Telestroke

Every year, approximately 62,000 people with stroke and transient ischemic attack (TIA) are treated in Canadian hospitals. The 2017 update of the Canadian Stroke Best Practice Recommendations Telestroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. These recommendations focus on the use of telemedicine technologies to rapidly identify and treat appropriate patients with acute thrombolytic therapies in hospitals without stroke specialized expertise; select patients who require immediate transfer to stroke centres for Endovascular Therapy; and for the patients who remain in community hospitals that facilitate their care on a stroke unit and provide remote access to stroke prevention and rehabilitation services.

The theme of the Sixth Edition of the CSBPR is Partnerships and Collaborations. This theme stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care of stroke patients to optimize recovery and outcomes.

Within telestroke partnerships and collaborations are imperative for stroke care and recovery, and are required at all levels of the systems of care, among healthcare providers, patients, system leaders and the broader community. Ongoing stroke quality of care initiatives indicate that many Canadians are not receiving optimal stroke services and that there are significant geographic variations in care. Telestroke is a care delivery modality that has emerged to bridge the geographic gap between patient and expertise. It can be used to support stroke diagnosis and decisions regarding recanalization therapy, as well as the optimization of stroke prevention and rehabilitation therapies,

Partnerships and Collaborations in Telestroke involve healthcare providers, policy makers, patients, and the public. Telestroke is a tool or care-delivery modality that can be used for both ‘on-demand’ (urgent, unplanned) and ‘scheduled’ access to specialized stroke services. To be successful, Telestroke has to be implemented within an established and coordinated stroke system, where stroke experts and referring sites can be connected in an efficient and organized manner and be available for other uses to maximize the value of investment.

Issues such as increased workload, scheduling challenges, equipment cost and functioning and physician reimbursement have all been posed as barriers to Telestroke implementation. However, Krueger et al., (2011) found that implementation of Telestroke resulted in significant cost-avoidance and was one of four major cost-avoidance drivers in stroke management (along with stroke unit care, tPA administration and early supported discharge).Healthcare providers should work together within systems of care to address the specific barriers to optimal stroke service delivery in their jurisdiction and consider whether a telestroke program could be used to facilitate improvements (Figure 2).

Partnerships and Collaborations in Telestroke implores providers to start thinking beyond the utility of Telestroke in the hyperacute phase for tPA decision-making and administration. There is an emerging set of demonstration projects and research initiatives where Telestroke is used as the care delivery model for prevention and rehabilitation services. These applications enable people access to expertise to manage risk factors which reduces recurrence rates for stroke, and therefore reduces burden on the healthcare system. Similarly, applications within the rehabilitation realm enable access to physiotherapy, occupational therapy and speech therapy to help further the gains made post stroke (positive patient-related outcomes) and, again, decrease the burden on the healthcare system.

Improved quality and availability of telemedicine technology has made the delivery of cross-continuum services possible within a variety of facilities and practice settings throughout Canada. This technology has been a major driver and opportunity for bridging the gap in access to equitable stroke services regardless of geographic location. The current challenge however, is that this known and available technology is significantly under-utilized for the care of patients who have experienced a stroke, and their family members.

The Canadian Telestroke Action Collaborative (CTAC) is led by an expert group within the Canadian Stroke Best Practice Recommendations initiative. The CTAC group is mandated to update current evidence-based recommendations for Telestroke, to gather the knowledge and experience of Telestroke experts across Canada in this implementation toolkit to support uptake of best practices. CTAC’s goal is to increase access to stroke specialists through Telestroke care delivery models for hyperacute stroke care, stroke rehabilitation, prevention services, and to support patients returning to the community.

The guiding principles for CTAC in the update of the best practices for Telestroke and the development of a comprehensive Implementation Toolkit include:

• Telestroke programs, whenever possible, should be established within coordinated systems of stroke care (not as stand-alone isolated projects) in order to increase the benefits of investment and enhance sustainability.
• Telestroke programs should be established across the continuum of stroke care, beyond the hyperacute phase, especially given the shortage of stroke rehabilitation experts in many smaller communities, and the increased burden on families and the stroke care system when stroke patients are not able to access services to assist them in achieving optimal recovery.
• Healthcare providers involved in Telestroke programs should be involved in ongoing education to maintain competency in stroke care and in the efficient use of the technology.
• Telestroke initiatives should utilize a quality improvement model, starting on a small scale with minimal technology investment as necessary, but continuing to develop and enhance as capacity increases.

The documents included in this toolkit are intended to support both consulting and referring sites with the implementation of Telestroke services in their facility. The information provided is considered a starting place – examples and templates provided for use by all sites to review, adopt or adapt to meet their own needs.

The information included here should also be considered dynamic – it will change and evolve as new evidence emerges, and we encourage all users to share their own materials with the broader Telestroke community through this resource. All submissions can be sent to strokebestpractices@heartandstroke.ca

The 2017 update of the Canadian Stroke Best Practice Recommendations Telestroke module reinforces the growing body of research evidence available to guide the use of Telestroke technology for assessment, diagnosis, interventions and ongoing management of stroke patients.

Key messages for 2017 include:

• Telestroke as a care-delivery modality is under-utilized in Canada.
• Telestroke should be implemented within established stroke systems of care to maximize effectiveness.
• Telestroke applications include hyperacute care to increase access to acute thrombolysis and to support decision-making for endovascular therapy.
• Telestroke applications are expanding and processes are being established to leverage Telestroke for broader use to support smaller stroke units with management of complex cases; increase access to rehabilitation services and specialists; provide secondary prevention services to areas where services are not available; and improve community support.

For detailed methodology on the development and dissemination of the Canadian Best Practice Recommendations for Stroke Care please refer to the stroke best practices website.

Dylan Blacquiere, M. Patrice Lindsay, Frank L. Silver; on behalf of the Telestroke Writing Group. Telestroke Module 2017. In Lindsay MP, Gubitz G, Dowlatshahi D, Harrison E, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: Telestroke Update 2017. Sixth Edition 2017; Ottawa, Ontario Canada: Heart and Stroke Foundation.

The detailed methodology and explanations for each of these steps in the development and dissemination of the CSBPR  is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website. 

We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations. Please forward comments to the Heart and Stroke Foundation’s Stroke Team at strokebestpractices@heartandstroke.ca

Telestroke Report 2012 – Executive Summary

Telestroke module contents:

• Telestroke guideline publication in the International Journal of Stroke 2017
• Canadian Stroke Best Practice Recommendations: Telestroke 2017 Module
• Writing Group and Reviewer List 2017
• Telestroke definitions 2017
• Clinical Considerations (New for 2017)
• Evidence Table and Reference List 2017
• Telestroke webinar – Integration and application of telestroke across the continnum 2017