LOG IN/REGISTER >
FORWARD TO A COLLEAGUE >
INDICATION/SAFETY INFORMATION >

Key elements of a successful telestroke system

Equipment and personnel

Configuration of a telestroke system may include


EquipmentPersonnel4 
  • Desktop PC or laptop1
  • High-speed Internet access1
  • Camera on monitor directed at both the patient and the remote physician1
  • IP/ISDN connection for videoconferencing2
  • Data encryption (supports HIPAA compliance)3
 Hub hospital:
  • Vascular neurologist
  • Emergency physician
  • Program coordinator/project manager
  • Information technologist
  • Nurse practitioner or physician assistant
 Spoke hospital:
  • Emergency physician
  • Information technologist
  • Radiologist
  • Emergency nurse

Back to top

Common challenges5

As telestroke networks are developed, a set of common challenges has emerged, along with some tips for overcoming them.

  • Funding for building network infrastructure
    • – Potential funding resources are available in the form of grants from the federal government, including the Telehealth Network Grant Program, the Rural Health Care Pilot Program, and the Distance Learning and Telemedicine Loan and Grant Program
  • Legislative and regulatory changes
    • – Public health regulations or legislation requiring hospitals that receive acute stroke patients to be acute stroke–capable hospitals or primary stroke centers will be a driving force in promoting telestroke networks
  • Methods for reimbursement
    • – Clarity in reimbursement for telemedicine has been improving, but issues regarding whether professional reimbursement for telestroke consultation will occur, as well as whether hospitals will be reimbursed for drip-and-ship patients, still require attention
  • Licensure and credentialing for consulting physicians
    • – In existing telestroke networks, the issue of licensure and credentialing of physicians consulting across state lines has been simplified by the hub hospital’s assuming full responsibility for ensuring appropriate licensure
  • Telestroke hardware and software issues
    • – Common technical problems associated with telestroke networks may be alleviated by use of open standards, permitting all devices to communicate seamlessly, as well as implementation of effective information technology systems
  • Medical errors
    • – Medical errors may be reduced by ensuring effective communication among providers, evaluating patients in a timely manner, documenting decision making processes, and providing access to experienced stroke specialists

Back to top

Best practices

The implementation and maintenance of a successful telestroke system may be promoted by a number of elements:

  • Appropriate licensure and credentialing for all consulting physicians5
  • A program leader to champion the effort3
  • Support from emergency departments at spoke hospitals4
  • Reporting mechanisms and frequent on-site visits between hub leaders and spoke sites to provide feedback3,4
  • Standardized protocols at all spoke sites3
  • Backup equipment to be used in the event of hardware problems3
  • Availability of Activase (Alteplase)3
  • Personnel trained in Activase (t-PA) administration3
  • Spoke hospital training (eg, mock stroke code exercises)3
  • Transfer agreements in place3

Encouragement of physician acceptance and use of a telestroke system5

As stated in the 2009 American Stroke Association (ASA) telestroke recommendations, physicians, nurses, and allied healthcare professionals are the key to telestroke program adoption and promotion. Enthusiasm for telestroke programs may be cultivated through active engagement of key team members at both hub and spoke hospitals starting at the beginning of the development process.

Promotion of a positive relationship between telestroke consultants and referring physicians also facilitates system development. Building trust and awareness of successful cases through physician-to-physician interaction helps to change attitudes and increase use of the telestroke system.

Ease of use of telemedicine technology, particularly in spoke hospitals, is another critical factor for successful adoption and implementation of telestroke.

Back to top

Matters of compliance associated with telemedicine5

Compliance with privacy and security laws

Telemedicine involves transmission of HIPAA-protected health information; therefore, per the 2009 ASA telestroke recommendations, telestroke programs must have processes in place to secure the following:

  • Live audio and video transmissions between hospitals
  • Storage of data collected during consultations
  • Network tools that physicians use to access data

To ensure HIPAA compliance, policies and procedures related to storage and dissemination of health information within the telestroke system should be documented.

Compliance with fraud and abuse statutes

Telestroke services are subject to federal and state laws designed to protect against fraud and abuse of Medicare and Medicaid. Individuals working to build telestroke networks should work closely with legal counsel to avoid violation of the statutes.*

Additional information on implementation of telestroke networks:

  • Access the 2009 AHA/ASA Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care
  • Download the module Telestroke: Coordinating Systems of Care from the Activase modular slide presentation
  • *
  • The Antikickback Statute prohibits physician remuneration for referral of services that are payable under a federal healthcare program such as Medicare or Medicaid. The Stark Law prohibits a physician from ordering certain healthcare services for Medicare or Medicaid patients from entities in which the physician has a vested interest.

Back to top


Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Important Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Shafqat D, Kvedar JC, Guanci MM, Chang Y, Schwamm LH. Role for telemedicine in acute stroke: feasibility and reliability of remote administration of the NIH Stroke Scale. Stroke. 1999;30(10):2141-2145.
2.
Hess DC, Wang S, Gross H, Nichols FT, Hall CE, Adams RJ. Telestroke: extending stroke expertise into underserved areas. Lancet Neurol. 2006;5(3):275-278.
3.
Demaerschalk B, Kiernan T. Stroke telemedicine in Arizona. Paper presented at: Mayo Clinic College of Medicine; 2008; Phoenix, AZ. http://www.azcvd.gov/pdf/Stroke%20Telemedicine%20Presentation.pdf. Accessed May 8, 2009.
4.
Demaerschalk BM, Miley ML, Kiernan T-E J, et al. Stroke telemedicine. Mayo Clin Proc. 2009;84(1):53-64.
5.
Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40. http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192361v1. Accessed May 7, 2009.