Connect
MJA

Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program

Chris F Bladin, Joosup Kim, Kathleen L Bagot, Michelle Vu, Natasha Moloczij, Sonia Denisenko, Chris Price, Nancy Pompeani, Lauren Arthurson, Casey Hair, Justin Rabl, Mick O'Shea, Patrick Groot, Leslie Bolitho, Bruce CV Campbell, Helen M Dewey, Geoffrey A Donnan and Dominique A Cadilhac
Med J Aust 2020; 212 (8): 371-377. || doi: 10.5694/mja2.50570
Published online: 13 April 2020
Correction(s) for this article: Erratum | Published online: 15 June 2020

Abstract

Objectives: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria.

Design: Historical controlled cohort study comparing outcomes during a 12‐month control period with those for the initial 12 months of full implementation of the VST program at each hospital.

Setting: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016.

Participants: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals.

Main outcome measures: Indicators for key processes of care, including symptom onset‐to‐arrival, door‐to‐first medical review, and door‐to‐CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke.

Results: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door‐to‐CT scan time (median, 25 min [IQR, 13–49 min] v 34 min [IQR, 18–76 min]) and door‐to‐needle time for stroke thrombolysis (73 min [IQR, 56–96 min] v 102 min [IQR, 77–128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period.

Conclusions: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

The known: Telemedicine support has improved access to acute stroke therapies in regional hospitals overseas, but has not been provided on a large scale in Australia.

The new: The Victorian Stroke Telemedicine (VST) program in 16 hospitals in regional Victoria was associated with improved delivery of acute stroke therapies, including providing thrombolysis more quickly and safely.

The implications: The VST program has improved access to stroke specialists in regional Victoria and the quality of care for people with acute stroke. The program is now fully funded by the Victorian government.

 

Stroke is a major cause of death and disability in Australia; about 65 000 people were hospitalised with stroke during 2016–17.1,2 Hospitals that admit fewer than 200 patients with stroke per year provide intravenous thrombolysis within 4.5 hours of an ischaemic stroke less frequently than the larger capacity hospitals typical of metropolitan areas.3 One of the major reasons for this difference is the lack of stroke expertise outside metropolitan areas, underscoring the need for acute stroke telemedicine services. Overseas, telemedicine has improved access to thrombolysis and other acute stroke therapies in non‐metropolitan hospitals.4 The risks of complications and mortality after thrombolysis delivered by clinicians without specialty expertise in stroke are lower when telemedicine clinical support is provided.5 Despite the positive overseas experience, large scale telemedicine programs for people with stroke have not been introduced in Australia.

The Victorian Stroke Telemedicine (VST) program was introduced as a new model of clinical care for supporting the treatment of patients with acute stroke in Victorian regional hospitals. Using advanced audio‐visual technology, clinicians at the 16 participating hospitals can discuss the diagnosis and treatment of patients with stroke specialists. Prior to the VST program, only five of the 16 hospitals routinely provided stroke thrombolysis for patients, and stroke care was provided by general physicians, apart from one hospital with a limited on‐site neurology service.

The aim of our study was to evaluate the impact of the VST program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to participating hospitals in regional Victoria.

Methods

The background to the program has been described elsewhere.6,7 Briefly, the VST program provides a telemedicine service for acute stroke to 16 hospitals in regional Victoria, 24 hours a day, 365 days a year (Box 1). The number of emergency department (ED) urgent cases seen per year (triage categories 1–4) at the participating hospitals during 2016–17 ranged from 5741 for Hamilton to 50 969 for Ballarat (data source: MyHospitals, https://www.aihw.gov.au/myhospitals).

Victorian Stroke Telemedicine program: clinical protocol and implementation

Patients with symptoms of suspected stroke were assessed by ED clinical staff according to the standard computed tomography (CT) imaging protocol (non‐contrast CT brain, CT angiogram). A stroke specialist on the VST program roster was contacted at the discretion of ED clinicians on a dedicated toll‐free telephone number. Audio‐visual consultation between the VST stroke specialist, ED clinical staff, and patients (and their family and carers) was facilitated by a telemedicine cart (mobile computer and camera) at the bedside of the patient. The stroke specialist connects to the telemedicine cart via embedded software that also provides rapid access to a picture archiving and communication system for reviewing brain images. A diagnosis is provided by the specialist and best practice treatments recommended for patients diagnosed with stroke, including thrombolysis or transfer for endovascular clot retrieval (from May 2016) when appropriate. On completion, the consultation is documented in a standardised form and sent to each hospital for filing with the patient's paper or electronic medical record.

