Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another.1
Figure 1: 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.
- Telemedicine-guided thrombolysis is feasible, safe and efficient.2,3
- The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) has shown a marked reduction of “death and dependency” (mRS >3).4
- 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).4
Telestroke is the use of telemedicine specifically for stroke care.1
Geography, lack of knowledge and poor funding are the 3 main reasons for unequal access to stroke care, and the rationale behind telestroke (figure 2).
Figure 2: Rational for telemedicine in stroke
The 2009 American Stroke Association (ASA) recommendations on telemedicine 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 center (or center of equivalent capability) within a reasonable distance or travel time to permit eligibility for intravenous thrombolytic therapy."
Telestroke unit concept
- 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
Telemedical pilot project for integrative stroke care (TEMPiS)
In TEMPiS, 12 community 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.
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 (figure 4).
Figure 4: Results from TEMPiS
RCT, randomised controlled trial; mRS, modified Rankin Scale
Telemedicine in acute stroke: learnings from TEMPiS3-5
- 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 (figure 5).
Figure 5: Indicators for quality of stroke care
"Drip and ship" approach6-8
Although telestroke is important for the confirmation of an acute ischaemic stroke and guidance in the decision to administer intravenous rt-PA, it is often still beneficial to transfer the patient (if conditions allow) to a hub stroke centre for further management – commonly known as the “drip and ship” approach.
There is currently not a large amount of evidence on the benefits and safety of this approach, but smaller studies that have been performed report comparable long-term functional outcomes and safety (sICH and mortality rates) to patients treated directly in a specialised stroke centre. Further benefits of the drip-and-ship approach include:
- Empowers emergency physicians and neurologists at outside hospitals
- Facilitates early administration of rt-PA
- Improves access to specialised stroke treatment and adjunctive therapeutic options
- 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.
- Schwab S, Vatankhah B, Kukla C et al. Long-term outcome after thrombolysis in telemedical stroke care Neurology 2007;69:898-903.
- 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.
- Pervez MA, Silva G, Masrur S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010;41:e18-e24.
- Martin-Schild S, Morales MM, Khaja AM, et al. Is the drip-and-ship approach to delivering thrombolysis for acute ischemic stroke safe? J Emerg Med 2011;42:135-141.
- Silverman IE, Beland DK, Chhabra J, McCullough LD. The "drip-and-ship" approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69:613-620.