trial): study protocol for a randomized controlled trial

Background

Increasing numbers of emergency calls, shortages of Emergency Medical Service (EMS), physicians, prolonged emergency response times and regionally different quality of treatment by EMS physicians require improvement of this system. Telemedical solutions have been shown to be beneficial in different emergency projects, focused on specific disease patterns. Our previous pilot studies have shown that the implementation of a holistic prehospital EMS teleconsultation system, between paramedics and experienced tele-EMS physicians, is safe and feasible in different emergency situations. We aim to extend the clinical indications for this teleconsultation system. We hypothesize that the use of a tele-EMS physician is noninferior regarding the occurrence of system-induced patient adverse events and superior regarding secondary outcome parameters, such as the quality of guideline-conforming treatment and documentation, when compared to conventional EMS-physician treatment.

Methods/design

Three thousand and ten patients will be included in this single-center, open-label, randomized controlled, noninferiority trial with two parallel arms. According to the inclusion criteria, all emergency cases involving adult patients who require EMS-physician treatment, excluding life-threatening cases, will be randomly assigned by the EMS dispatching center into two groups. One thousand five hundred and five patients in the control group will be treated by a conventional EMS physician on scene, and 1505 patients in the intervention group will be treated by paramedics who are concurrently instructed by the tele-EMS physicians at the teleconsultation center. The primary outcome measure will include the rate of treatment-specific adverse events in relation to the kind of EMS physician used. The secondary outcome measures will record the specific treatment-associated quality indicators.

Discussion

The evidence underlines the better quality of service using telemedicine networks between medical personnel and medical experts in prehospital emergency care, as well as in other medical areas. The worldwide unique EMS teleconsultation system in Aachen has been optimized and evaluated in pilot studies and subsequently integrated into routine use for a broad spectrum of indications. It has enabled prompt, safe and efficient patient treatment with optimized use of the “resource” EMS physician. There is, however, a lack of evidence as to whether the advantages of the teleconsultation system can be replicated in wider-ranging EMS-physician indications (excluding life-threatening emergency calls).

Trial registration

ClinicalTrials.gov, identifier: NCT02617875. Registered on 24 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1781-2) contains supplementary material, which is available to authorized users.

[Telemedicine: Comprehensive coverage and quality - Not a contradiction : Practical experience from the stroke network with telemedicine in northern Bavaria (STENO)]

Telemedicine is widely used in the field of stroke treatment. Following the pioneering and implementation phase, the quality of the whole stroke treatment process needs to be ensured in telemedically connected hospitals. This is particular important for telestroke hospitals without neurological expertise and can be achieved by integrating telemedicine into the stroke unit concept and stroke networks. The Stroke Network with Telemedicine in Northern Bavaria (STENO) provides an example of how quality management can be practically implemented. The implementation of STENO has established a network-wide quality management system which has been certified according to DIN EN ISO 9001:2008 since 2011.

Setting up a Neuroscience Stroke and Rehabilitation Centre in Brunei Darussalam by a transcontinental on-site and telemedical cooperation

Due to the world-wide aging population, there is a need for specialist neurological knowledge, treatment and care. Stroke treatment is effective in reducing mortality and disability, but it is still not available in many areas of the world. We describe the set-up process of a specialized Neuroscience, Stroke and Rehabilitation Centre in Brunei Darussalam (BNSRC) in cooperation with a German hospital. This study details the setup of a stroke-, neurological intensive care- and neurorehabilitation unit, laboratories and a telemedical network to perform all evidence-based stroke treatments. All neurological on-site services and the telemedical network were successfully established within a short time. After setup, 1386 inpatients and 1803 outpatients with stroke and stroke mimics were treated. All evidence-based stroke treatments including thrombolysis and hemicraniectomy could be performed. It is possible to establish evidence-based modern stroke treatment within a short time period by a transcontinental on-site and telemedical cooperation.

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care.

METHODS

A literature search was undertaken to examine the current status of telestroke and relevant quality indicators. The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus.

RESULTS

Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation.

A systematic review of the methodologies used to evaluate telemedicine service initiatives in hospital facilities

BACKGROUND

The adoption of telemedicine into mainstream health services has been slower than expected. Many telemedicine projects tend not to progress beyond the trial phase; there are a large number of pilot or project publications and fewer 'service' publications. This issue has been noted since 1999 and continues to be acknowledged in the literature. While overall telemedicine uptake has been slow, some services have been successful. The reporting and evaluation of these successful services may help to improve future uptake and sustainability. The aim of this literature review was to identify peer-reviewed publications of deployed telemedicine services in hospital facilities; and to report, and appraise, the methodology used to evaluate these services.

METHODS

Computerised literature searches of bibliographic databases were performed using the MeSH terms for "Telemedicine" and "Hospital Services" or "Hospital", for papers published up to May 2016.