After a successful pilot phase at Bendigo Health, the VST program formally commenced in 2013 and was incrementally expanded to a total of 16 hospitals by 2016.8,9 The process for implementing the VST program has been described elsewhere.8 Briefly, a governance committee and focused working groups (medical, information technology, research and evaluation, and communication and education) provided oversight or support for the iterative implementation of the program, and a VST coordinator was appointed for each hospital to integrate the VST protocol into routine ED workflows according to an implementation plan.6,9 A multidisciplinary stroke education program was provided for all clinical staff involved. The implementation process, including discussions with information technology, radiology (for access to the picture archiving and communication system), Ambulance Victoria, hospital executive, and ED clinical staff was typically completed within 6 months.

Data collection

We employed a historical controlled cohort design6 to evaluate the VST program. At each participating hospital, data for the 12 months preceding implementation (the control period) were retrospectively collated (Bendigo Health: 1 January 2010 – 31 December 2010; all other hospitals: during 1 January 2013 – 30 June 2016). After implementation of the telemedicine consultation service was completed at a site, data were collected prospectively for 12 months (intervention period) during 8 January 2014 – 31 December 2017.

During both the control and intervention study periods, data were collected in a similar manner on standardised forms. Basic clinical information was extracted from medical records for all patients over 18 years of age with suspected stroke when they arrived in the ED. Eligible patients were identified using International Classification of Diseases, Australian modification, version 10 (ICD‐10‐AM) codes (for ED patients: G45.9, I61.9, I62.1, I62.9, I63.9, I64, R41.0, R47.0, R47.1, S06.00, S06.01; for patients admitted to hospital: G45.0, G45.1, G45.2, G45.3, G45.8, G45.9, I61, I62.9, I63, I64, I67.8, I67.9). A screening log was used to determine whether each patient had a final diagnosis of ischaemic stroke and had arrived within 4.5 hours of symptom onset. For patients satisfying these criteria or who had received a VST consultation (irrespective of the final diagnosis and time of symptom onset), a purpose‐designed, standardised audit tool was used to collect further data on their hospital presentation, including details of any telemedicine consultation, management and treatment while in hospital, and outcomes at discharge from hospital. The final diagnosis was confirmed in medical records for the ED presentation and any subsequent inpatient admission.

Part‐time site coordinators were employed to educate staff about the VST clinical protocol and trained to collect data; they could therefore prospectively verify patient details only during the intervention period. Data for patients who had an in‐hospital stroke or had not had a stroke but received a telemedicine consultation were collected but not included in our analysis of the stroke telemedicine intervention. Data quality checks were routinely undertaken and errors flagged for correction by the hospital site coordinators.

The major outcome measures were statistics for key processes of care, including symptom onset‐to‐arrival, door‐to‐first medical review, and door‐to‐CT times; and provision and timeliness of provision of thrombolysis to patients with ischaemic stroke.

Statistical analyses

As the data were not normally distributed, differences between groups were assessed in χ2 tests for categorical variables and Kruskal–Wallis tests for continuous variables. The use of telemedicine and its association with patient treatment and outcomes were assessed by logistic regression; the use of telemedicine and its associations with time to diagnosis and treatment were assessed by median regression. All models were adjusted for age, sex, history of stroke, ability to walk on admission (as a marker of stroke severity), hospital size (annual number of admissions for stroke), and patient clustering by hospital. Regression analyses of stroke thrombolysis were limited to patients with ischaemic stroke.

Ethics approval

Data collection was approved by the twelve Human Research Ethics Committees overseeing research activities at the 16 hospitals (Supporting Information, table 1).

Results

A total of 2887 patients with a diagnosis of suspected stroke presented to participating EDs during the control period, and 3178 during the intervention period; the characteristics of the patients were similar for both periods (Box 2). During the intervention period, the median age of patients who arrived within 4.5 hours of symptom onset and had a final diagnosis of stroke was lower for those who had a VST consultation (75 years; interquartile range [IQR], 64–82 years) than for those who did not (78 years; IQR, 70–86 years); a greater proportion had received ED diagnoses of ischaemic stroke (90% v 57%) and a smaller proportion received ED diagnoses of transient ischaemic attack (2% v 14%). Ambulance pre‐notification of the hospital of the delivery of patients was more frequent for those who had VST consultations (67% v 50%) (Box 3).

