Geography, lack of knowledge and poor funding are the 3 main reasons for unequal access to stroke care, and the rationale behind telestroke (figure 1).
Figure 1: Rational for telemedicine in stroke
The angels (acute networks striving for excellence in stroke) initiative provides clinicians and stroke centres with the tools they need to adopt quality of care protocols and monitor quality and outcome indicators for stroke patient care.
Telestroke is the use of telemedicine specifically for stroke care.1
Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another, in order to have direct access to expert opinion and guidance.1
Figure 2: Imaging from a remote unit is transmitted to an experienced stroke physician for further management advice
- Telemedicine can overcome geographical barriers, may save money and improve knowledge in acute stroke care.5
- Telemedicine-guided thrombolysis is feasible, safe and efficient.2,4,5
- The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) has shown a marked reduction of “death and dependency” (mRS >3).6
- The mean length of stay in hospital was significantly reduced in TEMPiS patients compared with the control group (10.7 vs. 11.9 days; p<0.0001).6
The 2009 American Stroke Association (ASA) recommendations on telemedicine2 support the use of telestroke as a means of providing acute stroke care in rural, remote, or underserved areas:
"Telestroke networks should be deployed wherever a lack of readily available stroke expertise prevents patients in a given community from accessing a primary stroke centre (or centre of equivalent capability) within a reasonable distance or travel time to permit eligibility for intravenous thrombolytic therapy to permit access to specially trained stroke care providers. The use of telemedicine should be adopted within all stroke systems of care components to eliminate geographic disparities in care that may occur as a result of limited resources, manpower shortages, and long distances to specially trained providers."2
Moreover, the 2016 American Heart Association (AHA) Policy Statement on telehealth in stroke care3, which aims to outline unified policy suggestions states, “Telestroke is an evidence-based and accepted method of delivering expert stroke care…”
The AHA/ASA has also issued a statement detailing the importance of quality and outcome indicators in telestroke, encouraging telestroke centres to collect certain data and maintain quality of care protocols to increase the knowledge base of telestroke and to improve performance and delivery of care.5
- Specialised stroke wards in community hospitals
- 24-hour availability of diagnostics/monitoring
- Stroke teams
- Standardised stroke care protocols
- Comprehensive stroke training for all staff
- Continuous quality management
- Telemedicine network (figure 3)
Figure 3: Model for a telestroke system
In TEMPiS, 15 regional hospitals with little or no experience with thrombolysis were connected in 2003 to 2 university hospital stroke centres, which provide 24-hour telemedicine and image transmission.6,7
22 months into the project, comparable functional outcomes and mortality rates were seen in the telemedicine-linked community hospitals and in the stroke centres, and these results were in turn comparable to results from randomised trials.6,7 (Figure 4)
Figure 4: Results from TEMPiS at 22 months
mRS, modified Rankin Scale
TEMPiS investigators report a 10-year analysis8 investigating the sustainability of the initial 2-year results of the stroke care project. They report, over the first 10 years of TEMPiS, a significant increase in the rate of intravenous thrombolysis from 2.6% in 2003 to 15.5% in 2012 (p <0.001) as well as a significant increase in patients treated with intravenous thrombolysis within 1 hour of hospital admission (26% vs. 80%, respectively, p <0.001). TEMPiS data also shows a significant decrease in overall onset-to-treatment time. No difference was seen in the onset-to-door time. The number of teleconsultations increased over the 10-year period and the recommendation rate for secondary transfers from regional hospitals to stroke centres significantly decreased (Table 1).
Table 1: TEMPiS 10-year analysis*8
Figure 5 shows the number of patients diagnosed with stroke or TIA within the TEMPiS region, based on both TEMPiS data and local health insurance data. It also shows how many of these patients were treated in a hospital with a stroke unit, how many were admitted to a TEMPiS hospital, and the number of teleconsultations by year. While the number of patients with a stroke or TIA diagnosis remained relatively stable (according to insurance data), the number of patients treated within a stroke unit or treated with the help of teleconsultation rose steadily over the 10-year period.8
Figure 5: Patients with stroke/TIA within the TEMPiS region, by type of facility and teleconsultation use by year*8
*Adapted from data presented in Müller-Barna P, et al. Stroke 20148
Based on analyses of data collected over the first 10 years of TEMPiS, the investigators conclude, “…this type of telemedical stroke unit network is sustaining, offers state-of-the-art acute stroke care by increasing stroke units and improving thrombolysis service, and is associated with long-term improvement in terms of quality indicators of acute hospital care.”8
When comparing the various time phases in stroke care within a highly organised, centralised system9 to the decentralised, telestroke-based TEMPiS care system, investigators report no significant difference in overall onset-to-treatment times.
