The TeleStroke Mimic (TM)‐Score: A Prediction Rule for Identifying Stroke Mimics Evaluated in a Telestroke Network

Background: Up to 30% of acute stroke evaluations are deemed stroke mimics (SM). As telestroke consultation expands across the world, increasing numbers of SM patients are likely being evaluated via Telestroke. We developed a model to prospectively identify ischemic SMs during Telestroke evaluation. Methods and Results: We analyzed 829 consecutive patients from January 2004 to April 2013 in our internal New England–based Partners TeleStroke Network for a derivation cohort, and 332 cases for internal validation. External validation was performed on 226 cases from January 2008 to August 2012 in the Partners National TeleStroke Network. A predictive score was developed using stepwise logistic regression, and its performance was assessed using receiver‐operating characteristic (ROC) curve analysis. There were 23% SM in the derivation, 24% in the internal, and 22% in external validation cohorts based on final clinical diagnosis. Compared to those with ischemic cerebrovascular disease (iCVD), SM had lower mean age, fewer vascular risk factors, more frequent prior seizure, and a different profile of presenting symptoms. The TeleStroke Mimic Score (TM‐Score) was based on factors independently associated with SM status including age, medical history (atrial fibrillation, hypertension, seizures), facial weakness, and National Institutes of Health Stroke Scale >14. The TM‐Score performed well on ROC curve analysis (derivation cohort AUC=0.75, internal validation AUC=0.71, external validation AUC=0.77). Conclusions: SMs differ substantially from their iCVD counterparts in their vascular risk profiles and other characteristics. Decision‐support tools based on predictive models, such as our TM Score, may help clinicians consider alternate diagnosis and potentially detect SMs during complex, time‐critical telestroke evaluations

Telemedicine in pre-hospital care: a review of telemedicine applications in pre-hospital environment.

The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome

Time is Brain: How a Descriptive Analysis of Telestroke Metrics Can Improve Program Performance

In the event of an acute ischemic stroke, 1.9 million neurons are lost in the brain per minute. Since the inception of thrombolytic therapy and mechanical thrombectomy as effective tools in the treatment of acute ischemic stroke, the focal point of quality improvement in this field has become the time to treatment delivery. As rural and more interspersed environments exhibit high disability and mortality rates associated with these acute neurological conditions, inequities in timely care delivered to these patient populations persist. Limitations in access are now abated by the extension of neurologist expertise into these areas via Telestroke. This study seeks to understand variation among key performance measurements within a Telestroke network serving New York’s Hudson Valley and to determine if more time within this program results in improved performance. A descriptive analysis of several unique time metrics reveals associations among discovered variables that will guide targeted process improvement initiatives and promote evidence-based decision making. It is undetermined whether time within this network results in improved performance, yet the mission of continuously improving the ability to preserve brain tissue in acute stroke patients by reducing the time to treatment is accomplished through constant program monitoring and process improvement

Integrating acute stroke telemedicine consultations into specialists' usual practice: a qualitative analysis comparing the experience of Australia and the United Kingdom

Stroke telemedicine can reduce healthcare inequities by increasing access to specialists. Successful telemedicine networks require specialists adapting clinical practice to provide remote consultations. Variation in experiences of specialists between different countries is unknown. To support future implementation, we compared perceptions of Australian and United Kingdom specialists providing remote acute stroke consultations. Specialist participants were identified using purposive sampling from two new services: Australia's Victorian Stroke Telemedicine Program (n = 6; 2010-13) and the United Kingdom's Cumbria and Lancashire telestroke network (n = 5; 2010-2012). Semi-structured interviews were conducted pre- and post-implementation, recorded and transcribed verbatim. Deductive thematic and content analysis (NVivo) was undertaken by two independent coders using Normalisation Process Theory to explore integration of telemedicine into practice. Agreement between coders was M = 91%, SD = 9 and weighted average κ = 0.70. Cross-cultural similarities and differences were found. In both countries, specialists described old and new consulting practices, the purpose and value of telemedicine systems, and concerns regarding confidence in the assessment and diagnostic skills of unknown colleagues requesting telemedicine support. Australian specialists discussed how remote consultations impacted on usual roles and suggested future improvements, while United Kingdom specialists discussed system governance, policy and procedures. Australian and United Kingdom specialists reported telemedicine required changes in work practice and development of new skills. Both groups described potential for improvements in stroke telemedicine systems with Australian specialists more focused on role change and the United Kingdom on system governance issues. Future research should examine if cross-cultural variation reflects different models of care and extends to other networks

Building Cohesion in Distributed Telemedicine Teams Findings from the Department of Veterans Affairs National Telestroke Program

