East of England Stroke Telemedicine Stakeholder Partnership

The service’s key aim is to improve access to stroke thrombolysis across the region. In 2010, the recommended symptom onset to thrombolysis time window was 3 hours (later extended to 4.5 hours). Achieving this goal was severely limited, as many AIS patients, following assessment and diagnosis at a local hospital, required secondary ambulance transfer to a distant regional HASU for treatment. (NG128 recommendation 1:4 - Stroke and transient ischaemic attack in over 16s) (1)

The first objective was to make better use of limited, expert resources by increasing access to stroke expertise using videoconferencing telemedicine technology. Telemedicine has been utilised in other clinical areas such as dermatology, emergency medicine and the armed forces for many years. Technology has developed exponentially since the telemedicine service commenced and while health care demands continue to grow with a largely predictable increasing older, co-morbid population, meeting these patterns.

A second objective was to support the local stroke teams with appropriate education and training. The dissolution of the local cardiac and stroke networks resulted in a paucity of stroke education, reflected in the appropriateness of any of the stroke patients to the service. One of the stroke telemedicine consultants was appointed as the dedicated educational lead for the service. Their remit was to provide education aimed predominantly at the assessment of acute stroke, indications and contraindication for thrombolysis and stroke and the identification and treatment of stroke mimics. Education is a key feature of the service - the technology is stable and robust and has a proven track record of 10 years.

Our local stroke teams change regularly; with the annual change of junior doctors and the mobile stroke nurse workforce. Maintaining close links with a dedicated senior stroke nurse at each hospital is vital in ensuring that clinical staff remain updated and are aware of local and national policies and guidelines. (NG128 recommendation 1.4.3 - Stroke and transient ischaemic attack in over 16s).

A stroke diagnosis was previously a low priority within the NHS; viewed as an inevitable risk of aging and frequently resulted in a range of lifelong disabilities. Even in 2018, almost two thirds of patients are discharged from hospital with a disability. Stroke is now viewed as a medical emergency, with over 100,000 strokes annually in the UK. The majority of patients survive their stroke; it remains the largest cause of disability in the UK (2).

Our local 2010 review of the regional stroke services identified an increased incidence of AIS. This paralleled with limited access to appropriate thrombolytic therapy in addition to prolonged ambulance transfer times of 45 – 60 minutes to one of the region’s nearest HASU’s. The additional poor road infrastructure compounded the issue of rapid and timely access to thrombolysis for AIS patients.

Several models for addressing this issues for access to stroke care were considered. Such an infrastructure ruled out the London style ‘hub and spoke’ model linking the existing three HASUs (Addenbrookes, Southend and the Norfolk & Norwich Hospitals) being adopted across the region. Potentially thrombolysable AIS patients were diverted to larger 24/7 hospitals, creating a two-tier system. This was a specific issue OOH, due to the prolonged inter-hospital ambulance transfer times that further impacted on time to definitive treatment. This was clearly unsatisfactory for patients, their families and staff and a new model of stroke care was required.

A 2010 DH report initially identified telemedicine as a potential method of overcoming some of the barriers to stroke care, including accessing CT scanning and subsequent thrombolytic treatment (3). Evidence at this time highlighted that nationally less than 1% of ischaemic stroke patients received thrombolysis (4). Evidence suggesting a 10% thrombolysis rate in AIS patients would result in up to 1,500 people annually regaining their independence rather than suffering a lifetime of disability. The resultant economic annual health saving was estimated at £16 million (3).

The project initially commenced with four of the regional hospitals and with four stroke consultants on the regional telemedicine rota. In November 2011, many of the region’s 6,000 stroke patients were being referred to Addenbrooke’s Hospital, creating a significant demand on ED and the stroke beds. The subsequent repatriation and intra-hospital transfer to the referring hospital for on-going care, created further pressures on the local health economy.

Some of the key barriers have been the many ‘silos’ that exist within NHS Trusts. To effectively manage this telemedicine service requires good communication with local clinical teams, operations managers, radiology, I.T, finance, payroll, commissioning, purchasing and procurement departments - for each hospital. Navigating each hospital’s local systems and hierarchy can be a frustrating.