Key processes of care

A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received intravenous thrombolysis during the intervention period than during the control period (control, 107 of 351 [30%]; intervention, 185 of 503 [37%]). During the intervention period, two hospitals provided thrombolysis to patients with stroke for the first time. Median times to diagnosis and treatment were lower during the intervention, including door‐to‐first medical review (control, 8 min [IQR, 3–20 min]; intervention, 3 min [IQR, 0–9 min]), door‐to‐CT (control, 34 min [IQR, 18–76 min]; intervention, 25 min [IQR, 13–49 min]), and door‐to‐needle time for stroke thrombolysis (control, 102 min [IQR, 77–128 min]; intervention, 73 min [IQR, 56–96 min]). For patients who received thrombolysis, the proportion treated within 60 minutes of arrival increased from 13% (14 of 102) during the control period to 32% (58 of 158) during the intervention period (Box 4). During the entire study period (control and intervention), 271 of the 292 patients who received thrombolysis (92%) did so within 4.5 hours of symptom onset.

A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received intravenous thrombolysis during the intervention period than during the control period (control, 107 of 351 [30%]; intervention, 185 of 503 [37%]). During the intervention period, two hospitals provided thrombolysis to patients with stroke for the first time. Median times to diagnosis and treatment were lower during the intervention, including door‐to‐first medical review (control, 8 min [IQR, 3–20 min]; intervention, 3 min [IQR, 0–9 min]), door‐to‐CT (control, 34 min [IQR, 18–76 min]; intervention, 25 min [IQR, 13–49 min]), and door‐to‐needle time for stroke thrombolysis (control, 102 min [IQR, 77–128 min]; intervention, 73 min [IQR, 56–96 min]). For patients who received thrombolysis, the proportion treated within 60 minutes of arrival increased from 13% (14 of 102) during the control period to 32% (58 of 158) during the intervention period (Box 4). During the entire study period (control and intervention), 271 of the 292 patients who received thrombolysis (92%) did so within 4.5 hours of symptom onset.

During the intervention period, 165 of the 185 patients who received thrombolysis (89%) also had a telemedicine consultation. Among patients who received thrombolysis, the proportions who had a symptomatic intracerebral haemorrhage (control, 17 of 107 [16%]; intervention, eight of 185 [4%]) or died in hospital (control, 21 of 107 [21%]; intervention, 12 of 185 [6%]) were smaller during the intervention than during the control period (Box 4).

Compared with the control period, the odds of receiving thrombolysis were higher for patients who had a VST consultation (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.39–3.21), as was delivery of thrombolysis within 60 minutes of arriving at the hospital (aOR, 3.14; 95% CI, 1.21–8.15) (Box 5). In the multivariable median regression analysis, the VST program was associated with a reduction in median door‐to‐needle time for thrombolysis delivery of greater than 25 minutes, regardless of whether the patient had a VST consultation (Box 6). Time to thrombolysis and the odds of symptomatic intracerebral haemorrhage after thrombolysis were each lower during the intervention period (Supporting Information, tables 2 and 3).

Discussion

We report the first statewide telemedicine program for stroke care in regional hospitals in Australia. The VST program was associated with more timely assessment and treatment and improved outcomes for patients with suspected stroke. A larger proportion of patients who arrived at the ED within 4.5 hours of symptom onset received thrombolysis within 60 minutes, with more rapid processes of care and fewer adverse events. More than 95% of people living in regional Victoria are now within an hour's drive of a hospital with access to expert stroke care facilitated by the VST program, and some regional hospitals can now deliver stroke thrombolysis for the first time.10

The role of the stroke telemedicine doctor is, in collaboration with the local clinical team, to assess patients with suspected stroke, to review the relevant investigations (including brain imaging), and to establish the diagnosis (stroke, transient ischaemic attack, or non‐stroke). Treatment options, including reperfusion therapies, can then be planned.4,11 Diagnostic accuracy with telemedicine is comparable with that achieved with face‐to‐face specialist assessment.4 This is particularly important because stroke telemedicine consultations often involve non‐stroke cases and patients presenting with stroke mimics;12 in large hospital stroke centres, as many as 30% of patients with sudden onset neurological deficits have stroke mimics.4,13,14,15,16 Most incorrect diagnoses in the ED involve patients with possible transient ischaemic attacks or patients presenting with non‐specific clinical features.17 This may explain the increased ED diagnosis of ischaemic stroke and reduction in the diagnosis of transient ischaemic attack during the VST period. Conversely, most cases of intracerebral haemorrhage can be detected with CT, which may explain why ED clinicians initiated a VST consultation less frequently for patients with this condition (25 of 98 patients [26%] v 332 of 503 patients with a final diagnosis of ischaemic stroke [66%]).