RESULTS

A total of 164 papers were identified, representing 137 telemedicine services. The majority of reported telemedicine services were based in the United States of America (n=61, 44.5%). Almost two thirds of the services (n=86, 62.7%) were delivered by real time telemedicine. Of the reviewed studies, almost half (n=81, 49.3%) assessed their services from three different evaluation perspectives: clinical outcomes, economics and satisfaction. While the remaining half (n=83, 50.6%) described their service and its activities without reporting any evaluation measures. Only 30 (18.2%) studies indicated a two-step implementation and evaluation process. There was limited information in all reported studies regarding description of a structured planning strategy.

CONCLUSION

Our systematic review identified only 137 telemedicine services. This suggests either telemedicine service implementation is still not a part of mainstream clinical services, or it is not being reported in the peer-reviewed literature. The depth and the quality of information were variable across studies, reducing the generalisability. The reporting of service implementation and planning strategies should be encouraged. Given the fast paced technology driven environment of telemedicine, this may enable others to learn and understand how to implement sustainable services. The key component of planning was underreported in these studies. Studies applying and reporting more rigorous methodology would contribute greatly to the evidence for telemedicine.

Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety

BACKGROUND

In the context of the development of telemedicine in France to address low thrombolysis rates and limited stroke infrastructures, a star-shaped telestroke network was implemented in Burgundy (1.6 million inhabitants). We evaluated the safety and effectiveness of this network for thrombolysis in acute ischemic stroke patients.

METHODS

One hundred and thirty-two consecutive patients who received intravenous thrombolysis during a telemedicine procedure (2012-2014) and 222 consecutive patients who were treated at the stroke center of Dijon University Hospital, France (2011-2012) were included. Main outcomes were the modified Rankin scale (mRS) score and case fatality at 3 months. Comparisons between groups were made using multivariable ordinal logistic regression and logistic regression analyses, respectively.

RESULTS

Baseline characteristics of telethrombolysis patients were similar to those of patients undergoing thrombolysis locally except for a higher frequency of previous cancer and pre-morbid handicap, and a trend towards greater severity at admission in the former. The distribution of mRS scores at 3 months was similar between groups, as were case-fatality rates (18.9% in the telethrombolysis group versus 16.5%, P = 0.56). In multivariable models, telethrombolysis did not independently influence functional outcomes at 3 months (odds ratio for a shift towards a worse outcome on the mRS, 1.11; 95% confidence interval, 0.74-1.66, P = 0.62) or death (odds ratio, 0.86; 95% confidence interval, 0.44-1.69, P = 0.66).

CONCLUSION

The implementation of a regional telemedicine network for the management of acute ischemic stroke appeared to be effective and safe. Thanks to this network, the proportion of patients who benefit from thrombolysis will increase. Further research is needed to evaluate economic benefits.

Telestroke-the promise and the challenge. Part one: growth and current practice

Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the first of a detailed two part review, and explores the growth and current practice of telestroke, including the specific role it plays in the assessment and management of patients after emergent large vessel occlusion.

Teleneurocritical care and telestroke

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.

Intracranial hemorrhage: frequency, location, and risk factors identified in a TeleStroke network

Intracranial hemorrhages are associated with high rates of disability and mortality. Telemedicine in general provides clinical healthcare at a distance by using videotelephony and teleradiology and is used particularly in acute stroke care medicine (TeleStroke). TeleStroke considerably improves quality of stroke care (for instance, by increasing thrombolysis) and may be valuable for the management of intracranial hemorrhages in rural hospitals and hospitals lacking neurosurgical departments, given that surgical/interventional therapy is only recommended for a subgroup of patients. The aim of this study was to analyze the frequency, anatomical locations of intracranial hemorrhage, risk factors, and the proportion of patients transferred to specialized hospitals. We evaluated teleconsultations conducted between 2008 and 2010 in a large cohort of patients consecutively enrolled in the Telemedical Project for Integrated Stroke Care (TEMPiS) network. In cases in which intracranial hemorrhage was detected, all images were re-examined and analyzed with a focus on frequency, location, risk factors, and further management. Overall, 6187 patients presented with stroke-like symptoms. Intracranial hemorrhages were identified in 631 patients (10.2%). Of these, intracerebral hemorrhages were found in 423 cases (67.0%), including 174 (41.1%) in atypical locations and 227 (53.7%) in typical sites among other locations. After 14 days of hospitalization in community facilities, the mortality rate in patients with intracranial hemorrhages was 15.1% (95/631). Two hundred and twenty-three patients (35.3%) were transferred to neurological/neurosurgical hospitals for diagnostic workup or additional treatment. Community hospitals are confronted with patients with intracranial hemorrhage, whose management requires specific neurosurgical and hematological expertise with respect to hemorrhage subtype and clinical presentation. TeleStroke networks help select patients who need advanced neurological and/or neurosurgical care. The relatively low proportion of interhospital transfers shown in this study reflects a differentiated decision process on the basis of both guidelines and standard operating procedures.

