Abstract
The following telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies. Although telestroke practices may include the more broad utilization of telemedicine across the entire continuum of stroke care, with some even consulting on all neurologic emergencies, this document focuses on the acute phase of stroke, including both pre- and in-hospital encounters for cerebrovascular neurological emergencies. These guidelines describe a network of audiovisual communication and computer systems for delivery of telestroke clinical services and include operations, management, administration, and economic recommendations. These interactive encounters link patients with acute ischemic and hemorrhagic stroke syndromes with acute care facilities with remote and on-site healthcare practitioners providing access to expertise, enhancing clinical practice, and improving quality outcomes and metrics. These guidelines apply specifically to telestroke services and they do not prescribe or recommend overall clinical protocols for stroke patient care. Rather, the focus is on the unique aspects of delivering collaborative bedside and remote care through the telestroke model.
Keywords: : stroke, telemedicine, telestroke, guidelines, American Telemedicine Association, American Heart Association, American Stroke Association
Scope
The following telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies. Although telestroke practices may include a broader utilization of telemedicine across the entire continuum of stroke care, with some even consulting on all neurologic emergencies, this document focuses on the acute phase of stroke, including both pre- and in-hospital encounters for cerebrovascular neurological emergencies. These guidelines describe a network of audiovisual communication and computer systems for delivery of telestroke clinical services and include operations, management, administration, and economic recommendations. These interactive encounters link patients with acute ischemic and hemorrhagic stroke syndromes with acute care facilities with remote and on-site healthcare practitioners providing access to expertise, enhancing clinical practice, and improving quality outcomes and metrics. These guidelines apply specifically to telestroke services and they do not prescribe or recommend overall clinical protocols for stroke patient care. Rather, the focus is on the unique aspects of delivering collaborative bedside and remote care through the telestroke model.
Definitions
Terms and definitions that are commonly used in telemedicine/telestroke are available on the American Telemedicine Association (ATA) Web site. For this document, there are several terms that need to be defined specifically:
Distant Site—Telestroke provider location; sometimes used interchangeably with Hub Site when referencing a hub and spoke network.
Distributed Network—A model in which telestroke services are provided to multiple originating sites through arrangements with an independent corporation or an affiliated network of telestroke providers. In this setting, transfer agreements for endovascular therapy or subsequent stroke care should be defined in advance to facilitate all aspects of acute stroke care.
Endovascular Intervention—Intra-arterial thrombolysis or mechanical thrombectomy for selected patients with large vessel occlusions identified during the acute telestroke interaction.
Health Professionals—Individuals engaged in the provision of healthcare and health-related services.
Hub—Typically a comprehensive tertiary care center where vascular neurologists and other acute stroke specialists compose a call panel delivering telestroke services to network affiliate/partner sites—spokes. If a patient requires transfer to a higher level of care, a hub is usually the destination. Some networks may have multiple hubs.
Hub and Spoke—Networks of primary, secondary, and tertiary care settings that provide care to specific patient populations. Networks may vary in sophistication, with many working as loose coalitions of segregated services. Typically, specialty care is provided to patients at remote settings (often rural emergency departments [EDs]) by specialists affiliated with larger, more comprehensive tertiary care centers. Models are changing with an emphasis on keeping patients in their local community when possible, depending on the available level of care.
Organization—Groups, institutions, and business entities.
Originating Site—Patient location; sometimes used interchangeably with Spoke Site when referencing a hub and spoke network model.
Shall, Should, and May—This document contains requirements, recommendations, or actions that are identified by text containing the keywords shall, should, or may. Shall indicates a required action whenever feasible and practical under local conditions. These indications are found in bold throughout the document. Should indicates an optimal recommended action that is particularly suitable, without mentioning or excluding others. May indicates additional points that can be considered to further optimize the healthcare process. Shall not indicates that this action is strongly advised against.
Spoke—The affiliate or partner site in a telestroke network, underserviced or undersupported by neurologists, where patient services are delivered.
Telemedicine—Telemedicine is the use of medical information exchanged from one site to another using electronic communications in an effort to improve consumer health status. Videoconferencing, video clips, transmission of still images, and e-health, including patient portals, remote monitoring of vital signs, continuing medical education (CME), and nursing call centers, are all considered part of telemedicine. Telemedicine is not a discrete medical specialty. Products and services related to telemedicine frequently are incorporated as part of a larger investment by healthcare institutions in either information technology (IT) or delivery of clinical care, or both. Even in the reimbursement fee structure, there is commonly no distinction made between services provided on-site and those provided through telemedicine. Separate coding for billing of remote services may be required. Telemedicine encompasses a broad range of patient programs and services, requiring different providers and consumers.1
Teleneurology—Broad application of telemedicine to the field of neurology, both acute and ambulatory care.
Telestroke—A network of audiovisual communication and computer systems, which provide the foundation for a collaborative, interprofessional care model focusing on acute stroke patients. Telestroke service is designed to augment local services that are not immediately available by leveraging remote expertise and resources and the standardization of processes. It is a subdivision of teleneurology, involving telemedicine consultation for the treatment of neurovascular patients. The most common application of telestroke is for acute stroke patients (prehospital and hospital), but telemedicine services may extend well in advance and well beyond that time frame, and they may offer a wide variety of additional services from wellness, remote monitoring, disease prevention, subacute, rehabilitative, and reintegration into the community phases. While the primary role of telestroke is the facilitation of acute stroke patients' care, common stroke mimics will be identified and treatment recommendations may be offered.
