Integrated Stroke Care Research Articles

Telemedicine for acute stroke

In this issue of Neurology ®, The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS)1 adds noteworthy information about using emerging communication technology and organizational innovation to optimize treatment of acute ischemic stroke (AIS) in the general population, regardless of geographic location. Based on the largest published telemedicine for AIS data set to date, long-term mortality rates and functional outcomes (at 3 and 6 months) for telestroke-enabled community hospitals using recombinant tissue plasminogen activator (rt-PA) were similar and comparable to the results of previous trials.2 Their data suggest that less experienced physicians in 12 community hospitals, guided remotely by stroke experts who are informed through a telemedicine model that included video/audio conferencing and transmission of CT images, can achieve the same results the stroke experts obtain in their own centers. The telemedicine model included 24/7 remote support from two hubs that were committed to initiate telestroke consultation within 3 minutes after telephone contact. Remarkably, rt-PA use in the community hospitals increased 10-fold because of telemedicine. To place these findings in context, without treatment, a typical large vessel AIS kills roughly 2 million neurons, 14 billion synapses, and over 7 miles of myelinated fibers each minute.3 IV rt-PA quadruples the likelihood of minimum or no disability when a patient …

Admission Facility Is Associated With Outcome of Basilar Artery Occlusion

Basilar artery occlusion (BAO) is a stroke subtype with poor prognosis, but recanalizing therapies have been reported to be effective. We investigated whether initial admission to telemedically linked general hospitals with subsequent stroke-center transfer is related to poorer outcome than direct admission to stroke centers. All BAO cases of 3 stroke centers in Munich and 1 center in Regensburg between March 1, 2003 and December 31, 2004 were included, either if patients were directly admitted to stroke centers (n=23) or had initial admission to general hospitals of the telemedical network for integrative stroke care (TEMPiS) and secondary transfer to stroke centers (n=16). BAO was defined as angiographically (CTA, MRI or conventional angiography) confirmed occlusion of the basilar artery. Baseline parameters and therapeutic procedures were recorded. One-year follow-up was conducted prospectively. Differences in baseline parameters were not statistically significant. Time from onset to first angiography was significantly longer in patients with secondary transfer (mean: 355+/-93 minutes versus 222+/-198 minutes; P<0.01), mainly attributable to transfer duration (mean:156+/-73 minutes). In-hospital mortality (22% versus 75%; P<0.01) and 1-year-mortality (30% versus 81%; P<0.01) were lower for patients with direct admission to stroke centers. Fifty-two percent of directly admitted patients versus 13% of patients with secondary transfer (P=0.02) were living at home after 1 year. BAO patients who were admitted primarily to community hospitals had a worse prognosis. Patients with typical symptoms should have direct access to stroke centers, or may need bridging therapies.

Primary Prevention and Health Services Delivery

Stroke remains the third leading cause of death in the US and other Western countries,1 and at least 1 population-based study found that the incidence of stroke was greater than that of acute coronary syndromes.2 Although there have been substantial falls in stroke incidence in some countries over the last 2 decades,3 a large US study found that the advances in stroke prevention during the 1990s were not associated with decreases in the rate of stroke hospitalizations or in case-fatality rates between 1993 and 1999.4 Moreover, based solely on demographic changes in the population of selected countries within the European Union, the World Health Organization predicts a 27% increase in stroke events between the years 2000 and 2025.5 The proportion of deaths attributed to stroke is even higher in Asian countries.6 Although much of stroke risk may be related to socioeconomic factors, more effective prevention strategies are critical. Several studies have contributed to the body of knowledge related to primary stroke prevention over the last year. Numerous studies support an association between elevated homocysteine levels and atherosclerotic disease.7 The B vitamins (folic acid, B12, and B6) reduce homocysteine serum levels raising the hope that treatment would be associated with reduced risk. That hope was diminished with publication of results of the Vitamin Intervention for Stroke Prevention (VISP) trial in 2004.8 Although a secondary rather than a primary stroke prevention trial, VISP had compared high- and low-dose B-vitamin supplementation and found no treatment effect on the risk of recurrent stroke (risk ratio [RR] 1.0; 95% CI, 0.8 to 1.3), or in the combined risk of any stroke, coronary heart event, or death (RR, 1.0; 95% CI, 0.8 to 1.1). The difference in homocysteine levels between treatment groups, however, was small …

Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany

Telemedical networks are a new approach to improve stroke care in community settings. We aimed to assess the effects of a stroke network with telemedical support in Germany on quality of care, according to acute processes and long-term outcome. Five community hospitals without pre-existing specialised stroke care were included in a network with telemedical support by two academic hospitals. In a non-randomised, open intervention study, five community hospitals without specialised stroke care served as the control group, matched individually to the network hospitals by predefined characteristics. Stroke patients admitted consecutively to one of the participating hospitals between July 7, 2003, and March 31, 2005, were included in the study. Patients in network and control hospitals were assessed in the same manner and were followed up for vital status, living situation, and disability at 3 months. Poor outcome was defined by death, institutional care, or disability (Barthel index <60 or modified Rankin scale >3). Predefined indicators for quality of acute stroke care were achieved. A total of 5696 patients with a sudden, non-convulsive loss of neurological function who were diagnosed with having suspected stroke were admitted to the ten hospitals participating in the study. After exclusion, 3122 were included in the final analysis, of whom 1971 (63%) were treated in the network hospitals. All indicators related to quality of acute stroke care were more commonly met in the network than in the control hospitals. After 3 months, 44% of patients treated in network hospitals versus 54% treated in control hospitals had a poor outcome (p<0.0001). In multivariate regression analysis, treatment in network hospitals independently reduced the probability of a poor outcome (odds ratio 0.62, 95% CI 0.52-0.74; p<0.0001). Telemedical networks with academic stroke centres offer new and innovative approaches to improve acute stroke care at community level for stroke patients living in non-urban areas.

Comparison of Tissue Plasminogen Activator Administration Management Between Telestroke Network Hospitals and Academic Stroke Centers

Systemic thrombolysis is the only therapy proven to be effective for ischemic stroke. Telemedicine may help to extend its use. However, concerns remain whether management and safety of tissue plasminogen activator (tPA) administration after telemedical consultation are equivalent in less experienced hospitals compared with tPA administration in academic stroke centers. During the second year of the ongoing Telemedical Pilot Project for Integrative Stroke Care, all systemic thrombolyses in stroke patients of the 12 regional clinics and the 2 stroke centers were recorded prospectively. Patients' demographics, stroke severity (National Institutes of Health Stroke Scale), frequency of administration, time management, protocol violations, and safety were included in the analysis. In 2004, 115 of 4727 stroke or transient ischemic attack patients (2.4%) in the community hospitals and 110 of 1889 patients in the stroke centers (5.8%) received systemic thrombolysis. Prehospital latencies were shorter in the regional hospitals despite longer distances. Door to needle times were shorter in the stroke centers. Although blood pressure was controlled more strictly in community hospitals, symptomatic intracerebral hemorrhage rate (7.8%) was higher (P=0.14) than in stroke centers (2.7%) but still within the range of the National Institute of Neurological Disorders and Stroke trial. In-hospital mortality rate was low in community hospitals (3.5%) and in stroke centers (4.5%). Although with a lower rate of systemic thrombolysis, there was no evidence of lower treatment quality in the remote hospitals. With increasing numbers of tPA administration and growing training effects, the telestroke concept promises better coverage of systemic thrombolysis in nonurban areas.

