Telestroke Models of collaboration of care

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TelestrokeModels of collaboration of care

• Salvador Cruz-Flores, MD
• Saint Louis University

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Objectives

• To understand
• Current state of stroke care
• Rationale for telestroke
• System models of remote presence

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Current state of stroke care

• 2nd leading cause of death worldwide and 3rd
  leading cause in US
• Major contributor to adult disability 15-30
  permanently disabled
• Economic burden 65.5 billion n US in 2008
• 87 of stroke mortality occurs in low- and
  middle-income regions
• access to care not readily available
• Strikes all ages, genders, race and ethnic groups

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Stroke readiness
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Current state of stroke care

• Two thirds of stroke patients arrive by EMS
• Limited EMS in rural areas
• Reluctance to use tPA in absence of stroke
  expertise

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Current state of stroke care

• 4 neurologists/100,000 people
• Fewer with stroke expertise
• 385 interventional neuroradiologists in US in 238
  hospitals, 45 states
• Litigation and liability
• Greatest risk is from failure to document reasons
  for withholding therapy and not from injury
  related to therapy
• lt5 (perhaps lt2) stroke patients receive tPA

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Rural Hospitals

• 5759 Hospitals in the US
• 4919 community Hospitals
• 2003 Rural Hospitals (AHA statistics 2006)
• 1464 Community hospitals in a network
• 2669 hospitals in a system

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tPA usage

• MEDPAR database
• 64 of US hospitals did not reat a single
  medicare patient with tPA over a 2 years period
• Kleindorfer D, Stroke 2009 presented at ISC

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Why the limited usage

• 40 od ER physicians reluctant to use tPA
• In 2006-2007 only 32 fellows in approved vascular
  neurology fellowships in the US
• Many neurologists are abandoning emergency room
  call

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Stroke Systems Models of Care

• Stroke call with in person response to ER
• Telephone drip and ship
• Helicopter ship and drip
• Telestroke
• Telestroke with helicopter

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Rationale for telestroke

• Access to stroke consultation remotely
• Reliability
• Neurological exam compared to face to face exam
• NIHSS
• Teleradiology
• Thrombolysis via telestroke appears safe
• Decision making more accurate
• Rate of tPA treated patients higher than rates in
  community hospitals

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REACH
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Stroke systems of care

• Regionalization
• Levels of care
• Comprehensive stroke center
• Primary stroke center
• Stroke center capability
• Stroke unit
• Evidence based stroke management
• Collection of stroke quality measures
• Clinical and educational collaborations between
  hubs and spoke facilities
• QI
• If no capability transfer agreements
• Partial capability drip and ship

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Stroke system models
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Telestroke modelsRegionalization of care

• Hub and Spoke Models
• Frontier/Rural
• Rural-Urban
• Suburban-Urban
• Urban Underserved

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• The Alaska Native Stroke Registry A
  Frontier/Rural Health Delivery Model

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Alaska in Relation to the Lower 48 States
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Population 663,661 Size 571,951 sq. miles
1Artic (polar bears/walrus) 2Western
3Southwestern (Aleutians) 4Interior
(Fairbanks) 5Southcentral (Anchorage)
6Southeastern (panhandle)
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Hierarchy of Care in Alaska

• Villages without health aids
• Villages with health aids (n500 for 170 remote
  villages)
• Village with subregional clinic (midlevel
  practitioners)
• 6 regional hospitals (inpatient, outpatient and
  ER services but only 1 has a CT scan) and FPs
• 1 referral/specialty hospital Alaska Native
  Medical Center, Anchorage, Alaska
• An estimated 58 of individuals live in
  communities without regional hospitals (villages
  may contain lt200 persons)
• Source Alaskan Natiave Tribal Health Consortium,
  2003
• FP Family Practitioner

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Hubs and Spokes 12 regions and 6 tribal hubs
Primary Linkage Telephone and Fax
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Challenges of frontier/rural model

• Slow feed into hubs.
• Standard stroke care may never be given (e.g.,
  thombolytic therapy)
• Air travel to the spokes and other remote areas
  is costly and time consuming
• Access to specialty care may be limited and costly

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Rural US Stroke Model

• Critical Access Hospitals

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REACH
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Rural Areas May Lack Specialty Care Single hub
and spoke system and then upscale to multiple hub
and spoke systems
Courtesy of David Hess, MD REACH Telemedicine
System
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Telestroke systems for neurological emergencies

• Intracerebral hemorrhage
• Traumatic brain injury
• Post cardiac arrest
• Spinal cord injury
• Status epilepticus
• Subarachnoid hemorrhage
• Other disease states beyond neurology

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Suburban urban model
Comprehensive stroke center
Primary stroke center
Primary stroke center
Primary stroke center
Community hospital
Community hospital
Community hospital
Community hospital
Community hospital
Community hospital
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Thrombolysis by telephone
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Thrombolysis by phone

• OSF stroke network Peoria Il
• St. Lukess Stroke Center KC
• 53/142 tpa treated started in referring hospitals
• University of Kentucky
• Limited data on safety and efficacy

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tPA plus

• Bridging IV tPA IA tPA
• Mechanical embolectomy
• Sonotrhombolysis
• Participation in clinical trials

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Potential models with telestroke

• Ship and drip
• Drip and ship
• Drip and keep
• Drip, ship and randomize
• Drip, randomize and ship
• Drip, randomize, and keep

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Challenges to Medical OutsourcingTelemedicine

• Information privacy (HIPAA regulations)
• Infrastructure funding and operation costs
• Regulatory and billing compliance
• Malpractice and liability (uncharted territory
  regarding what constitutes telemedicine
  malpractice and standard of care)
• Physician licensure/credentialing
• Informed consent needed?
• Measuring and ensuring quality of care
• Source Singh SN, Wachter RM. NEJM 2008 358 15
  1622-27

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Missouri
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Summary

• Stroke affects underserved areas
• Telemedicine can breach that gap
• Regionalization and time critical diagnosis
  nature favor Hub and Spoke model
• Air transport may continue to be critical for
  frontier regions
• Regulatory changes (with regards to stroke care)
  will probably force adoption of telestroke
  systems and early deployment of air transport
• Video audio teleconferencing is the current
  recommended mode
• Safety of teleconsultation via phone and
  teleradiology
• Challenges are many but regulatory/liability,
  financial/funding and confidentiality remain as
  significant issues
• Research on efficacy and safety is needed

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• Recommendations for implementation of
  telemedicine within stroke systems of care.
  Schwamm LH, Audelbert HJ, Amarenco P et al.
  Stroke 2009 (DOI10.116/StrokeAHA.109.192361
• A review of the evidence for the use of
  telemedicine with stroke systems of care. Schwamm
  LH, Holloway RG, Amarenco P, et al. Stroke 2009.
  (DOI10.1161/StrokeAHA.109.192360)