Telestroke Network—A group of primary, secondary, and tertiary care settings that provide acute stroke care to their patient population. Telestroke networks consist of originating sites where the patients are located and distant sites where the telestroke provider is situated. Telestroke systems exist either as a distributed or a hub and spoke model.
Introduction
Despite advances in acute stroke treatment, stroke remains the fifth most common cause of death and the leading cause for long-term adult disability worldwide.2 There is evidence for effective means to reduce recurrence and improving outcomes by means of early platelet inhibition,3 intravenous alteplase,4 stroke unit utilization,5 endovascular thrombectomy,6 and hemicraniectomy in malignant middle cerebral artery infarction.7 However, high patient numbers, limited specialized expertise, and geographic determinants remain major barriers that negatively impact implementation of evidence-based management.8 These issues are especially true for remote and rural areas. In the late 1990s, the idea of telestroke took shape in an effort to bring much needed special expertise to a larger proportion of stroke patients.
Telestroke is the use of interactive videoconferencing technologies, specifically for the treatment of patients with acute stroke.9 The terms “telestroke,” “TeleStroke,” “teleStroke,” and “Tele-stroke” all refer to the same care concept; a centralized or remotely based stroke care team with a stroke physician at a distant site networked with the remote stroke patient at an originating site. Telestroke programs provide services for acute stroke patients in a variety of settings, including, but not limited to, mobile stroke units, EDs, intensive care units (ICUs), and medical surgical units, which do not have access to on-site stroke physician services.
Approximately 87% of acute strokes are ischemic.10 Selective patients are generally good candidates for IV alteplase, a thrombolytic agent that helps reverse or prevent disability from this type of stroke if administered within the guideline-recommended timeline window for thrombolytic therapy. The more quickly the patient receives alteplase, the greater the chances for recovery with minimal to no deficits. Patients who receive alteplase within the first 90 min of symptom onset are nearly three times more likely than patients who did not receive alteplase to have favorable outcomes 3 months after the stroke experience.11 Alteplase remains the only Food and Drug Administration (FDA)-approved reperfusion drug in acute ischemic stroke.
The following guidelines are designed to aid in the development of effective, safe, and sustainable telestroke practices. The development of these guidelines has been a collaborative systematic approach based on the best available evidence and clinical expertise. These guidelines are intended to promote standardization of telestroke care delivery, providing guidelines for minimum requirements for delivering safe and effective care, and thus positively impacting clinical outcomes. It is advised that guidelines, position statements, and standards from other professional organizations and societies be reviewed and incorporated into practice as well.
Administrative Guidelines
Organizations
Professional entities providing and receiving telestroke services shall follow the agreed-upon standard operating and administrative policies and procedures of the relevant governing organizations.
Leadership
Executive leadership at the originating site shall cultivate a shared vision of incorporation of the telestroke model of care into the innovative care delivery model. This vision should be clearly articulated throughout the entire organization.
Executive leadership at the originating site shall incorporate principles of change management and the American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments12 to guide strategic planning and executive decision-making.
Executive leadership at both the originating and distant sites should recruit and develop leaders (sometimes referred to as Stroke Champions) to implement and sustain care models that support interprofessional partnerships with the goal of transforming clinical work by building collaborative relationships to enhance patient care.
Executive leadership at the originating and distant sites shall ensure that telestroke clinical leaders are appropriately positioned within the organization to participate in key decision-making forums with the authority to make necessary decisions. Policies and procedures shall reflect that telestroke roles are integrated into the acute stroke response as well as quality assurance processes and sentinel event reviews.
Escalation processes should be created and sustained to focus on patient safety and allow healthcare professionals advocacy on behalf of patients and their families, regardless of practice setting. All healthcare professionals should have a mechanism to report, investigate, and resolve issues surrounding patient safety and quality. The mechanism should be nonpunitive and sensitive to ensure that the close collaborative relationship between telestroke consultants and receiving facility staff is not compromised. The same standards should be applied to providers participating in a distributed network through a provider organization or other cooperative arrangements. Ideally, providers may be part of a larger organization.
Roles and Responsibilities
For successful operation of a telestroke system, there should be agreed-upon key roles and responsibilities. There should be support and buy-in of key stakeholders, such as hospital administrators, IT, clinical personnel, human resources, legal, and finance, among others.
The telestroke hub/distant site physician director
The physician champion for telestroke at both the hub/distant and spoke/originating sites shall supervise the administrative issues that commonly arise. At the hub/distant site, the telestroke physician champion may be named medical director. This role should cultivate enthusiasm for telemedicine among other stroke center clinicians, develop and maintain relationships with spoke/originating telestroke sites, and design evidence-based care pathways. This role may be best served by a vascular neurologist or vascular neurosurgeon or other stroke expert. Qualifications for this role shall include vascular neurology fellowship training or equivalent, attendance at courses in cerebrovascular diseases and telemedicine, and CME credits in stroke and telemedicine. A telestroke champion at the spoke/originating site should be familiar with telestroke protocols, telemedicine technology platforms, criteria for transfer to a site providing higher levels of care, referral arrangements, cerebrovascular disease, and telemedicine in general.
