The acute telestroke model of care in Australia: a potential roadmap for other emergency medical services?

Telestroke is an example of technology facilitating the delivery of time‐dependent therapies in regional Australia

Stroke telemedicine, or “telestroke”, refers to the diagnosis and treatment of patients using telecommunications technology. Acute stroke care is time-critical and regional hospitals typically do not have ready access to specialist stroke expertise. Stroke reperfusion therapies (thrombolysis and endovascular thrombectomy) are time-dependent (with an increased proportion of poor outcomes associated with delayed therapy delivery1), resource-intense, and potentially hazardous.

Diagnosis and selection of candidates for therapy in a telestroke network requires rapid, expert clinical assessment with immediate interpretation of brain computed tomography (CT) imaging — ideally, multimodal CT, which includes brain non‐contrast CT, CT angiography and CT perfusion. Although there are varied models of care, a comprehensive network should also include two‐way visibility and communication between the stroke physician, the patient, carers, and local medical staff.

Australian telestroke services were developed in response to a gap in clinical service delivery in regional and remote areas. Although acute stroke care has evolved rapidly in metropolitan centres over the past decade, patients outside these areas have not directly benefited, exacerbating the 17% higher risk of stroke in regional and rural Australia.2 The geographic and demographic challenges of regional Australia (large distances between hospitals and low population density, especially in the outback) make delivery of acute stroke therapies particularly difficult. Telestroke has the potential to reduce inequities in stroke care for individuals living in these remote environments.

In Australia, the largest telestroke networks have been funded and organised at the state level and require a dedicated specialist workforce. New South Wales, Victoria and Western and South Australia have statewide networks, and the networks in Queensland and the Northern Territory are currently under development. These networks provide assessment, diagnosis and treatment of patients presenting to hospital emergency departments (EDs) with suspected stroke. This has enabled increased delivery of hyperacute reperfusion therapies in regional hospitals, with performance metrics comparable to metropolitan acute stroke centres.3,4 Furthermore, patients treated through these networks achieve similar outcomes to those managed at larger comprehensive stroke centres.5,6

Due to the acuity of stroke, the workforce should be rostered specifically for the telestroke service, with adequate flexibility in rostering to allow immediate full attention to the call, rather than duties merely being superimposed upon regular hospital or clinic duties.

The required infrastructure includes a centralised telephone portal, appropriate technologies for audiovisual clinical assessment, software tools to allow rapid analysis of the imaging (Box), and standardised protocols and clinical documentation. Finally, the new system of care must be implemented by all personnel helping the patient journey. Ideally, this involves a change management process and extensive education requiring before and after “go‐live” simulations.

Perceived barriers to the implementation of telestroke have been i) insufficient neurologist workforce, ii) accessing funding to provide structural support (personnel and technology), and iii) providing and accessing health records securely across multiple radiology providers, multiple electronic medical records, and paper platforms.

Telestroke: beneficial beyond hyperacute ischaemic stroke

Standardised stroke care pathways and guidelines. Protocolised pathways at telestroke referring sites ensure care is consistent with best practice guidelines both during and after the acute care interaction, whether or not reperfusion treatments are actually provided. Being involved in a telestroke service requires development and use of stroke protocols that are consistent with published evidence‐based guidelines. This enables the living guidelines model to be implemented in real time in regional settings, where the dissemination of this information historically has taken months or years.7

Non‐stroke neurological diagnosis and treatment. In addition to ischaemic stroke and intracerebral haemorrhage management advice, the acute telestroke consultation will often lead to diagnosis of other neurological conditions, including aneurysmal subarachnoid haemorrhage and a wide range of stroke mimics conditions (including Bell palsy, functional neurological disorders, migraines and seizures). The tele‐expertise of a stroke specialist allows for a precise diagnosis, which can direct correct treatment options, reduce unnecessary investigations, prevent unnecessary transfers and decrease length of stay in regional hospitals, while helping build local capacity.

Optimised health care irrespective of state borders. Telestroke delivers equity of stroke care regardless of geographical location (eg, SA provides telestroke consults to Alice Springs, NT, and Broken Hill, NSW, and Victoria to northwest Tasmania). Similarly, stroke patients may move between states for endovascular thrombectomy; for example, stroke patients from Broken Hill (NSW) and Alice Springs and Darwin (NT) are transferred to Adelaide (SA), and patients from Lismore (NSW) are transferred to the Gold Coast (Queensland).