Imaging of prehospital stroke therapeutics

Despite significant quality improvement efforts to streamline in-hospital acute stroke care in the conventional model, there remain inherent layers of treatment delays, which could be eliminated with prehospital diagnostics and therapeutics administered in a mobile stroke unit. Early diagnosis using telestroke and neuroimaging while in the ambulance may enable targeted routing to hospitals with specialized care, which will likely improve patient outcomes. Key clinical trials in telestroke, mobile stroke units with prehospital neuroimaging capability, prehospital ultrasound and co-administration of various classes of neuroprotectives, antiplatelets and antithrombin agents with intravenous thrombolysis are discussed in this article.

Post t-PA transfer to hub improves outcome of moderate to severe ischemic stroke patients

Background and Purpose

Telemedicine offers rural hospitals the ability to treat acute ischemic stroke on site with intravenous tissue plasminogen activator (t-PA). Most patients are subsequently transferred to a hub hospital with a primary stroke center for post t-PA care. There is little evidence that such transfer is beneficial. The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial.

Methods

We retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012. We compared the outcome of patients who were transferred to a “hub” with those who remained at the “spoke” hospital where thrombolysis took place. We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher’s exact test, two-tailed, and significance was considered at p < 0.05.

Results

Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy. The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS). However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026).

Conclusions

Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.

An effective support system of emergency medical services with tablet computers

BACKGROUND

There were over 5,000,000 ambulance dispatches during 2010 in Japan, and the time for transportation has been increasing, it took over 37 minutes from dispatch to the hospitals. A way to reduce transportation time by ambulance is to shorten the time of searching for an appropriate facility/hospital during the prehospital phase. Although the information system of medical institutions and emergency medical service (EMS) was established in 2003 in Saga Prefecture, Japan, it has not been utilized efficiently. The Saga Prefectural Government renewed the previous system in an effort to make it the real-time support system that can efficiently manage emergency demand and acceptance for the first time in Japan in April 2011.

OBJECTIVE

The objective of this study was to evaluate if the new system promotes efficient emergency transportation for critically ill patients and provides valuable epidemiological data.

METHODS

The new system has provided both emergency personnel in the ambulance, or at the scene, and the medical staff in each hospital to be able to share up-to-date information about available hospitals by means of cloud computing. All 55 ambulances in Saga are equipped with tablet computers through third generation/long term evolution networks. When the emergency personnel arrive on the scene and discern the type of patient's illness, they can search for an appropriate facility/hospital with their tablet computer based on the patient's symptoms and available medical specialists. Data were collected prospectively over a three-year period from April 1, 2011 to March 31, 2013.

RESULTS

The transportation time by ambulance in Saga was shortened for the first time since the statistics were first kept in 1999; the mean time was 34.3 minutes in 2010 (based on administrative statistics) and 33.9 minutes (95% CI 33.6-34.1) in 2011. The ratio of transportation to the tertiary care facilities in Saga has decreased by 3.12% from the year before, 32.7% in 2010 (regional average) and 29.58% (9085/30,709) in 2011. The system entry completion rate by the emergency personnel was 100.00% (93,110/93,110) and by the medical staff was 46.11% (14,159/30,709) to 47.57% (14,639/30,772) over a three-year period. Finally, the new system reduced the operational costs by 40,000,000 yen (about $400,000 US dollars) a year.

CONCLUSIONS

The transportation time by ambulance was shorter following the implementation of the tablet computer in the current support system of EMS in Saga Prefecture, Japan. The cloud computing reduced the cost of the EMS system.

Efficacy of telemedicine for thrombolytic therapy in acute ischemic stroke: a meta-analysis

The aim of this study was to assess the benefits of telemedicine in the delivery of thrombolytic therapy for patients with acute ischemic stroke. We performed a meta-analysis using combinations of the following terms: telestroke, telemedicine, tissue plasminogen activator/t-PA, and acute ischemic stroke. The primary outcome was favorable outcome based on the modified Rankin score. Secondary outcomes were incidence of symptomatic intracranial hemorrhage and overall mortality. We found no significant difference in favorable outcome between the telemedicine and control groups, and no significant difference was found between these groups in the rate of symptomatic intracranial hemorrhage or overall mortality. Patients with acute ischemic stroke who were treated with intravenous thrombolysis had similar outcomes regardless of whether telemedicine was used or they were treated in-person at a medical facility. Telemedicine can be used to support hospitals with limited experience in administering thrombolytic therapy for stroke.