Telestroke program manager
This role based at the hub/distant site should interface with medical staff services, IT, and legal offices at both the stroke center and at all supported spoke/originating sites/hospitals. This role should ensure contracts are in place, licensure and credentialing are current, training and education are being delivered, billing and coding are accurately performed, quality measures are in place, quality assurance processes are being followed, and overall administrative oversight is provided for the telestroke program, under the medical director's supervision.
ED stroke champion
ED physician roles at telestroke spoke/originating site facilities should include familiarity with telestroke alert criteria, processes and procedures for initiating a telestroke call and consultation, telemedicine technology platforms, and stroke clinical protocols. ED nurse roles should include interaction with emergency medical system (EMS) personnel, intake of an acute stroke patient, triage, recognition, rapid evaluation, and stroke treatment protocols.
Other telestroke roles
Qualifications for roles of other contributing telestroke providers should be focused on optimal acute stroke care, telemedicine technology proficiency, troubleshooting, and familiarity with working effectively within regional stroke systems of care. Other hospital provider roles may depend on the scope of the practice, but could include hospitalists, neurointerventionalists, intensivists, and radiologists.
Telestroke roles at spoke/originating sites may also include EMS personnel, physician assistants (PAs), advanced practice nurses (nurse practitioners), laboratory and radiology personnel, IT administrators, or other personnel who are committed to training clinical providers and providing quality oversight to the program. The originating and receiving facilities shall designate an IT liaison with specialized training in the hardware, software, and clinical algorithms associated with telestroke services as this role is critical to the seamless functioning of the technology.
Many small or rural hospitals may not have IT resources to ensure someone has special training. It could be the responsibility of the distant site or the telemedicine technology vendor to provide support to the originating site.
The oversight should include a review of consecutive telestroke cases for timeliness of emergency evaluations, correctness of clinical decision-making, appropriateness of treatment delivery, and comprehensiveness of post-ED care for the patients not transferred to the stroke center.
For those organizations that utilize telestroke services for inpatients with suspected acute stroke syndromes, the same oversight should be applied. Additional personnel, including hospitalists, neurohospitalists, rapid response teams, and other emergency responders, would be included in these reviews.
Human Resource Management
The organization shall create guidelines for EMS, ED, general inpatient, and ICU settings, which specifically describe telestroke processes, roles and responsibilities, appropriate staffing models, hours of operation (24/7/365 unless telestroke services are backfilling specific vacant time slots), methods of communication (e.g., telephone, video, voice over Internet protocol audio integrated with video), procedures around routine and emergency stroke care delivery, and plan for escalation processes (e.g., power, equipment, or Internet failure, or patient requiring transfer to another facility for higher level of care or endovascular treatment). These guidelines should match the needs of the patient population and bedside healthcare professionals. Each organization should support orientation, staff development, and competency of telestroke programs. An on-call list shall be available so that staff know exactly who to call when an acute stroke patient presents. Ideally, a single call should activate the acute stroke team, which includes the telestroke consultant.
Health Professionals: Regulatory Consideration (Accreditation/Certification)
Telestroke professionals (typically neurologists, neurosurgeons, and emergency medicine physicians) shall be fully licensed, registered, and credentialed with their respective regulatory, licensing, and accrediting agencies, with consideration to administrative, legislative, and regulatory requirements of the site where the patient and spoke/originating site healthcare professional are located. This consideration shall include all federal and state regulations regarding prescriptive authority and it shall be updated as changes occur. Credentialing through reciprocity processes shall be adopted to minimize recurrent paperwork burden on both ends.
State licensure and regulation rules are undergoing increasing national and regional debate. The ATA (www.americantelemed.org), the Federation of State Medical Boards (FSMB) (www.fsmb.org), and the Robert J. Waters Center for Telehealth and e-Health Law (CTel) (http://ctel.org) provide helpful resources for locating the most current state requirements for practicing telemedicine.
Healthcare professionals shall be aware of their locus of accountability and all requirements (including those for liability insurance) that apply when providing telestroke services. The telestroke leadership and the organization's legal counsel should ensure that malpractice carriers are notified when a new clinician is planning to provide clinical services through telemedicine. Likewise, when a physician is no longer providing clinical care, the carrier should also be notified. The use of telestroke modalities shall establish a healthcare professional–patient relationship, which includes all responsibilities inherent in that relationship.
Telestroke healthcare professionals may need to negotiate with local facilities to allow an exemption from certain obligations contained in the facilities' regulations and bylaws (e.g., TB testing requirement, nonstroke-related committee meetings) while providing telestroke services. These negotiations should not exempt telestroke healthcare professionals from participation in local hospital committees relevant to their telestroke programs.
Healthcare professionals providing telestroke services shall have the necessary clinical preparation, orientation, ongoing education, and professional development to ensure they possess the necessary competencies to promote quality care and patient safety.
