New AHA/ASA Statement on Telemedicine in Stroke

November 09, 2016

The American Heart Association (AHA)/American Stroke Association (ASA) has released a new scientific statement on quality measures and outcomes for use of telemedicine in stroke.

The document — which is endorsed by the American Academy of Neurology and the American Telemedicine Association — was published online November 3 in Stroke.

"Telestroke has evolved over the last decade and is now used quite extensively to take care of acute stroke patients in the US and the rest of the world," Lawrence R. Wechsler, MD, chair of the writing committee, commented to Medscape Medical News. "Because of this we felt it was time to bring out this statement, which provides a structure against which hospitals can measure the quality of their telestroke programs so patients can be assured of getting the quality they deserve. These are suggestions from a group of experts that will help anyone involved in a telestroke program to run the best service possible."

Dr Wechsler explained that telestroke programs are mostly run by established stroke centers, which support smaller, more rural hospitals that lack a neurology department or have only a very limited stroke expertise present. In such programs, a neurologist or physician with stroke expertise at the established stroke center can evaluate the patient over a video and audio link and also analyze scans, which are sent electronically. By doing so they can diagnose stroke and decide the best course of action for the patient, including treatment options, such as local administration of thrombolysis or transfer to a larger center for endovascular therapy.

"By having access to such a telestroke program smaller, more rural hospitals without stroke expertise on site can be certified as a primary stroke center in that they have stroke support available 24 hours a day, 365 days of the year," he noted.

"The current statement sets out standards — recommendations on how telestroke programs should be measured for quality and outcomes," he said. "This is the first time such standards have been proposed for this field."

Telestroke involves the use of complex technology, he added. "Measures to ensure it is used optimally are of utmost importance."

The standards described include process measures, such as time to consultation and time to treatment; information on where patients are transferred to and reasons for that decision; and outcomes such as mortality, clinical status, hemorrhage rates, and patient satisfaction; and quality of communication. The information gathered will be used to assess the standards of care delivered and evaluate what improvements are needed.

The document states that screening of patients for endovascular therapy and transferring patients who might benefit from this therapy are now additional goals of telestroke networks, given the large treatment effects of endovascular therapy in recent randomized trials.

Dr Wechsler noted that prehospital telestroke programs connecting established stroke centers with ambulances are also starting to appear now, and they should be able to expedite treatment with both tissue plasminogen activator (tPA) and endovascular therapy.

"Some of these systems have CT [computed tomography] scans in the ambulance and can give tPA right there and then. Others just use an iPad in the ambulance to connect to the stroke expert — although you can't make a certain diagnosis this way, you can make an educated guess just by assessing the severity of the deficit on the NIHSS [National Institutes of Health Stroke Scale], and this allows advice to be given on the best center for the patient to be taken to," he said. "For example, if a patient has an NIHSS score more than 10 or so, it is likely that they have a large-vessel occlusion and could be a candidate for endovascular therapy if they are within time limits. This whole field is evolving very fast."

In the statement, the authors note that although evidence supporting the equivalence of telestroke to in-person care is accumulating, the limits of medical care provided remotely by telemedicine remain to be defined.

"Ongoing monitoring of quality becomes increasingly important, given the relatively limited experience with stroke care in this environment."

They stress that time is of the essence in treating acute stroke patients, and telestroke systems must ensure that technology does not introduce time delays that could reduce the probability of recovery after acute stroke therapy. "Both the stroke center and the originating site must work together to institute appropriate protocols to ensure that eligible patients are identified, evaluated, and treated expeditiously," they write.

"Although the goal of telestroke at present is to achieve equivalence with in-person care, there is an opportunity to go further and perhaps improve stroke care through the application of this technology," they suggest. "Even in places with available stroke expertise, telestroke might provide additional speed or quality aids that increase protocol adherence and further improve outcomes."

The authors conclude: "It is hoped that these suggestions serve as a foundation for ongoing improvement of telestroke networks and increasing quality across all providers."

Stroke. Published online November 3, 2016. Full text

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