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Examples of successful telestroke networks

Would you like your telestroke network to be featured?

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.

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).

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.