Privacy and Confidentiality
Telestroke healthcare professionals and healthcare organizations in the United States shall incorporate the requirements for privacy and confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information for Economics and Critical Health Act (HITECH). In the United States, additional state regulations shall be followed for privacy, confidentiality, and patient rights; these may apply above and beyond requirements in place for general healthcare interactions. Telestroke services provided to patients physically located in other countries shall operate in conformance with the privacy laws in effect for that country. Other international laws shall be consulted and implemented as appropriate.
Policies and procedures shall address the privacy and security needs of the patient from both a technological and human rights perspective. Examples include capabilities, communication restrictions, and processes that protect patient privacy during remote audio/visual assessment. Providers should consult their legal counsel regarding recording consults.
Organizations providing telestroke services shall have policies to maintain patient privacy/confidentiality when visitors from outside of the organization tour the telestroke center/facilities/equipment.
All identified possible acute stroke patients and their families shall receive information, including the role of the telestroke program in patient management, the use of technology, and assurance of confidentiality, as time permits in the emergent setting. Information not conveyed before the therapeutic interaction ensued can be communicated after treatment has been delivered and stabilization established.
Some state regulations may require consent for telemedicine consultations; therefore, these telemedicine consents shall be included as part of the organization's general consent process. Frequently, the telemedicine consent is included as part of the general consent for treatment.
Fiscal Management
Organizations shall establish budgets that encompass the cost of implementation, which may include such items as hardware, software, data lines, licensing fees, credentialing fees, call reimbursement, marketing and communication costs, personnel, supplies, and real estate. The budget should also include ongoing expenses related to maintenance of the program, which may include such items as hardware and software upgrades, equipment replacements, and staff education.
The budget should also identify current and projected revenue for operating the telestroke services. Revenue items may include payer reimbursements, private contributions, grants, and general support from the healthcare facility and/or healthcare system.
Organizations may consider a financial model that addresses possible expansion and/or enhancement of the telestroke services. These modifications may include expansion to additional spoke/originating sites, additional equipment, and/or using existing equipment for other services such as teleneurology. Fiscal metrics should be customized to reflect the goals of the individual telestroke program and they require regular reevaluation at the executive level.
Management of Patient Records
The telestroke program should use processes and policies for documentation, storage, and retrieval of health records, consistent with the organization, industry, and government standards. Interoperability should be prioritized to ensure the seamless flow of information between patient information systems to enhance clinical support and promote provision of emergency stroke care. Direct interfaces between the telestroke program and hospital electronic health records (EHRs), laboratory, pharmacy, and bedside monitoring system represent the highest standards of interoperability. Due to the emergent nature of acute stroke management and the reality that consultants often provide services at many different facilities, this ideal, two-way shared interface of information systems may not be feasible or realistic. However, this level of interface should be the goal.
Documentation and EHR
Policies and procedures regarding clinical documentation that originates from the telestroke service shall be established in compliance with organizational legal and risk management oversight. The goal of such documentation should be clarity of the telestroke clinical intervention (evaluation, assessment, consents, and recommendations) and a complete clinical picture based on the available data in the telestroke consultant's note that are integrated into the patient's permanent EHR. If the patient is transferred, the telestroke consultation note shall be part of the records sent with the patient to the receiving facility.
Coordination, and when possible, integration of the EHR for telestroke consult documentation should be done as it is important for the prevention of errors and timely access to accurate patient data.
Dedicated telemedicine software packages may be used to facilitate standard telestroke consult documentation across a network, where direct access to the EHR is not feasible or practical.
Workflow and Communication
Documentation policies and procedures shall be developed for the successful patient care hand-off or transfer of responsibility. Direct peer-to-peer communications shall be encouraged to minimize possible miscommunications.
Data Retrieval
There shall be the ability for the telestroke physician to access and review current data specific to the consult from picture archiving communication systems (a radiology image transmission system) to facilitate communication and the decision-making process. There shall be access to bedside data to further facilitate communication and decision-making.
Telestroke Training
Adequate orientation and training of EMS, hospital, ED staff, radiology technologists, and physicians participating in telestroke shall be offered as they are vital to the success and collaboration between the remote hub/remote stroke consultant/neurologist and the on-site spoke/originating telestroke team. Ongoing training may be necessary during software upgrades, during quality initiatives, and for new hospital employees and physicians. For those originating facilities that access telestroke services on a part-time basis (e.g., off hours or nights/weekends—when there may be a gap in neurology coverage), there would be two algorithms for directing acute stroke evaluation. As such, intermittent or mock training sessions may be warranted to ensure that staff on all shifts maintain competency with the use of telestroke when included in the acute stroke algorithm.
Training should encourage staff acceptance of the use of telestroke services. This training should include efforts to build trust and develop integrated team workflows, incorporating both on-site staff and remote physicians. Special training may be required.
Patient Rights and Responsibilities
Patients and families shall be informed and educated about the role of telestroke in the integrated care delivery model. Use of remote healthcare professionals and audio/visual technology shall be included as part of telestroke-specific patient education.