In 2017, the Stroke Foundation reported that only 30% of patients with ischaemic stroke in Australia received thrombolysis within 60 minutes of hospital arrival, compared with 59% in the United States and 62% in the United Kingdom.18 People living in regional Australia are 19% more likely than those in metropolitan areas to have a stroke, but only 53% of regional hospitals offer thrombolysis for patients with stroke (compared with 83% of metropolitan hospitals).18 Further, the Stroke Foundation has also reported that only 32% of patients arriving at the hospital within 4.5 hours of an ischaemic stroke receive this critical treatment in regional areas, compared with more than 40% in metropolitan hospitals.18 With the VST program, 37% of patients who arrived within 4.5 hours of the onset of an ischaemic stroke received thrombolysis, of whom 32% were treated within 60 minutes of arrival, comparable with processes of care in metropolitan hospitals with specialist stroke teams. With the support of stroke telemedicine, all key regional hospitals in Victoria can now provide stroke thrombolysis.

Stroke telemedicine programs in Europe and North America have reported similar success since the early 2000s. The TEMPiS network in Bavaria, Germany (operational since 2002) provides more than 5000 consultations each year; 80% of patients who underwent thrombolysis were treated within 60 minutes of presenting to hospital (median door‐to‐needle time, 40 min) and the in‐hospital mortality rate is 6.3%.19 Functional outcomes were similar whether the patient was treated in a stroke telemedicine hospital (spoke) or in a stroke centre hospital (hub).20 Similar findings have been reported in the US and Canada.21,22,23 In a meta‐analysis of 26 studies (6605 patients receiving thrombolysis), no significant differences were found between stroke telemedicine and control groups in terms of in‐hospital mortality, 90‐day mortality, symptomatic intracranial haemorrhage, and clinical outcome at discharge or at 90‐day follow‐up.24

Capacity building and integration with other medical systems were major unplanned benefits of the VST program.25 Most of the 16 hospitals now have salaried stroke coordinators; quality of care is being monitored through participation of the hospitals in the Australian Stroke Clinical Registry.26 The VST program has also facilitated access to new evidence‐based treatments, including the transfer of patients for endovascular clot retrieval since May 2015. In 2018, the VST program was integrated into the Victorian health system under the governance of Ambulance Victoria.

Limitations

We have systematically assessed the early impact of telemedicine on emergency stroke care in regional hospitals of varying sizes. Data quality monitoring and analysis were undertaken by researchers not involved in the delivery of stroke telemedicine. A limitation of this pragmatic study, however, was the retrospective data collection for the control period. Time of symptom onset was less frequently recorded in medical records for patients with suspected stroke during the control period than during the intervention. This difference could partly account for the 31% increase in the proportion of patients with ischaemic stroke who arrived at hospital within 4.5 hours of symptom onset during the intervention period. Had symptom onset time been better documented during the control period, the number of patients categorised as arriving within 4.5 hours of symptom onset would have been higher and the proportion of eligible patients receiving thrombolysis consequently lower. In the course of implementing the VST, stroke care processes were established at some hospitals for the first time or received more attention, including routine documentation of stroke‐specific assessments and treatment; important measures of stroke severity and contraindications for thrombolysis were inconsistently documented prior to the VST program. Practical adjustments to data collection were made; for example, ability to walk was collected as a proxy measure of stroke severity.27 Information on outcomes was limited, as patient data were collected only until discharge from hospital.

Conclusion

The VST program has delivered acute stroke care to regional hospitals, with outcomes equivalent to, if not better than those achieved in metropolitan hospitals in Australia. Further data monitoring and analysis will focus on longer term outcomes, and a comprehensive health economic evaluation will be undertaken.