Verbesserung der Schlaganfall-Behandlung in einem regionalen Versorgungskrankenhaus

Although treatment in a stroke unit has been proven to be effective, most stroke patients in rural areas have no access to it. The community hospital of Ebersberg (Bavaria/Germany) joined the Telemedic Project for Integrative Stroke Care (TEMPiS) in order to optimize the quality of stroke care. This analysis focuses on changes in stroke management using generally accepted indicators for quality of acute stroke treatment. The core elements consisted of the setting up of a stroke ward in the community hospital, continual stroke education and a 24-hour telemedical consultation service offered by stroke centers. Treatment of stroke patients was documented during two 12-months periods before the project was started start (i.e. retrospectively) and during the course of the project (prospectively). In addition, data on fatal outcome and institutionalization of patients who had lived at home before the qualifying event were collected 12 months after stroke onset. There were 299 admissions for stroke or transient ischemic attacks between 1 Nov 2001 and 31 Oct 2002, and 305 between 7 July 2003 and 6 June 2004. Length of in-hospital stay decreased from 12.1 to 9.2 days. More patients (10.3 vs. 1.3%) were transferred to other acute hospitals during the later period. Indicators for stroke care quality improved: numbers of cerebral imaging rose from 56.5% to 96.4%, of duplex sonography of cervical arteries from 43.5 to 72.8 %, of speech therapy from 0% to 50.8% and of occupational therapy from 0 to 33.4%. One year after admission, 18.9% and 17.2%, respectively, of the patients had died, while 10.2% and 6.1% were living in institutions. Participation in the TEMPiS network substantially improved stroke care quality according to national and international guidelines. These improvements may lead to a better prognosis after a stroke.

Telemedicine for Safe and Extended Use of Thrombolysis in Stroke: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria

Telemedicine for Safe and Extended Use of Thrombolysis in Stroke: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria

Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project

This article considers the question if measurable improvements are achieved in the quality of care in stroke services by using a Breakthrough collaborative quality improvement model. Despite the availability of explicit criteria, evidence based guidelines, national protocols and examples of best practices; stroke care in the Netherlands did not improve substantially yet. For that reason a national collaborative started in 2002 to improve integrated stroke care in 23 self selected stroke services. Characteristics of sites, teams, aims and changes were assessed by using a questionnaire and monthly self-reports of teams. Progress in achieving significant quality improvement has been assessed on a five point Likert scale (IHI score). The stroke services (n=23) formed multidisciplinary teams, which worked together in a collaborative based on the IHI Breakthrough Series Model. Teams received instruction in quality improvement, reviewed self reported performance data, identified bottlenecks and improvement goals, and implemented "potentially better practices" based on criteria from the Edisse study, evidence based guidelines, own ideas and expert opinion. Quality of care has been improved in most participating stroke services. Eighty-seven percent of the teams have improved their care significantly on at least one topic. About 34% of the teams have achieved significant improvement on all aims within the time frame of the project. The project has contributed to the further development and spread of integrated stroke care in the Netherlands.

Early supported discharge: a valuable alternative for some stroke patients

In this issue of The Lancet, Peter Langhorne and colleagues report the benefits of early supported discharge (ESD) teams as an effective health-service option for a selected group of stroke patients. Since 1997, when Langhorne and his co-workers in the Stroke Unit Trialists Collaboration reported the advantages of integrated stroke care, 1 Stroke Unit Trialists Collaboration How do stroke units improve patient outcomes?. Stroke. 1997; 28: 2139-2144 Crossref PubMed Google Scholar this care is now embedded in most stroke services worldwide. However, between countries the organisation of stroke care differs; different types of institutions participate, which have their own specific treatment modalities. Several treatment options are usually available, depending on the patient's need for further rehabilitation therapy; each option has specific admission criteria, and consists of some form of inpatient or outpatient treatment in specialised care centres. District sick bays or similar institutions might serve as hotel facilities where the patient can recover from the stroke during a limited period without receiving specific rehabilitation treatment. Some countries have inhospital rehabilitation facilities, which lengthen hospital stay, while in other countries, transfer to a specialised rehabilitation centre will take place as soon as the patient is medically stable. In their recent meta-analysis Langhorne and his fellow Early Supported Discharge Trialists refer to treatment at home given or coordinated by a multidisciplinary team as ESD; 2 Early Supported Discharge Trialists. Early supported discharge services for stroke patients: Cochrane Database Syst Rev (in press). Google Scholar in today's Lancet they evaluate the effects of this new health-service product. Early supported discharge services for stroke patients: a meta-analysis of individual patients' dataAppropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays. Full-Text PDF