Expedited and rationalised regional–metro transfers. Stroke patient transfers for endovascular thrombectomy require optimal end‐to‐end coordinated care. Telestroke identifies the subset of patients who are likely to benefit from thrombectomy and also sets the right expectations to patients and families about potential benefits and risks. Moreover, the initial review and expedited diagnosis performed by the stroke physician reduces unnecessary transfers for specialist assessment and investigations at the comprehensive stroke centre.

Supporting regional locum doctors and upskilling staff. Locum rural medical staff are often working in unfamiliar settings, managing medically complex patients and often in understaffed hospitals. This exacerbates prevalent “neurophobia” (the fear of neural sciences and neurology among medical students and doctors). The connection with the telestroke physician allows conjoint review of the patient’s medical history, imaging, and neurological assessment, allowing for improvement in their stroke knowledge. It supports the confidence of regional clinicians in dealing with complex neurological conditions. Furthermore, some of the telestroke networks invite rural physicians and stroke coordinators to join weekly case review meetings in order to learn best practices and share experiences with others.

Telemedicine helping to close the gap. Enhancing access to stroke specialists in rural and remote areas may also enhance access to Indigenous populations. Indigenous populations are proportionately more likely to live in a rural and remote setting,8 and the burden of stroke is 2.3 times as high as that of non‐Indigenous Australians.9

Next steps in telestroke

We are now extending the use of telemedicine beyond the acute phase of stroke. Several national and international projects are currently underway.

Telestroke outpatient clinics. These clinics allow the patient to be reviewed by the stroke specialist in their own community. Moreover, they increase attendance rate, as a proportion of patients cannot drive due to post‐stroke disability. Different models are being tested, from direct video assessment of the patient at their homes to a hybrid model,10 where the patient is reviewed at the local hospital by the stroke coordinator or general practitioner while having the stroke specialist joining the consultation remotely.

Expansion to pre‐hospital phase. The use of video assessment supporting ambulance paramedics would increase their ability to bring “the right patient to the right hospital,” decreasing the number of secondary transfers and delays in delivery of time‐dependent therapies.11

Telestroke ward rounds and telerehabilitation. Several projects are currently testing the use of embedding telemedicine in daily ward rounds and post‐stroke rehabilitation.

Applicability to other medical conditions and conclusions

Telestroke networks have had a major impact on the provision of complex treatments to stroke and acute neurological patients in regional, rural and remote Australia — something that was inconceivable even just a few years ago. We believe that patients with other urgent medical conditions where ED physicians require subspecialist consultation might benefit as much as patients with stroke do, especially in conditions where the specialist input is critical to diagnosis and management, such as psychiatry or neonatal care. Acute specialist ED telehealth consults are a powerful tool to reduce health inequities, and the same technology backbone can support multiple user groups.

The key principles in establishing our telestroke networks have been patient‐focused care and local clinician empowerment; our driving motivation has been to reduce health inequity. In our experience, we have only succeeded when the vision is shared and the solution codesigned with local clinicians. Importantly, these services have not sought to replace local expertise, but rather to leverage and support the local teams. We do believe that this supportive codesign approach explains the quick adoption, acceptability and success of telestroke in rural Australia.

There are some potential downsides of telestroke networks. They require an advanced technology platform, precluding access in areas without adequate internet reception or workable telehealth endpoints. The centralised telestroke workforce might be seen as a “bandaid” response to recruitment shortages in rural areas, which may demotivate lasting recruitment solutions. Regardless of the effort made by the Australian networks in enhancing local teaching and education, it might lead towards deskilling of staff, as the telestroke neurologist takes greater responsibility for acute patient care. Unforeseen long term benefits or harms of telestroke networks are yet to be determined. Finally, there is a risk of lower patient satisfaction with the use of audiovisual assessment.

In conclusion, telemedicine can ameliorate the “postcode lottery” of acute stroke care. Rural and remote patients deserve equal access to hyperacute specialist care, with advances in high technology videoconferencing and image‐sharing solutions making this possible. Its full potential is beyond the Australian borders; collaborative projects between Australian stroke specialists and Pacific physicians focused on acute stroke care and reperfusion therapies are being planned.

We similarly encourage other health providers to consider investing in telehealth for their practice domain, and hope that lessons learned by each specialty might be mutually reinforcing. Telehealth to reduce health care disparities is not the future, but the present: “Tomorrow belongs to those who can hear it coming”.12

Box – Telestroke pathway

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CT = computed tomography; ED = emergency department, EVT = endovascular thrombectomy.