Box 1 – Victorian regional hospitals participating in the Victorian Stroke Telemedicine program, January 2019*


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source: Chris Bladin, Ambulance Victoria. Werribee commenced participation after the completion of the evaluation reported in this article.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 2 – Characteristics of patients with suspected stroke who presented to 16 participating emergency departments in regional Victoria during the 12 months preceding the local introduction of the Victorian Stroke Telemedicine (VST) program (control) and during the first 12 months of its full operation (intervention)

 

Control

Intervention


Number of patients

2887

3178

Age (years), median (IQR)

74 (63–83)

74 (63–83)

Age (years)

 

 

 Under 65

799 (28%)

891 (28%)

 65–74

666 (23%)

735 (23%)

 75–84

825 (29%)

918 (29%)

 85 or more

597 (21%)

634 (20%)

Sex (men)

1521 (53%)

1709 (54%)

Emergency department diagnosis

 

 

 Ischaemic stroke

1217 (42%)

1462 (46%)

 Intracerebral haemorrhage

216 (8%)

262 (8%)

 Transient ischaemic attack

1248 (43%)

1181 (37%)

 Not stroke

195 (7%)

269 (9%)

 Missing data

11

4

Symptom onset time known

1473 (51%)

1897 (60%)

Emergency department separation

 

 

 Ward (admission)

2100 (73%)

2243 (71%)

 Other acute hospital

112 (4%)

194 (6%)

 Home

494 (17%)

502 (16%)

 Residential care

51 (2%)

41 (1%)

 Other

130 (5%)

198 (6%)

VST consultations

NA

803 of 3178 (25%)

 Patients with final diagnosis: not stroke

NA

315 of 803 (39%)

Patients with final diagnosis of stroke and arrived within 4.5 hours of symptom onset

423 of 2887 (15%)

601 of 3178 (19%)

 Patients with final diagnosis of stroke and arrived within 4.5 hours of symptom onset: ischaemic stroke

351 of 423 (83%)

503 of 601 (84%)


IQR = interquartile range; NA = not applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 3 – Characteristics of 601 patients with a final diagnosis of stroke who arrived at an emergency department within 4.5 hours of symptom onset (intervention period only)

 

Victorian Stroke Telemedicine program consultation


Not provided

Provided


Number of patients

244

357

Age (years), median (IQR)

78 (70–86)

75 (64–82)

Age (years)

 

 

 Under 65

38 (16%)

90 (25%)

 65–74

58 (24%)

88 (25%)

 75–84

75 (31%)

129 (36%)

 85 or more

73 (30%)

50 (14%)

Sex (men)

138 (56%)

213 (60%)

Emergency department diagnosis

 Ischaemic stroke

140 (57%)

321 (90%)

 Intracerebral haemorrhage

58 (24%)

21 (6%)

 Transient ischaemic attack

33 (14%)

8 (2%)

 Not stroke

13 (5%)

7 (2%)

Final diagnosis

 

 

 Ischaemic stroke

171 (70%)

332 (93%)

 Intracerebral haemorrhage

73 (30%)

25 (7%)

History of stroke

64 (26%)

81 (23%)

Ability to walk on admission*

65 (27%)

93 (26%)

Arrived after hours

61 (25%)

100 (28%)

Transfer from another hospital

11 (5%)

23 (6%)

Arrival by ambulance

207 (85%)

308 (86%)

Emergency department pre‐notified of patient arrival

102 (50%)

206 (67%)


IQR = interquartile range. * Proxy for stroke severity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 4 – Indicators of processes of care for patients with a final diagnosis of stroke who had arrived at a participating emergency department in regional Victoria within 4.5 hours of symptom onset

 

Control

Intervention

P


Time taken for diagnostic procedures

 

 

 

 Number of patients

423

601

 

 Symptom onset‐to‐arrival (min), median (IQR)

100 (64–152)

93 (59–140)

0.07

 Door‐to‐first medical review (min), median (IQR)

8 (3–20)

3 (0–9)

< 0.001

 Door‐to‐CT (min), median (IQR)

34 (18–76)

25 (13–49)

< 0.001

 Door‐to‐telemedicine consultation (min), median (IQR)

NA

43 (27–65)

Discharge destination

 

 

< 0.001

 Acute metropolitan hospital

46 (11%)

109 (18%)

 

 Acute regional hospital

10 (2%)