Healthcare professionals should be particularly mindful with the use of audio/visual technology for the provision of patient/family privacy with sensitivity to cultural considerations. Appropriate language translation services should be employed for patients and families when appropriate.
Apprehensions regarding the role of telestroke and/or components of the audio/visual technology should be addressed collaboratively with the patient/family, the telestroke consultant, and the bedside team. They also may be addressed through organizational policies.
Quality and Outcomes
Telestroke services shall have systematic quality improvement and performance management processes in place that comply with all organizational, regulatory, and accrediting requirements. The quality indicators shall include administrative, technical, and clinical components for the provision of telestroke services. Furthermore, they shall be used to make technical, programmatic, and clinical changes based upon best new evolving technology, practice principles, evidence-based guidelines, clinical research, and any changing service requirements.
Telestroke staff, administrators, and local stroke coordinators/champions should be aligned to meet specific program outcomes and process measures. In addition to shared goals, the hospital and telestroke service may have unique metrics based on their unique contributions to the program. A process for the reporting and dissemination of quality metrics and outcomes should be developed to facilitate both administrative and operational analyses.
Telestroke value is optimized by increasing quality and access while controlling cost. Ongoing monitoring and evaluation of costs, access, and quality should be performed by both the hospital receiving telestroke services and the telestroke-providing organizations to identify opportunities at each site for enhanced value.
Telestroke services shall have a process in place to monitor quality and outcome metrics. Domains of quality measures should include technology parameters and process measures. The adequacy of video and audio connections during telestroke consultations and technology failures preventing adequate patient evaluations should be documented and reported. CT quality and readability are also important to telestroke assessments. Telestroke networks should record, at a minimum, times from door to CT scan, camera connection, completion of consult, and administration of intravenous alteplase when applicable. For patients transferred for endovascular therapy, time to decision and time from door-in to door-out are also important measures. The training of personnel involved in telestroke networks, including physicians, nurses, and administrators, should be defined and documented. Relevant outcomes should include percent of patients treated with intravenous alteplase, stroke mimics, transfers, complications, and patient and provider satisfaction. Quality and outcome measures should be reviewed by telestroke leadership on a regular basis. Results should be used to improve processes by a continual loop of feedback and reassessment. In hub/distant and spoke/originating networks, both hub/distant and spoke/originating sites should contribute to a common quality and outcome monitoring process, and they should share results to ensure uniformity of patient care, implementation of improvements system-wide, and identification of opportunities for enhanced value.
Research Protocols/Incorporating Clinical Trials into Telestroke Networks
Research involving telestroke's contributions to patient care and clinical outcomes and patient recruitment into larger studies, especially trials recruiting rural populations, should be encouraged and supported by the organization; such research opportunities shall be in compliance with the organizations' institutional review board (IRB) approval process.
Telestroke networks should be encouraged to contribute to knowledge by offering patients the opportunity to participate in clinical trials. Using telemedicine, investigators can identify patients appropriate for clinical trials. Physicians performing telestroke consults should be aware of active clinical trials and the inclusion/exclusion criteria. Clinical features, details of history, and CT findings can be reviewed remotely to select patients appropriate for specific trials. With accurate remote assessments, unnecessary transfers to assess possible trial candidates can be avoided. In some cases, the trial might be initiated at the remote site, and in other situations, a transfer may be necessary for the patient to be enrolled at a participating site. Identification and recruitment of patients from rural hospitals increase the diversity of study populations and reach areas not typically included in clinical trials. Recruitment through large telestroke networks also expands the pool of stroke patients contributing to higher enrollment, more rapid completion of studies, and greater opportunities for generalization. Telemedicine itself could be the subject of trials comparing telestroke and in-person evaluations. Research activities should always conform to study protocols and comply with good research practices, as outlined by the local or central IRBs.
Physical Considerations
The physical layout (including space, equipment placement, and secure examination space) and ergonomics of the ED, general admissions floor, and ICU should be addressed early in the telestroke planning process. This process should include input from clinicians, technology engineers, and physical plant engineers. Architectural design should consider communication essentials between and among telestroke team members and staff from the various potential care areas. These may include audio/visual equipment storage, wireless equipment placement, as well as dedicated bandwidth to provide stable reliable communication, and assurance of quiet environments to allow clear optimal interactions throughout the acute care facility. To facilitate its administration, storage of alteplase in the ED is strongly recommended.
Networks
Hospitals receiving telestroke consultations will have varying services they can provide, but minimally include head CT scan imaging and administration of IV alteplase. If there is need for unavailable ICU care, additional stroke diagnostic workup or care, or endovascular intervention, transfer should proceed to the closest available and qualified facility by ground or air transport, as safety, time, or complexity concerns dictate. Prearranged network transfer protocols should help expedite and facilitate patient transfers to these destination facilities.
Clinical
Setting Program Goals
Executive leadership shall direct both the telestroke and bedside stroke leadership in the review of program goals and the determination of priorities. Telestroke service is not designed to replace local services, but to complement or augment local stroke care through the leveraging of resources and standardization of processes.
Operational execution shall be designed to attain program goals within defined standards of care. Telestroke programs frequently have similar goals, including improved patient outcomes, cost savings, and the leveraging of resources, but the structure of each program may vary depending upon the organizational goals, types of available technical and human resources, and types and sizes of acute care facilities receiving clinical service.
