Telehealth supported rural stroke units – lessons from the pilot

Matt Page1, Jodie Turvey2, Greg Cadigan3

 

1 Queensland Health, GPO Box 48, Brisbane, Queensland 4001, matthew.page2@health.qld.gov.au

2 Queensland Health, GPO Box 48, Brisbane, Queensland 4001, greg.cadigan@health.qld.gov.au

3 South West Hospital and Health Service, PO Box 1006, Roma, Queensland 4455, Jodie.turvey@health.qld.gov.au

 

Background:

Validated evidence (31 RCTs) indicates admission to an acute stroke unit significantly reduces mortality and disability associated with stroke when compared to care in a general ward.  Additionally, reduction in stroke mortality is associated with the prevention and treatment of complications, particularly those related to infection and mobility3.

Queensland has 21 endorsed stroke units, all of which admit >100 stroke admissions per year – however there is a disparity in accessing evidence based stroke care for people living in rural areas due to their remoteness. Thrombolysis, an intervention for treating ischaemic strokes, is only effective if administered within three hours of symptom onset and only in a lysis capable centre.

Excluding thrombolysis, admission to a stroke unit within three hours as opposed to six hours resulted in significantly better outcomes without a statistically significant difference in mortality4.  Interventions such as rapid “door to brain” imaging, thrombolysis, clot retrieval and admission to a stroke unit remain inaccessible for a considerable proportion of Queensland’s decentralised population living in rural areas.

Establishing telehealth supported stroke units in key rural/remote sites has the potential to improve equity of access to specialist and interventionist treatment.  Other potential benefits include reduced emergency retrievals, reduced travel burden for post-acute care, up-skilling of local healthcare teams and improved efficiencies within the healthcare system.

Method:

In collaboration with the Queensland Health Statewide Stroke Clinical Network SSCN a regional “hub” provider with an existing endorsed stroke unit, and a rural recipient site admitting <15 stroke admissions were recruited for an informal telehealth model of care pilot, supporting a rural acute stroke unit.

Pathway development consisted of collaboration across multiple levels/key stakeholders from both facilities.  Initial site visits were complex given the local hospital was not equipped with a CT scanner and support was from a private radiology service located 250 metres away and off campus.  Local Queensland Ambulance Service (QAS) played an important role in the transfer of suspected stroke patients to and from scanning facility.  The local nursing team was provided with in-service education in the model of care and management of the videoconferencing component, and the Emergency Department team received training in the administration of remote thrombolysis via telehealth.

Results:

The pilot program was significantly under-utilised.

Discussion:

We considered potential causes of the low utilisation. The following challenges were considered as contributing factors:

  • Few stroke presentations despite historical data trends, thus difficult for the clinical teams to retain knowledge of the model of care.
  • No stroke presentations were candidates for remote thrombolysis.
  • The model was dependent on the hub site providing specialist telehealth stroke support but with an already over-committed HHS workload, single specialist engagement, and cross HHS medical care, ward reviews were performed on an ad-hoc basis, and for deteriorating patients requiring palliation/transfer decisions.
  • The primary medical lead and enthusiastic clinical champion from the rural recipient site retired.
  • The model was informal and changed significantly across the duration of the pilot.
  • The pilot commenced on a public holiday and included the Christmas/New Year period, meaning there were extensive periods without a providing stroke specialist at the hub site.
  • Despite the site visits and training of local nursing team, the draft procedure was frequently not followed.
  • Other challenges were as a result of cross hospital jurisdiction and determining the responsibilities of each site.

Despite the pilot not achieving the initial business case goals or planned model of care – it can be said that the rural site’s engagement and telehealth support structure retains executive and clinician support. The regional site acknowledges it still has a role to play in providing the best possible care and patient outcome.

References:

  1. (https://strokefoundation.com.au/About-Stroke/Facts-and-figures-about-stroke).
  2. Australian Institute of Health and Welfare 2014, Australia’s Health 2014.
  3. Stroke Foundation, Clinical Guidelines for Stroke Management 2010.
  4. Silvestrelli G, Parnetti L, Paciaroni, Caso, Corea, Vitali, et al. Early admission to stroke unit influences clinical outcome. Eur J Neurol. 2006;13:250–5.