45 (7%)

 

 Home

135 (32%)

187 (31%)

 

 Residential aged care

17 (4%)

29 (5%)

 

 Rehabilitation

132 (31%)

136 (23%)

 

 Palliative care

4 (1%)

4 (1%)

 

 Died in hospital

72 (17%)

69 (11%)

 

 Other

7 (2%)

22 (4%)

 

Patients with ischaemic stroke who arrived within 4.5 hours of symptom onset

351 (83%)

503 (84%)

 

 Stroke thrombolysis received

107 [30%]

185 [37%]

0.06

 Symptomatic intracerebral haemorrhage*

17 (16%)

8 (4%)

0.001

 Door‐to‐needle (min), median (IQR)*

102 (77–128)

73 (56–96)

< 0.001

 Door‐to‐needle time less than 60 min*

14 (13%)

58 (32%)

< 0.001

 Symptom onset‐to‐needle (min), median (IQR)*

211 (170–245)

169 (134–210)

< 0.001

 Died in hospital*

21 (20%)

12 (6%)

0.001


CT = computed tomography imaging; IQR = interquartile range. * For patients who received thrombolysis. † Includes discharge destination from emergency department and after admission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 5 – Factors associated with receiving thrombolysis: multivariable logistic regression with clustering by hospital

 

Odds ratio (95% confidence interval)


Thrombolysis

Door‐to‐needle within 60 minutes*

Intracerebral haemorrhage after thrombolysis


Number of patients with outcome

854

291

292

Data collection phase

 

 

 

 Control period (reference)

1

1

1

 VST period: no consultation

0.30 (0.13–0.76)

2.07 (0.72–5.92)

0.50 (0.14–1.76)

 VST period: with consultation

2.11 (1.39–3.21)

3.14 (1.21–8.15)

0.18 (0.04–0.84)

Age (years), per year

0.97 (0.96–0.99)

1.00 (0.98–1.02)

1.04 (1.01–1.07)

Sex (men)

0.87 (0.63–1.19)

1.31 (0.77–2.24)

1.08 (0.38–3.08)

First ever stroke

1.71 (1.08–2.73)

2.16 (1.07–4.35)

2.19 (0.71–6.72)

Unable to walk on admission

3.22 (1.92–5.39)

1.60 (0.69–3.66)

0.81 (0.25–2.61)

Hospital size (stroke admissions per year)

 

 

 

 Less than 75 (reference)

1

1

1

 75–199

1.56 (0.73–3.34)

2.93 (0.75–11.46)

1.10 (0.13–8.97)

 200 or more

1.32 (0.61–2.87)

1.41 (0.39–5.05)

0.58 (0.06–5.87)


VST = Victorian Stroke Telemedicine program. * One person with missing time to thrombolysis. † Proxy for stroke severity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Box 6 – Factors associated with time to diagnosis and treatment: multivariable median regression with clustering by hospital

 

Processes of care: β (95% confidence interval)


Onset‐to‐arrival

Door‐to‐review

Door‐to‐scan

Door‐to‐needle


Number of patients

1024

830

991

291

Data collection phase

 

 

 

 

 Control period (reference)

1

1

1

 

 VST period: no consultation

–3.99 (–16.3 to 8.30)

–2.40 (–4.73 to –0.06)

3.71 (–4.71 to 12.1)

–25.4 (–47.2 to –3.66)

 VST period: with consultation

–13.6 (–23.8 to –3.37)

–5.88 (–7.31 to –4.45)

–17.0 (–21.7 to –12.3)

–26.5 (–40.6 to –12.4)

Age (years), per year

0.47 (0.15 to 0.80)

0.05 (0.00 to 0.09)

0.19 (0.04 to 0.34)

0.15 (–0.31 to 0.60)

Sex (men)

2.40 (–6.59 to 11.4)

0.17 (–0.95 to 1.29)

0.96 (–2.87 to 4.80)

2.12 (–7.89 to 12.1)

First ever stroke

3.26 (–7.60 to 14.1)

–0.18 (–1.39 to 1.04)

0.89 (–4.95 to 6.73)

–14.18 (–30.9 to –2.50)

Unable to walk on admission*

–1.73 (–12.9 to 9.42)

–2.45 (–3.97 to –0.94)

–6.33 (–11.2 to –1.46)

–12.9 (–28.7 to 3.01)