Operational/Service Hours
Telestroke operational/service hours should be 24 h/day, 7 days/week, and every day of the year. There shall not be downtime except when the technology unexpectedly malfunctions. For all facilities, there should be a backup plan in which the acute stroke team can rely on other communication modalities to confer necessary clinical information to make an informed recommendation for acute management.
Types of Patients Served
The executive, stroke, and telestroke leadership shall determine the scope of telestroke patient service. When the scope of the telestroke responsibility is determined, flexibility should be based on patient needs, available services, and maintenance of the standard of care, according to the goals of the telestroke program.
By definition, the telestroke service is designed to provide assessment, diagnosis, management, and disposition decision-making services to patients with acute stroke. However, how an organization defines the utilization of the telestroke resource varies. The decision to provide telestroke services to all patients, regardless of classification (ischemic and hemorrhagic), severity, time since stroke onset, and treatment opportunities, should be determined by the telestroke and stroke leadership team.
Additionally, some telestroke programs provide service to acute stroke patients located outside the traditional ED, such as in prehospital mobile stroke units, in ICUs, in medical or surgical units, and in interventional neuroradiological suites, with the use of either mobile devices or hardwired technologies. Mobile stroke units are a relatively new application in which an ambulance with a built-in CT scanner and telemedicine system are used with qualified medical personnel to guide and support administration of IV alteplase in the field.
Some telestroke programs incorporate endovascular intervention. Patients requiring endovascular intervention may well receive IV thrombolytic bridging therapy. However, the clot burden may be too great to lyse with IV thrombolytic therapy alone. If available, these patients should be transferred rapidly to a comprehensive stroke center that has vascular interventionalists who may attempt invasive procedures to reopen an occluded vessel. For these patients, the timed emergent period is not over until the invasive procedure opens the vessel or the procedure is determined to be contraindicated.
Staffing Models
Telestroke network models generally consist of spoke/originating sites, where the acute stroke patients are located, and hub/distant sites where the telestroke provider is located. Telestroke models exist either as distributed staffing models or hub and spoke staffing models. In the distributed model, telestroke services are delivered to hospitals from providers at distant sites on a contractual basis. The distant providers generally have no affiliation with the hospital other than that concerning the discrete episode of care. If a patient requires a higher level of care, protocols exist to transfer the patient to a primary or comprehensive stroke center in the community. Staffing coverage for telestroke consults may be supplied by an independent for-profit company or by an organized group of providers. In the hub and spoke staffing network model, a regional stroke center generally provides telestroke services at the distant site to hospitals within the region (originating sites). The stroke staff members are generally credentialed at the originating sites. When transfers are indicated, the regional hub stroke center receives the patient from the spoke hospital. Continuity of stroke care is provided, beginning by virtual care, and then (post-transfer) by direct in-person care.
Telestroke Workflows
Implementation of a time-sensitive and efficient workflow for telestroke services is the basis for a successful clinical operation for evaluating and managing suspected acute stroke patients using remote expertise. The workflow at the spoke/originating site should include a stepwise set of processes that outlines the practice for establishing a time window for identifying a suspected acute stroke patient, activating an acute stroke team for the rapid evaluation, and incorporating actions for initiating a telestroke consultation into that process. Depending on the service model (hub and spoke vs. distributed), the contracted services may have specific requirements for activating a consult, such as a time to call, turnaround–time response, and initial available patient-related information. The actual videoconferencing consultation component should mimic the bedside consultation, in that the workup should follow recommended guidelines for the evaluation and management of acute stroke. Consideration also needs to be given to the final disposition of the patient, depending on the recommendations for treatment and management. The workflow should include several options for post-telestroke care, such as “remains at the spoke/originating site” or “transfers to a higher level of care.”
Required resources (i.e., personnel and equipment) needed for telestroke services should be clearly outlined in both the business plan and the workflow algorithm. This documentation applies not only to EDs but also to facilities that have inpatient services that may require an acute stroke response team. For some facilities, telestroke services may have already been built in as an original component of their acute stroke services. For facilities that had established stroke code processes and are subsequently implementing telestroke services as a new option in their stroke code algorithm, the workflow should be modified to accommodate the additional resources. Regardless of the model, successful telestroke workflows should have built-in processes that can accommodate variations that inevitably arise during the hyperacute stroke phase by relating the interaction with other workflow processes, as well as considering factors such as volumes, workload, staff schedules, and technology interference. The orientation and training of personnel who interface with telestroke services encompass the multiple services involved with the acute stroke process, including the EMS teams, ED personnel, ancillary support services (radiology and diagnostic services), communications offices, and IT support. Training shall be organized and directed by the stroke program leadership and it should be integrated into the general orientation to the stroke program.
The orientation of telestroke services shall consider the following:
Who needs to know?
• Prehospital EMS personnel
• Providers that will utilize the services
• Bedside practitioners (including ED and critical care staff)
• Radiology
• IT support
• Rapid response teams
• The community
• All new hires who may be involved
What should be included?