Early supported discharge: a valuable alternative for some stroke patients

In this issue of The Lancet, Peter Langhorne and colleagues report the benefits of early supported discharge (ESD) teams as an effective health-service option for a selected group of stroke patients. Since 1997, when Langhorne and his co-workers in the Stroke Unit Trialists Collaboration reported the advantages of integrated stroke care,1 this care is now embedded in most stroke services worldwide. However, between countries the organisation of stroke care differs; different types of institutions participate, which have their own specific treatment modalities.

The Use of Telemedicine in Combination With a New Stroke-Code-Box Significantly Increases t-PA Use in Rural Communities

The benefit of tissue plasminogen activator (t-PA) is strongly associated with the time to treatment. In Bavaria, Germany, only half of the population has the opportunity to be transferred to 1 of the 19 stroke units within the critical time window of less than 3 hours. The aim of this study was to investigate the benefit of a new stroke-code-box for t-PA thrombolysis combined with a telemedicine network system to increase the use of acute stroke thrombolysis. Two specialized stroke centers in Germany established a 24-hour telemedicine network (Telemedicine Pilot Project of an Integrated Stroke Care [TEMPiS]) to advise 12 community hospitals in eastern Bavaria. These clinics are linked via telemedicine in a 24-hour/7-day service network that allows patients to be examined by experts via a videoconference system Additionally, a special stroke-code-box for acute t-PA thrombolysis was designed to reduce time in the application and documentation process. In the 12-month period before implementation of the TEMPiS network system, 10 patients had received systemic thrombolysis. In our 6-month study period (from July to December 2003) and after implementation of a stroke-code-box for t-PA thrombolysis within the telestroke network, 164 patients with acute stroke were presented with t-PA treatment indications. Of this patient population, 27.4% (45 of 164) received t-PA. Stroke care, including t-PA thrombolysis in non-urban areas, is feasible using a modern stroke unit concept within a telestroke network. With the expertise of specialized stroke centers accessed via telemedicine and the design of a stroke-code-box for t-PA thrombolysis, nearly one-third of patients presented with a possible indication for systemic thrombolysis can be treated with t-PA, thereby increasing the options for a successful stroke treatment.

Telemedicine for Safe and Extended Use of Thrombolysis in Stroke

Systemic thrombolysis represents the only proven therapy for acute ischemic stroke, but safe treatment is reported only in established stroke units. One major goal of the ongoing Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria is to extend the use of tissue plasminogen activator (tPA) treatment in nonurban areas through telemedic support. The stroke centers in Munich-Harlaching and in Regensburg established a telestroke network to provide consultations for 12 local hospitals in eastern Bavaria. The telemedic system consists of a digital network that includes a 2-way video conference system and CT/MRI image transfer with a high-speed data transmission up to 2 Mb/s. Each network hospital established specialized stroke wards in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 hours per day. A total of 106 systemic thrombolyses were indicated via teleconsultations between February 1, 2003, and April 7, 2004. During the first 12 months, the rate of thrombolyses was 2.1% of all stroke patients. Mean age was 68 years, and median National Institutes of Health Stroke Scale score was 13. Mean delay between onset and hospital admission was 65 minutes, and door-to-needle time was on average 76 minutes, which included 15 minutes for the teleconsultation. Symptomatic hemorrhage occurred in 8.5% of patients, and in-hospital mortality was 10.4%. The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.