Telestroke: Telemedicine and Stroke

Educational Objectives

The goal of this program is to improve the management of stroke using telestroke. After hearing and assimilating this program, the clinician will be better able to:

1. Use telestroke in the assessment of stroke.
2. List benefits of using telestroke.

Summary

Telemedicine: is a telecommunication technology (eg, phone, fax, email, audio and video over the internet); first used in the 1900s for transmission of electrocardiography (ECG); used in the 1920s by Norwegian doctors for radio recommendations for people at sea; term was coined by Thomas Bird in the 1970s to describe “healing at a distance”; in the 1940s, radiography was being transmitted in Pennsylvania; neurologic examinations were transmitted via television in the 1950s; emergency care provided via telemedicine in the 1960s at Logan Airport in Boston; telestroke was described in a journal in 1999

Need for telestroke: there are regional disparities in stroke care and shortage of neurologic resources; shortage is 11% at present and projected to increase to ≈19% by 2025; currently there are only ≈4 neurologists for every 100,000 persons in the United States

Treatments for stroke: 2 main treatments include intravenous tissue plasminogen activator (tPA) and endovascular treatment; the sooner treatment is given, the safer it is for patients and better the outcomes that are achieved

Regional disparities in stroke treatment: there is drop in percentage of patients who receive tPA even if arrival to emergency department (ED) is <2 hr after stroke; stroke-certified centers help to ensure patients receive treatment; treatment rates with tPA are higher in urban centers compared with rural areas; urban centers provide better access to stroke care and therefore increase the chances of getting tPA vs endovascular treatment

Evolution of stroke care: treatment was simpler before 1996 and the approval of tPA, based on the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (NINDS) trial; established the 0- to 3-hr window for treatment; European Cooperative Acute Stroke Study III (ECASS III) 2008 trial results extended treatment window to 3 to 4.5 hr for some patients; trials in 2013 showed benefit of treatment with endovascular devices for ≤8 hr; additional trials in 2015 to 2018 showed further advancement of endovascular treatments

Using telestroke for stroke assessment: typically used in hospital ED; computer, camera, and video device on wheels; augments the standard components of typical stroke consultation; can get history from family and verify onset of stroke; nurse or physician needed at the bedside to perform visual field and sensory examinations; coordination between nurse and physician to deliver tPA or endovascular treatment; physician on the other end of the telestroke communication verifies examination, imaging, and laboratory work

Models for implementation of telestroke: “ship and drip” — least ideal; transfer patient to stroke center if community hospital has no ability to give treatment, no accessibility to a neurologist; delays treatment; “drip and ship” — community hospital can administer tPA, may have telestroke, but needs to transfer patient to a tertiary center for further treatment; “drip and keep” — patient able to stay at primary center through help of a teleneurologist; “hub and spoke” — smaller spoke hospitals feed into larger hub hospital with a stroke specialist; use of multiple computer systems with this model can be a challenge; multipoint acute telestroke consultation — technology is centralized at a server and is accessible by multiple providers at different sites; for-profit model — organization employs physicians and has technology with no specific affiliation to one specific hospital; consultations provided for multiple spokes, and spokes can transfer to a hub; may involve private practice physicians; advantages of teleconsultation — with the help of teleconsultation, cases can be filtered and patients kept closer to home at a primary care center; speaker’s telestroke program has 9 sites; has done >1700 consultations since 2017

Benefits of telestroke: helps expedite rapid neurologic expertise; reduces transfer between hospitals; limits cost; improves patient and caregiver satisfaction; helps with enrollment and recruitment of patients from rural areas for clinical trials