Background: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid virtual stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identied cohesion-related factors inprogram development and support. Methods: We conducted a case study of the stroke specialists employed by the NTSP. Semi-structured, condential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and teamcohesion, and we identied factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. Results: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with local colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP.Conclusion: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promotecohesion in distributed telemedicine teamsThis work was funded by the Veterans Health Administration (VHA) Office of Rural Health (016ORH), VHA Office of Specialty Care, VA Health Services Research and Development (HSR&D) Precision Monitoring Quality Enhancement Research Initiative (QUE 15-280). Funding sources had no role in study design, data collection, data analysis, data interpretation, or manuscript writing. The views expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Department of Veterans Affairs

Vascular Neurology Nurse Practitioner Provision of Telemedicine Consultations

Objective. The objective was to define and evaluate a role for the Vascular Neurology-Nurse Practitioner (VN-NP) in the delivery of telemedicine consultations in partnership with a vascular neurologist. Methods. Prospective stroke alert patients at participating hospitals underwent a two-way audio video telemedicine consultation with a VN-NP at a remotely located stroke center in partnership with a vascular neurologist. Demographic information, National Institutes of Health Stroke Scale (NIHSS) scores, diagnoses, CT contraindications to thrombolysis, thrombolysis eligibility, and time interval data were collected. The inter-rater agreement between VN-NP and vascular neurologist assessments was calculated. Results. Ten patients were evaluated. Four were determined to have ischemic stroke, one had a transient ischemic attack, two had intracerebral hemorrhages, and three were stroke mimics. Overall, three patients received thrombolysis. The inter-rater agreement between VN-NP and vascular neurologist assessments were excellent, ranging from 0.9 to 1.0. The duration of VN-NP consultation was 53.2 ± 9.0 minutes, which included the vascular neurologist supervisory evaluation time of 12.0 ± 9.6 minutes. Conclusion. This study illustrated that a stroke center VN-NP, in partnership with a vascular neurologist, could deliver timely telemedicine consultations, accurate diagnoses, and correct treatments in acute stroke patients who presented to remotely located rural emergency departments within a hub and spoke network. VN-NPs may fulfill the role of a telestroke provider

The South Carolina Telestroke Program: Does County-level Telestroke Access Increase the Odds that Patients Will Receive t-PA?

Stroke is a disease that is responsible for disabling more of its victims that any other disease in the United States. There are four types of stroke. However, ischemic stroke is responsible for 87% of all strokes. T-PA is a pharmaceutical that has proven an effective treatment for ischemic stroke patients since 1996. T-PA works by dissolving the thrombosis that has become lodged in a brain vessel. This pharmaceutical has its limitations; mainly it must be administered within 4.5 hours of symptom onset. Nationally, the medical field experiences low utilization rates, between 3-5%. The many variables that affect this low usage rate, however, this study focuses on patient’s residence in a county that offers telestroke services compared to counties that do not have telestroke services. In completion, of the necessary research, archival data from the 2013 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for South Carolina was utilized. Hospital encounters that had a primary diagnosis code of 424.xx & 436.xx (ICD- 9-CM) were identified for analysis. The analysis revealed 9,311 South Carolinians suffered a stroke in 2013 while a total of 461 patients were administered t-PA (4.95%). The study found a greater percentage of patients living in “Telestroke Access” counties received t-PA compared to those that did not, 5.11% to 4.76%, respectively. However, the county in which patients resides was not a statistically significant indicator because of the p-value = 0.36

A new telestroke network system in northern area of Okayama prefecture

Background Telestroke network can provide rapid access to specialized treatment and improves on‐site management of acute stroke patients through the “hub‐and‐spoke” model. In the northern part of Okayama Prefecture, there has been a regional gap of stroke care due to the shortage of stroke specialists and facilities. In addition, due to the novel coronavirus disease 2019 (COVID‐19), it is required to reduce the unnecessary contact with stroke patients from other hospitals. Aim We organized a novel cost‐free telestroke network with an image and video sharing for neurological diseases in the northern part of Okayama Prefecture to improve the stroke management in the area. Method We prepared the tablet device on which Skype® application was installed for each hospital and recruited the patients who visited or hospitalized in the spoke hospitals and were suspected to have some neurological diseases from April 2019 to May 2020. The patient's clinical data were recorded and analyzed. Results During the study period, 5 patients were recruited including the cases with the initial diagnosis of stroke or brain tumor. Among them, 2 cases were transferred to the hub hospital, 2 cases were transferred to other hospitals, and 1 case was treated on site under specialist's advice. Conclusion The new telestroke network system may be beneficial for acute stroke management and reducing the unnecessary patient's transfer in the rural area, especially under coexistence with COVID‐19