Hospital size (stroke admissions per year)

 

 

 

 

 Less than 75 (reference)

1

1

1

1

 75–199

8.48 (–5.68 to 28.3)

–1.83 (–3.99 to 0.32)

–17.8 (–31.9 to –3.76)

–2.13 (–19.8 to 15.5)

 200 or more

14.6 (–5.68 to 35.0)

1.85 (–0.65 to 4.34)

–6.84 (–21.2 to 7.53)

7.94 (–11.6 to 27.5)


β coefficient: median difference in time (in minutes) between groups. * Proxy for stroke severity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Received 6 August 2019, accepted 18 December 2019

  • Chris F Bladin1,2
  • Joosup Kim1,3
  • Kathleen L Bagot1,3
  • Michelle Vu4
  • Natasha Moloczij5
  • Sonia Denisenko6
  • Chris Price7
  • Nancy Pompeani1
  • Lauren Arthurson8
  • Casey Hair9
  • Justin Rabl10
  • Mick O'Shea11
  • Patrick Groot12
  • Leslie Bolitho13
  • Bruce CV Campbell14,15
  • Helen M Dewey16
  • Geoffrey A Donnan15
  • Dominique A Cadilhac1,3

  • 1 Florey Institute of Neuroscience and Mental Health, Melbourne, VIC
  • 2 Ambulance Victoria, Melbourne, VIC
  • 3 Monash University, Melbourne, VIC
  • 4 Epworth HealthCare, Melbourne, VIC
  • 5 Victorian Comprehensive Cancer Centre, Melbourne, VIC
  • 6 Department of Health and Human Services, , Melbourne, VIC
  • 7 Brotherhood of Saint Laurence, Melbourne, VIC
  • 8 Echuca Regional Health, Echuca, VIC
  • 9 Ballarat Health Services, Ballarat, VIC
  • 10 Goulburn Valley Health, Shepparton, VIC
  • 11 Albury Wodonga Health, Wodonga, NSW
  • 12 South West Healthcare, Warrnambool, VIC
  • 13 Northeast Health Wangaratta, Wangaratta, VIC
  • 14 Melbourne Health, Melbourne, VIC
  • 15 Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC
  • 16 Eastern Health, Melbourne, VIC

Correspondence: chris.bladin@unimelb.edu.au

Acknowledgements: 

We received financial support for our investigation and for preparing this article from the Windermere Foundation, the Victorian Departments of Business and Innovation and of Health, and the Australian Government. The Florey Institute of Neuroscience and Mental Health acknowledges the support of the Victorian Government, particularly with an Operational Infrastructure Support Grant. Dominique Cadilhac holds a National Health and Medical Research Council fellowship co‐funded by the National Heart Foundation (1063761). Chris Bladin and Dominique Cadilhac have received unrestricted educational grants from Boehringer Ingelheim. The full list of participants in this study is included in the online Supporting Information.

Competing interests:

No relevant disclosures.