Evidence for telestroke: STRokE DOC trial showed that accuracy of decisions made by telemedicine was better than that of telephone consultation; no difference between groups in percentage of tPA treatment, hemorrhage, and overall outcomes; a Bavarian study showed no difference in outcomes between patients having telestroke consultations performed at spoke hospitals compared with in-person evaluations at hub hospitals; long-term outcomes at 3 to 6 mo and overall mortality similar; a study by speaker’s group recently submitted to the International Stroke Conference showed no difference in treatment times between in-person during regular hours and telestroke used overnight and weekends within the same centers; studies — found increased use of tPA with telestroke; after implementation of telestroke, University of Pittsburgh study showed increased use of tPA from 2.8% to 6.8%; and the Bavarian study mentioned showed 10-fold increase in a year’s time; Medical University of South Caroline (MUSC) and Thomas Jefferson in Philadelphia showed drop in rates of transfers; fewer transfers are easier on families, with less financial strain

Limitations of telestroke: reimbursement is a challenge but is slowly improving; bill was introduced recently in Texas to increase Medicaid reimbursement for telemedicine; licensing and credentialing are obstacles in terms of time and resources; technological barriers occur (eg, weak internet signals); social perception that reliance on technology results in impersonal patient care; provider must be sensitive to the importance of a personal presence and engagement; family may react negatively to lack of presence of provider; important to educate the family about the benefits that are being provided

Implementing telestroke: it requires resources beyond a computer and a neurologist; necessary to survey the hospital resources, eg, where tPA is stored, where patients enter ED, processes of hospital; telestroke network should include a stroke neurologist, partnership with ED, inpatient physicians and providers, stroke coordinator, project coordinator, neurology staff, and information technology professionals; need legal input; hospital must be surveyed for occupancy and suitability for telemedicine; administrative buy-in is key to fulfilling financial requirements

Workflow for telestroke: triage patient; obtain laboratory work and computed tomography; communicate with telestroke neurologist and obtain recommendation for electronic medical record in timely manner; beyond the initial consultation there is feedback and communication with, eg, spoke hospitals, regarding process improvement; new treatment technologies must be also be assessed for usefulness

Future of telestroke: currently telestroke is primarily used for acute disease; uses are now being found for, eg, nursing home, patient home, ambulance; internet speeds increase and technology continues to evolve, allowing for better interface between patient and hospital; artificial intelligence has potential use for diagnosis and decision process; examples of evolving telemedicine include mobile stroke units, Apple watch, and augmented reality (eg, HoloLens)

Readings

Bowry R et al. Time to decision and treatment with tPA (tissue-type plasminogen activator) using telemedicine versus an onboard neurologist on a mobile stroke unit. Stroke. 2018;49:1528-1530; doi: 10.1161/STROKEAHA.117.020585; Hacke W et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329; doi: 10.1056/NEJMoa0804656; Henderson SJ et al. Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke. J Thromb Haemost. 2018;16:1932-1940; doi: 10.1111/jth.14215; Khandelwal P et al. Acute ischemic stroke intervention. J Am Coll Cardiol. 2016;67:2631-2644; doi: 10.1016/j.jacc.2016.03.555; Meyer BC et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7:787-795; doi: 10.1016/S1474-4422(08)70171-6; Powers WJ et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344-e418; doi: 10.1161/STR.0000000000000211; Solenski NJ. Telestroke. Neuroimaging Clin North Am. 2018;28:551-563; doi: 10.1016/j.nic.2018.06.012; The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1588; doi: 10.1056/NEJM199512143332401; Wallace AN et al. Evolution of endovascular stroke therapies and devices. Expert Rev Med Devices. 2016;13:263-270; doi: 10.1586/17434440.2016.1143772; Wechsler LR et al. American Heart Association Stroke Council; Council on Epidemiology and Prevention; Council on Quality of Care and Outcomes Research. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48:e3-e25; doi: 10.1161/STR.0000000000000114.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Nguyen was recorded at the Baylor Scott & White Neuroscience Symposium, held July 1-2, 2019, in Austin, TX, and presented by Baylor Scott and White Hospital. For information on future CME activities from Baylor Scott and White Hospital, please visit bswhealth.med/education. Audio Digest thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE120601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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