A key factor in the successful implementation of the project has been the stakeholder partnership. The Partnership is comprised of key personnel from our partner hospitals, including clinical and management, to aid development of the stroke pathway and oversee organisational issues. The stakeholder partnership has been vital in the progression from project to service; a fundamental aspect of our development and evolution into an integral aspect of the stroke services across the region.

Over time, we have advanced from regular face-to-face meetings to teleconferencing and videoconferencing as the large geographical nature of the area and clinical commitments impacts on clinician availability. Other strategies to overcome these barriers have included:

• a good sense of humour!
• identifying a local stroke nurse as a champion.
• our contractual agreement requires a stroke consultant to join the rota.

Several telemedicine models and concepts were considered to address the issue of meet the need of stroke thrombolysis. The secure online videoconferencing system by IOCOM (now called Visionable) was finally adopted, running on PCs in the telemedicine carts. Since 2011, a further three hospitals have subsequently joined the service, and currently we are in discussions with two other hospitals who are looking to restructure their OOH stroke care.

The current annual cost of this managed service is £62,000 per hospital and covers the costs of the stroke consultants salary, access to the regional rota, provision of all hardware and software, IT and management support, and all appropriate training and education.

Since November 2011 we have:

• Assessed over 3,500 patients.

• Advised thrombolysis treatment for a median of 40% of our presenting patients.

• An overall DTN time of 58 mins (median IQR) representing a 37% improvement (133 mins in 2012 - 59 mins in 2018).

• Onset to Needle (OTN) time of 1 hour 21 mins (81 mins) (median IQR).

This has ensured that many more patients have been treated closer to home, reducing costs to them and their families. The improved thrombolysis rate wil have had an impact on reducing length of hospital stay and rehabilitation issues. We are currently undertaking a health economic review of the service with the UEA and will be performing a patient feedback review in the Autumn 2019. For those patients NOT thrombolsyed, we have identified the three top reasons:

• Patient presents outside the 4.5 hour timeframe for thrombolysis (22%).
• Symptoms resolved/ing (19%).
• Stroke mimic (17%) These three rationale have been consistent over the years, although slowing decreasing, and relate largely to stroke knowledge and expertise of the local referring stroke teams.

We have met and exceeded our original aims & objectives, with a further 2 regional hospitals hoping to join the service. A continued lack of suitably qualified clinicians remains a challenge in 2019, and even with available staff, each participating hospital would incur an additional £400 - 500, 000 salary cost for each hospital without the telemedicine service.

A financial appraisal with our regional ambulance service has estimated that the telemedicine service has resulted in £700,000 of savings, as the previous inter-hospital transfers were necessary to move patients to definitive care. A 2014 study demonstrated the safety and effectiveness of a ‘horizontal’ networking approach for stroke telemedicine, which may be applicable to areas where traditional “hub-and-spoke” models may not be geographically feasible (5).

• A dedicated telemedicine manager with overall operational view of the service has proved valuable; helping to achieve the aims and objectives of the service. The benefits of one individual overseeing the service ensure its aims and objectives remain at the heart of care delivery and prevent ‘mission slip’. A dedicated role (even as a job share) not only acknowledges and appreciates the importance of the service, but also allows for all related NHS staff to identify with this lead for the service. We have also supported the telemedicine manager with a medical and clinical/nursing lead to provide support as required and these individuals are drawn from some of the partner hospitals.
• The local nurses are key to this service since the local clinical team need the ability to deliver the advised care - in this case the facility to administer thrombolysis and manage to thrombolysed patient. Telemedicine would be inoperable if the local care team were unable to deliver this expert care.
• Education is key to delivering stroke education to our local clinic teams. Stroke education and training are vital in ensuring staff are updated and feel competent to use telemedicine for the benefits of their patients. We have appointed an education lead for the service; a stroke consultant to deliver local stroke master classes locally as needed, also supporting the paramedic project. We are currently working with the Stroke Association is re-establishing the East of England Stroke Forum to ensure a more regional approach to stroke training and education.
• Focus on the clinical aspect rather than the technical aspect
• Telemedicine is a very useful tool in modern health care with the ability to link remote clinicians to patients for expertise. This ‘care without walls’ model allows for some innovative health care models, with potential cost-effectiveness care.