  • 1. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2015 (Cat. no. BOD 22). Canberra: AIHW, 2019.
  • 2. Australian Institute of Health and Welfare. Cardiovascular disease (Cat. no. CVD 83). Updated 30 Aug 2019. https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/cardiovascular-health-compendium/contents/what-is-cardiovascular-disease (viewed Mar 2020).
  • 3. Stroke Foundation. National stroke audit: acute services report 2015. Nov 2015. https://informme.org.au/-/media/A3039E82D9FF4BC7803B5C67B42DBBB0.ashx?la=en (viewed Nov 2019).
  • 4. Wechsler LR, Demaerschalk BM, Schwamm LH, et al. Telemedicine quality and outcomes in stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2017; 48: e3–e25.
  • 5. Audebert HJ, Schenkel J, Heuschmann PU, et al; Telemedic Pilot Project for Integrative Stroke Care Group. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006; 5: 742–748.
  • 6. Cadilhac DA, Moloczij N, Denisenko S, et al. Establishment of an effective acute stroke telemedicine program for Australia: protocol for the Victorian Stroke Telemedicine project. Int J Stroke 2014; 9: 252–258.
  • 7. Bladin CF, Molocijz N, Ermel S, et al; VST program investigators. Victorian Stroke Telemedicine project: implementation of a new model of translational stroke care for Australia. Intern Med J 2015; 45: 951–956.
  • 8. Bagot KL, Cadilhac DA, Kim J, et al; Victorian Stroke Telemedicine Programme Consortium. Transitioning from a single‐site pilot project to a state‐wide regional telehealth service: the experience from the Victorian Stroke Telemedicine programme. J Telemed Telecare 2017; 23: 850–855.
  • 9. Cadilhac DA, Vu M, Bladin C. Experience with scaling up the Victorian Stroke Telemedicine programme. J Telemed Telecare 2014; 20: 413–418.
  • 10. Bray JE, Denisenko S, Campbell BCV, et al. Strategic framework improves access to stroke reperfusion across the state of Victoria Australia. Intern Med J 2017; 47: 923–928.
  • 11. Etherton MR, Schwamm LH. Telestroke for the newly minted vascular neurologist. Stroke 2018; 49: e162–e164.
  • 12. Freeman WD, Barrett KM, Vatz KA, Demaerschalk BM. Future neurohospitalist: teleneurohospitalist. Neurohospitalist 2012; 2: 132–143.
  • 13. Mehta S, Vora N, Edgell RC, et al. Stroke mimics under the drip‐and‐ship paradigm. J Stroke Cerebrovasc Dis 2014; 23: 844–849.
  • 14. Hand PJ, Kwan J, Lindley RI, et al. Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke 2006; 37: 769–775.
  • 15. Ali SF, Hubert GJ, Switzer JA, et al. Validating the TeleStroke Mimic score: a prediction rule for identifying stroke mimics evaluated over telestroke networks. Stroke 2018; 49: 688–692.
  • 16. Ali SF, Viswanathan A, Singhal AB, et al; Partners Telestroke Network. The TeleStroke mimic (TM)‐score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network. J Am Heart Assoc 2014; 3: e000838.
  • 17. Tarnutzer AA, Lee SH, Robinson KA, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta‐analysis. Neurology 2017; 88: 1468–1477.
  • 18. Stroke Foundation. National stroke audit: acute services report 2017. Nov 2017. https://informme.org.au/-/media/7D1480925C2046BA914F3F66D392B83A.ashx?la=en (viewed Nov 2019).
  • 19. Müller‐Barna P, Hubert GJ, Boy S, et al. TeleStroke units serving as a model of care in rural areas: 10‐year experience of the TeleMedical project for integrative stroke care. Stroke 2014; 45: 2739–2744.
  • 20. Schwab S, Vatankhah B, Kukla C, et al; TEMPiS Group. Long‐term outcome after thrombolysis in telemedical stroke care. Neurology 2007; 69: 898–903.
  • 21. Almallouhi E, Holmstedt CA, Harvey J, et al. Long‐term functional outcome of telestroke patients treated under drip‐and‐stay paradigm compared with patients treated in a comprehensive stroke center: a single center experience. Telemed J E Health 2019; 25: 724–729.
  • 22. Porter J, Hall RE, Kapral MK, et al. Outcomes following telestroke‐assisted thrombolysis for stroke in Ontario, Canada. J Telemed Telecare 2018; 24: 492–499.
  • 23. Demaerschalk BM, Boyd EL, Barrett KM, et al. Comparison of stroke outcomes of hub and spoke hospital treated patients in Mayo Clinic Telestroke Program. J Stroke Cerebrovasc Dis 2018; 27: 2940–2942.
  • 24. Baratloo A, Rahimpour L, Abushouk AI, et al. Effects of telestroke on thrombolysis times and outcomes: a meta‐analysis. Prehosp Emerg Care 2018; 22: 472–484.
  • 25. Bagot KL, Bladin CF, Vu M, et al; VST collaborators. Exploring the benefits of a stroke telemedicine programme: an organisational and societal perspective. J Telemed Telecare 2016; 22: 489–494.
  • 26. Cadilhac DA, Lannin NA, Anderson CS, et al. Protocol and pilot data for establishing the Australian Stroke Clinical Registry. Int J Stroke 2010; 5: 217–226.
  • 27. Cadilhac DA, Kilkenny MF, Levi CR, et al. Risk‐adjusted hospital mortality rates for stroke: evidence from the Australian Stroke Clinical Registry (AuSCR). Med J Aust 2017; 206: 345–350. https://www.mja.com.au/journal/2017/206/8/risk-adjusted-hospital-mortality-rates-stroke-evidence-australian-stroke

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.