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Examples of successful telestroke networks

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Learn more about telestroke networks by exploring case studies of successful real-life systems.

Individual telestroke networks vary in infrastructure and patient outcomes.

Case study 1: The STARR network1

In the 2009 review Stroke Telemedicine, Dr Bart Demaerschalk et al detail the process of establishing the STARR network. The network was developed in response to data regarding the scarcity of hospitals staffed by on-call neurologists in Arizona, as well as general interest in exploring the benefits and challenges of telemedicine.

A needs assessment of all nonmetropolitan Arizona hospitals revealed that 41% were dependent on consultant recommendations for use of a thrombolytic in acute ischemic stroke care. Additionally, 44% of hospitals shipped patients to other sites (ship and drip or drip and ship). With >75% of surveyed hospitals interested in telestroke, the establishment of the STARR network addressed a widespread need.2

Within the STARR network, the hub is located in Phoenix, Arizona, and the 2 spokes are located in Kingman and Yuma, 190 and 184 miles away, respectively.1

Key steps in developing the STARR network from initiation to maintenance included2

  • Visits to established telestroke networks to study best practices and technologies
  • Assessment of the statewide need for a telestroke network via telephone and e-mail surveys
  • Acquisition of funding via a state research grant
  • Partnership of vascular neurology and emergency departments
  • Building of teams for neurology, emergency medicine, administration, contracts, legal, credentialing, licensing, information technology, radiology, training/education, research, institutional review board specialists, and finance/reimbursement
  • Face-to-face site visits and videoconferences with spoke sites
  • Hiring of a full-time project manager to oversee the network
  • Distribution of weekly e-newsletters and progress reports between hub and spoke sites
  • Independent state qualitative assessment and survey

From establishment of the STARR network on December 1, 2007, until May 31, 2008, the following statistics were collected1:

  • 4 teleconsultants
  • 33 consultations performed
  • 30% of evaluated patients were deemed eligible and received t-PA (an increase from the historical baseline of ~5%)

The STARR network plans to add additional spoke sites to the system, and assesses possible new sites with regard to

  • Size of spoke hospital
  • Volume of patients with stroke
  • Regional need for stroke services
  • Desire and willingness of spoke personnel to participate

"...therapies for acute [ischemic] stroke, such as tissue plasminogen activator (tPA), are underused by hospitals that cannot provide patients with timely access to stroke expertise. To overcome this gap in availability of and access to stroke specialists and to address the underuse of therapies for acute stroke, telemedicine techniques that are adapted to the emergency evaluation of acute stroke can be used."1

"The telestroke team should consist of a broad range of clinical, administrative, and research members at both the hub and spoke to fulfill all aspects of the telestroke dynamic."1

Genentech is neither affiliated with nor endorses any of the organizations described in these case studies.

Case study 2: The UPMC telestroke network3

Implementing a virtual system of care for improved stroke patient outcomes

The UPMC telestroke network is centered around a hub site, UPMC Presbyterian, a Joint Commission–certified primary stroke center (PSC) since 2004. The network was initiated in March 2006 and began with UPMC Presbyterian and 2 spoke hospitals. Currently, UPMC Presbyterian serves as the hub for 15 spoke sites, at distances that range from 7.5 miles to 150 miles from the hub.5

The UPMC telestroke network continues to grow as spoke hospitals are added, including one from across the state line in Maryland. Washington County Hospital in Hagerstown, Maryland has 3 in-house neurologists, though they are not always on-site. More than 50 telestroke connectivity ports throughout the hospital allow for consultation at any time.4

An expanding network of telestroke coverage

Hub and spoke hospital sizes and acute ischemic stroke (AIS) patient profiles5

UPMC telestroke network hospitalNumber of beds in hospitalAverage number of AIS patients per year

Hub

685

663

Spokes

49 to 399

7 to 400

The hub: UPMC Presbyterian5

UPMC Presbyterian has strived to improve its clinical capabilities as a hub since 2004 by increasing the number of patients treated and decreasing the time to treat. Patients treated with thrombolytics at UPMC Presbyterian have been 28 to 98 years of age with a range of National Institutes of Health Stroke Scale (NIHSS) scores of 2 to 30. From 2005 to 2008, UPMC Presbyterian administered IV t-PA to 97% of all eligible stroke patients (as determined by the Joint Commission harmonized DSC stroke measure STK-4.) The percentage of all AIS patients treated with a lytic has likewise increased from 6.6% (2005 to 2007) to 7.4% (2005 to 2008).

In 2008, the UPMC Presbyterian door-to-needle time was 71 minutes. In an effort to reduce door-to-needle time, the hospital has instituted new polices, including:

  • Emergency medical services (EMS) prenotification of ED en route, which allows the stroke team to meet the patient as soon as he or she gets to the door
  • Standing orders for ED — stroke initiation and stroke admission/discharge orders
  • Training of ED nurses in NIHSS and immediate assessment
  • Training and informing staff of time goals; placing digital clocks over ED beds

As a result of these efforts, UPMC Presbyterian has been able to reduce its door-to-needle time from 71 to 66 minutes and is striving to achieve the 60-minute goal by the end of 2009.

The spokes5

Based on data collected from several spoke sites, acute ischemic stroke patients given thrombolytics have been 45 to 99 years of age with a range of NIHSS scores of 4 to 27. While most spoke sites have staff to fulfill ED, ICU, laboratory, CT, quality improvement, and administrative duties, they generally lack neurologist and certified registered nurse practitioner capabilities and therefore rely on the hub for these services.

Since implementing telemedicine, UPMC spokes now administer thrombolytics and either transfer (drip and ship) the patient to the hub (UPMC Presbyterian) or admit these patients (drip and keep), depending on the spoke capabilities and patient needs.

Communication within the network

The 2007 American Heart Association/American Stroke Association (AHA/ASA) Guidelines for the Early Management of Adults with Ischemic Stroke permit EMS bypass of the nearest hospital if a more appropriate hospital is available within a reasonable transport interval.7

In collaboration with EMS, UPMC Presbyterian has implemented an EMS prenotification system covering the entire city of Pittsburgh and the surrounding area. Prenotification begins an assessment process that includes a Cincinnati Prehospital Stroke Scale screening, glucose test, and notification of the ED, at which point UPMC Presbyterian's stroke team is activated.5

The UPMC telestroke network allows stroke specialists, UPMC and non-UPMC community hospitals, and local EMS to work as a team, with the mission of improving stroke treatment.

All UPMC telestroke network hospitals perform stroke outreach in their respective communities, ranging from a few events per year to annual programs for Stroke Awareness Month, complete with themes (diabetes, women and stroke, etc) and educational tools (magnets, brochures, etc).5 Click here for additional examples of community outreach.

The model used by the UPMC telestroke network represents only 1 strategy for successful implementation of telemedicine technology for stroke. For examples of other stroke networks across the United States, click here.

Genentech is neither affiliated with nor endorses any of the organizations described in these case studies.


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.
Demaerschalk BM, Miley ML, Kiernan T-E J, et al; for STARR Coinvestigators. Stroke telemedicine. Mayo Clin Proc. 2009;84(1):53-64.
2.
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.
3.
UPMC. Stroke telemedicine program. UPMC Web site. http://www.upmc.com/Services/StrokeInstitute/Pages/telemedicine.aspx. Updated 2009. Accessed July 30, 2009.
4.
King M. Stroke patients connect with doctors via television. Your4State.com. July 22, 2009. http://your4state.com/content/fulltext/?cid=73282. Accessed July 31, 2009.
5.
Data on file. Genentech, Inc.
6.
National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587.
7.
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38(5):1655-1711.