The onset-to-door time in the centralised system was significantly longer compared to the telestroke system. However, this was off-set by the significantly shorter door-to-needle time of the centralised facility. The findings from this comparison show telestroke can help achieve similar onset-to-treatment times to those of highly organised, centralised stroke care facilities (Figure 6).10
Figure 6: Time delays (minutes) in centralised vs. decentralised stroke networks*10
*Adapted from data presented in Hubert et al. Stroke 201610
Learnings from TEMPiS4,6,7
- Telemedicine-guided thrombolysis is feasible, safe and efficient.
- Use of telemedicine not only gives patients rapid access to specialised care, but can also increase accessibility to other stroke services.
- Telemedicine networks can improve many other aspects of acute stroke care.
A recent meta-analysis, which aimed to investigate the safety and efficacy of thrombolysis in patients with acute ischaemic stroke treated within a telestroke network, found these patients had similar outcomes (sICH, mortality and functional independence at 3 months) to those treated in a stroke unit. The meta-analysis included 7 studies published between 2006 and 2011. It should be noted that most of the patients included in the studies within the meta-analysis were treated within 3 hours or less of stroke symptom onset, and further analysis for the 3-4.5 hour time window is needed.11
Following initial emergency stroke care with telemedicine, patients should be immediately transferred to a stroke unit or a comprehensive stroke centre when timely endovascular intervention is considered or indicated. Indeed, where telemedicine is performed, the imaging can allow lysis and/or indicate endovascular. When lysis is given, patients should be transferred to stroke unit (if place of telemedicine is not) or a comprehensive stroke centre, where endovascular treatment could be performed if indicated, considered AND within timelimes (AHA/ASA guidelines, Class IIb, Level of Evidence C).12
Efficient timely transfer requires a stroke network to be in place to ensure that transfer is rapid and efficient and the patient is admitted to a centre that provides the necessary specialist stroke services.11
Competent and comprehensive pre-hospital triaging should effectively allow emergency services to deliver a patient with a suspected stroke directly to a stroke unit, by-passing the hospital emergency department and saving valuable time.12
The use of mobile stroke treatment units (for example in Berlin) in combination with telemedicine resources may improve efficiency and lower the costs involved in transferring stroke patients to tertiary stroke centres and especially lower times from door to CT and from door to needle compared to admission via the emergency department of a clinic.13
- Demaerschalk BM. Telestrokologists: treating stroke patients here, there, and everywhere with telemedicine. Semin Neurol 2010;30(5):477-491.
- Schwamm LH, Audebert HJ, Amarenco P et al. Recommendations for the Implementation of Telemedicine Within Stroke Recommendations for the Implementation of Telemedicine Within Stroke. Stroke 2009;40:2635-2660.
- Schwamm LH, et al. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement from the American Heart Association. Circulation 2017;135:00-00. DOI: 10.1161/CIR.0000000000000475.
- Schwab S, Vatankhah B, Kukla C et al. Long-term outcome after thrombolysis in telemedical stroke care Neurol 2007;69:898-903.
- Wechsler LR, et al. Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2016;47:00-00.DOI 10.1161/STR.0000000000000114.
- Audebert HJ, Schultes K, Tietz V et al. Long-Term Effects of Specialized Stroke Care With Telemedicine Support in Community Hospitals on Behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke 2009;40:902-908.
- Audebert HJ, Schenkel J, Heuschmann PU et al. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006;5:742-748.
- Müller-Barna P, et al. TeleStroke Units Serving as a Model of Care in Rural Areas: 10-Year Experience of the TeleMedical Project for Integrative Stroke Care. Stroke 2014;45:2739-2744.
- Meretoja A, et al. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurol 2012;79:306-313.
- Hubert GJ, et al. Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network). Stroke 2016;47:2999-3004.
- Kepplinger J et al. Safety and efficacy of thrombolysis in telestroke. Neurol 2016;87:1344-1351.
- Itrat A, et al. Telemedicine in prehospital stroke evaluation and thrombolysis. Taking stroke treatment to the doorstep. JAMA Neurol. doi:10.1001/jamaneurol.2015.3849
- Powers W, et al. 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46:000-000. DOI:101161/STR0000000000000074.