• The actual process
• What to do in case there is an IT failure
• Benchmark times
Content/training/competency
• Knowledge of specific roles in the process
• Mock codes
• Quizzes
• Providing and reviewing documentation
• Stroke team leadership
• Benchmark times
• Determining accuracy of the evaluation
• Ensuring a high-quality neurological examination in collaboration with the telestroke MDs
• Processes and procedures after the decision is made—no treatment, treatment, or transfer
Patient and family education
• Bedside providers and telestroke practitioners shall be responsible
• Pre- and postencounter teaching
• Explanation of the service as part of the process
• Brief description—pictures encouraged
• Identification of community resources
Integration Strategies
Stroke systems of care integrate regional stroke facilities, including acute stroke-ready hospitals that often have telemedicine and teleradiology capability, primary and comprehensive stroke centers, EMS, and public and governmental agencies and resources. The goals of creating stroke systems of care include stroke prevention, community stroke education, optimal use of EMS, effective acute and subacute stroke care, rehabilitation, and performance review of stroke care delivery. Essential to effective stroke systems of care are hospitals with the capacity and commitment to deliver acute stroke care, both in the ED and the stroke unit.13
The telestroke team should consist of a broad range of clinical, administrative, and research members at both the hub/distant and spoke/originating sites to fulfill all aspects of the telestroke dynamic. Neurologists, ED physicians, nurses, and radiologists should collaborate on the provision of remote care for patients with acute stroke.14
To gain the endorsement of spoke hospitals, a successful collaboration between neurology, neurosurgery/neurointerventionalists, and emergency medicine practitioners is essential. Collaboration between emergency medicine and neurology practitioners is likely the most important element of a successful telestroke program.14
Potentially efficient models of telestroke systems may use vascular neurology specialty-trained nurse practitioners, PAs, or neurology residents and fellows to perform preliminary triage, screening, and neurologic assessments. This preliminary work should then be followed by a reassessment or review by a supervising vascular neurologist, depending on applicable state laws. Having emergency medicine physician stroke leaders participate at hub/distant and spoke/originating centers is a model that appears to be associated with program success.14
Technical
Equipment
Organizations should refer to the ATA Core Guidelines for Telemedicine Operations documentation for minimum technical requirements. Additional technical requirements or specifications unique to telestroke applications are described below. For the purposes of this section, we will distinguish between acute stroke evaluation in the ED or hospital setting (acute care) versus follow-up care rendered in the hospital, postacute care, and the community (subacute) care.
Organizations shall provide technology that optimizes audio and visual clarity for enhancement of clinical assessment (i.e., real time, two-way audiovisual solutions with minimal latency). Acute care interactions ideally require high-quality videoconferencing cameras enabled with pan–tilt–zoom capability, whereas subacute care may be able to be rendered with simpler technology and fixed lens cameras, such as in laptops, tablets, or mobile devices. It is particularly important to ensure that any equipment used during the encounter shall meet the minimum technology and performance standards necessary and they shall comply with all appropriate privacy requirements. If specific applications call for the use of peripheral devices or digitally capable medical equipment, such as stethoscopes, otoscopes, and ultrasound devices, these devices also shall adhere to recognized medical standards and be interoperable with the telehealth encounter platform. Connectivity can be achieved through wireless or hardwired interfaces, but there should be redundant capability to ensure reliable performance. Organizations should provide adequate telecommunications bandwidth to connect near and far end equipment to support the program goals and ensure quality patient care services. The minimum bandwidth used should be determined in consultation with the clinical, IT, and biomedical staff of all facilities for sufficient clinical diagnosis and data transfer. Because different technologies provide different video quality results at the same bandwidth, each end point should use bandwidth sufficient to achieve dependable and reliable quality service during normal operation. The adequacy of bandwidth should be tested during the expected hours of operation to ensure that adequate bandwidth exists when consultations are likely to occur.
Ensuring adequate bandwidth for all times and equipment is especially important if providers or patients will be using personal devices to conduct these encounters. Adequate technical support should be provided to ensure compliance of these devices, proper functioning, and software compatibility. Periodic testing is necessary to meet these program goals. If using a personal computer or mobile device, the healthcare professional should conform to the IT policies of the enterprise. Devices shall have up-to-date security software that is HIPAA compliant. Healthcare professionals should ensure that their personal computer or mobile device has the latest security patches and updates applied to the operating system and third-party applications that may be utilized for this purpose.15
Healthcare professionals and organizations should utilize mobile device management software to provide consistent oversight of applications, devices, data configuration, and security of the mobile devices used within the organization.15 When the healthcare professional uses a mobile device, special attention shall be placed on the relative privacy of information being communicated over such technology, and access to any patient contact information stored on the mobile device must be adequately restricted.15 This protection includes provider awareness of the physical environment in which they will perform the consultation and the security of any mobile networks that might be accessed. Privacy screens and earphones should be considered for laptops or tablets that will be used or accessed in public spaces. All devices or applications shall require a passphrase, biometric identification, or equivalent security feature before the device can be accessed. If multifactor authentication is available, it should be used.15 All devices should be configured to utilize an inactivity time-out function that requires a passphrase or reauthentification to access the device after the time-out threshold has been exceeded. This time-out should not exceed 15 min.15 If video clips are used, appropriate processes for disposition of those clips shall be in place.
