International Stroke Conference
Deepak Gulati, MD
During “Telestroke 3.0. Beyond Acute Ischemic Stroke,” one of the last symposium sessions on day one of ISC 2018 in Los Angeles, many national and international speakers discussed the innovative use of telestroke beyond acute ischemic stroke care in different settings.
The first presentation was on “Telestroke Networks Providing Community Education: Stroke ECHO” by Dr. Chung from the University of Utah. He discussed the project ECHO — Extension for Community Healthcare Outcomes — which is a rural, resource-limited focus initiative by the University of Utah. It is an extensive network with spokes in other states and countries, including Canada and West Africa. There is a growing demand of vascular neurologists nationally and internationally. Project ECHO is based on a case review model, and the initial focus is on acute stroke care while addressing multiple changing practice updates, along with CME and outreach beyond spoke ED’s. The future opportunities with the telestroke include pre-hospital and post-hospital long term care, expanding educational and clinical needs, and inter-disciplinary partnerships.
The second presentation was on “International Collaboration in Telestroke” by Dr. Annemarei Ranta from Capital & Coast DHB & Otago University. She discussed the telestroke program between New Zealand and Scotland to address the issue of limited resources, understaffed hospital and restricted time hours of health care providers. This international project is the result of extensive efforts by multiple personals from hospital, including administrators and physicians along with policymakers at local and national levels, and it required some change in the law as well. The major barriers were slow IT progress, institutional policies and geographical distance. This international telestroke program is an excellent example of telestroke across the globe making use of time zones, which could also support developing countries where the resources are limited.
Another interesting presentation was on “To Transfer or Not: Using Telestroke for Inpatient Stroke Follow-up of Complicated Cases” by Dr. Heinrich J. Audebert from Berlin. The key elements of telestroke units are specialized stroke wards (24/7 availability of diagnostics, stroke team and standardized protocols), comprehensive stroke training for all staff members, continuous quality management and a telemedicine network with comprehensive stroke centers. In Germany, severe primary stroke centers are developed with endovascular capabilities (usually angiography suits in cardiology) in geographically scattered locations with the concept of neuroendovascular physicians flying to the patient instead of waiting for them (FIT – The Flying Interventional Trial). With the help of the telestroke program in Germany, most patients stay onsite in local hospitals with interhospital transfers restricted to the few patients who need complex diagnostics and treatment. The FIT trial will show whether flying interventionists saves time and improves outcome. Telemedicine enables follow-up needed to ensure high quality in post-interventional care.
The last presentation was on “Telestroke for Outpatient Stroke Follow-up” by Dr. Christine Holmstedt from the Medical University of South Carolina (MUSC). The MUSC Telestroke grew to 26 partners in 2017 with 12 primary stroke centers. The MUSC Telestroke outpatient clinic was started in 2017 with major advantages being improved access, decreased travel expenses (and other challenges by disabled patients), job creation, facility fees and outpatient testing referrals for partner sites, along with major physician, patient and family satisfaction. The major challenges are getting privileges for advanced practice providers, credentialing at the partner site, clinic space, scheduling, platform fluency, EMR challenges (Outpatient template), and inability to perform rapid access appointments.
Dr. Lawrence Wechsler, Chair of the Department of Neurology at the University of Pittsburgh Medical Center (UPMC), emphasized the utility of telestroke across the whole spectrum of stroke care. Dr. Wechsler also mentioned that a group at UPMC is involved in promoting a telestroke program in China in an advisory and supervisory role. He said, “With the expanding role of telestroke, this is the time when we need to readdress the systems of care, reorganize, and find coherent ways to cost-effective solutions for telestroke program in the USA.” Overall, telestroke is shown in multiple settings to be a very useful tool in providing a continuum of stroke care, including pre-hospital and post-hospital long-term care, and addressing a growing shortage of vascular neurologists. Telestroke plays a major role in improving stroke care disparity in rural and underserved communities.