Mobile devices should be kept in the possession of the healthcare professional when traveling or in an uncontrolled environment. Unauthorized persons shall not be allowed access to sensitive information stored on the device or use the device to access sensitive applications or network resources.15 Healthcare and institutional IT professionals should have the capability to remotely disable or remove data from any mobile device containing personal health information or sensitive institutional data, should the device be lost or stolen.15 Given the need for access to multiple services and systems by modern healthcare providers, policies should require unique usernames and passwords for all providers to prevent sharing of access keys, and providers should not use the same username and passwords across multiple platforms unless the organization supports single sign on or federated authentication. Providers who must use multiple different username and password combinations should be encouraged to use password management software to generate and maintain strong passwords.
Telestroke applications should support at minimum point-to-point, and ideally, multiparty connectivity. Providers should be able to access the system from within or outside of the healthcare facility, using the same interface and user experience. Organizations should consider technology interoperability when selecting systems for integration of other telemedicine services or documentation systems. Interoperability will be increasingly important as telestroke applications enter mobile stroke units, postacute care facilities, and other avenues of care delivery. Increasingly, organizations leverage telemedicine equipment to serve the needs of multiple clinical programs. Whenever possible, equipment used for telestroke should be adaptable to serve the needs of other clinical programs.
Systems shall comply with all current and applicable state and federal laws and regulations governing the use of medical devices and medical information, that is, FDA, HIPAA, HITECH, and waste electrical and electronic equipment. All efforts shall be taken to make audio and video transmission secure by using point-to-point encryption that meets recognized and accepted standards. Systems shall comply with the Federal Information Processing Standard, the U.S. Government security standard used to accredit encryption standards of software, and lists encryption such as Advanced Encryption Standard. Healthcare professionals should familiarize themselves with the technologies available regarding computer and mobile device security and they should help educate patients.15 If organizations intend to provide services to patients located in other countries, they should be aware of relevant technical restrictions placed on information systems technology exports to certain countries.
Organizations shall ensure proper testing and maintenance for all functionalities for each newly installed infrastructure or endpoint. Organizations shall implement planned and unplanned downtime procedures that ensure continued service and may include the use of appropriate backup technologies and clinical protocols. Examples may include N + 1 redundancy, device component redundancy, geographic dispersed infrastructure, fast failover, failure notifications/alerts, and/or documented on-call procedures during planned or unplanned system downtime. Policies and procedures should proactively address ongoing equipment maintenance, anticipated equipment and software upgrades, performance of periodic remote tests for operation and functional verification, evaluation of resource allocation, and 24/7 technical support.
Infection Control
Organizations shall have infection control policies and procedures in place for the use of telestroke equipment and patient peripherals that comply with organizational, legal, and regulatory requirements.
Data Policy and Procedure
Organizations shall implement policies that address adequate data storage and retrieval, device security, time zone management, and follow long-term storage standards, such as Storage Management Initiative Specification. Recordings of audio or video footage should be performed with appropriate oversight and patient/provider consent when appropriate. Maintenance and secure storage of all sensitive information should be governed appropriately with written policies and procedures. Access to this material should be restricted to those with legitimate needs. Organizations that document medical information in third-party or EHR systems, other than the standard health record system of the requesting site or consulting site, should ensure these records are stored in a manner compliant with relevant privacy and security regulations. There should be a written policy for how this information is stored and communicated to the referring site or consulting site, as appropriate. If multiple providers contribute to the documentation of the clinical encounter, then all providers involved should be indicated in the documentation, as would be expected in a traditional face-to-face encounter. The organization should have written policies regarding the sharing of information about the quality of consultations or benchmark performance criteria that allow for continuous quality improvement within the telestroke network.
Conclusion
These telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine technologies. These guidelines
• Define commonly used telestroke terminology
• Introduce the need for telestroke
• Propose administrative and leadership structure, roles, and responsibilities
• Outline regulatory considerations for health professionals
• Review privacy and confidentiality considerations
• Establish fiscal management strategies
• Set out management principles for documentation and EHRs
• Propose workflow and communication
• Highlight requisite training and qualifications for providers
• Establish patient rights and responsibilities
• Feature quality and outcomes
• Incorporate opportunities for research protocols
• Define physical and network considerations
• Present program and operational goals and expectations
• Display various staffing models and systems of care integration strategies
• Make technical specifications
Telestroke interactive encounters link patients with acute ischemic and hemorrhagic stroke and acute care facilities with remote and on-site healthcare practitioners to provide access to expertise, enhance clinical practice, and improve quality outcomes and metrics. When a clinical domain in telemedicine accrues a body of evidence supporting reliability and validity of the virtual examination, accuracy of the remote diagnosis and treatment management decision-making, safety and efficacy of the telemedicine assessment, and clinical and cost effectiveness of the paradigm, it is sufficiently primed for implementation of guidelines designed for the telemedicine practitioner, administrator, and technician alike. Such is the state of telestroke today.
Disclosure Statement
No competing financial interests exist.
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