1. Needs Assessment

2. System Development

3. Clinical and Operational Implementation

4. Training

5. Evaluation

Case Study

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Appendix: Research Methods


The material in the toolkit originates from three main sources:

  1. Systematic review of the research and evaluative literature on telestroke;
  2. Content analysis of implementation resources from existing telestroke projects;
  3. Case study interviews and examples of documentation to support implementation collected during the development of one UK telestroke project.

1. Systematic Review

Search Strategy

The search was designed to identify best practice in the process of implementation of telemedicine in acute stroke. A wide range of material was therefore considered relevant including project descriptions or case studies; evaluative or experimental research; process evaluations or feasibility studies; qualitative research or surveys of stakeholders. The search strategy was therefore narrowly limited to the use of telemedicine in acute stroke, but was not limited by type of information or research design.  The following sources were searched:

  1. databases of published studies:  including The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, PsychInfo, Web of Knowledge, International Bibliography of the Social Sciences (IBSS), Health Management Information Consortium (HMIC); from inception to April 2010;
  2. handsearch of key journals:  Journal of Telemedicine and Telecare, Telemedicine Journal & Ehealth(Jan-Jun 2010);
  3. citation searching of all included studiesvia Web of Knowledge
  4. conference proceedings: main telemedicine and stroke conferences from 2008-10
  5. internet searching

Methods of the Review

Criteria for considering studies for this review

Types of studies: Studies published in a peer-reviewed journal between 2000 to 2010 and containing original data assessing the process or outcome of a telestroke system, including observational or experimental studies, process evaluations or case studies describing the development, implementation or evaluation of a telestroke system or processes; or qualitative studies/surveys collecting data from stakeholders about their views or experiences of using a telestroke system.

Types of participants: People with suspected or acute stroke, receiving emergency treatment in a health care setting.

Types of intervention: Telestroke systems were defined as the use of a communication medium for remote consultation with a service provider or specialist at a site distant from the patient.  There must be an actual consultation between two providers, with the patient present at one point of care, for neurological assessment, stroke diagnosis or acute stroke treatment.  To be relevant to current technology, the communication media must use audio-visual real-time transmission. Interventions were limited to hospital or clinic-based consultations, but could involve qualified healthcare practitioners from any discipline. 

Types of data:  The type of data to be extracted depended on the type of study, but included description of the processes involved in the set-up, operation, management, or evaluation of a telestroke system; or stakeholder views on challenges to the development, implementation, use or sustainability of a telestroke system.

Data extraction and analysis from research studies

After removal of duplicate records and records obviously not relevant to the review by one reviewer, two reviewers independently screened the remaining records on title and abstract, and filtered all full-text papers for inclusion. Eligible publications were scanned for information describing or evaluating the process of implementing telestroke, or factors influencing implementation. Data extracted across studies for a specific telestroke systems included:

  1. bibliographic and methodological details of the study (experimental, observational, qualitative);
  2. system description: type, content, components, primary purpose, other uses, qualifications of people using system, financial and legal agreements;
  3. system operation: patients included/excluded, parameters for system use, process of system connection/use, training, standard operating procedures or clinical protocol availability for: informed consent, clinical examination, review of scans; documentation for: assessment, diagnosis, treatment;
  4. system evaluation: data collection/outcome measurement, audit of standards/procedures, recording of protocol adherence/violations.
  5. details of resources developed by other projects e.g. implementation toolkits, protocols, standards, criteria etc.

Findings relating to barriers/problems or enablers/solutions for telestroke system operation or management were extracted from process evaluation data, or from author comment. A preliminary analysis categorised factors as relevant to stages of the implementation process for a telestroke system as follows:

Factors were further categorised as barriers or enablers for successful implementation of telestroke. Author comment and conclusion are expressed as recommendations for good practice as in the following example:

Develop governance policies to support staff working across organisations, and make institutional arrangements for reimbursement 3, 4, 11

2. Content Analysis Of Implementation Resources

Contact details for active telemedicine systems additional to those identified in existing systematic reviews of telestroke 1, 14, 15, 16, 17, 18, 19 were culled from reports in the literature, conference proceedings, and an Internet search. Contacts for specific systems were emailed to ask about the availability of, and public access to any (English language) procedural manuals, decision aids, guidelines, protocols, or algorithms used within their telestroke system to guide implementation, including:  

In addition, sites in the United Kingdom were asked for:

A content analysis of the implementation resources was undertaken, then the descriptive details were categorised into discrete “implementation tasks” in the development of a telestroke system. For each implementation task, the pooled detail of the content analysis is summarised as in the example below:

Implementation  task


Assess the availability and quality of the clinical resource

  • Current provision of day time in house service
  • Meets quality standards e.g.  successful RCP accreditation for 24/7 service,  stroke network
  • CT scanner + staff available + able to scan in <30 minutes 24/7
  • Laboratory service + communication of results 24/7 within time limits
  • Able to admit to a hyper-acute stroke unit bed
  • Sufficient on site skilled staff to care for thrombolysed patients 24/7
  • Adherence to stroke best practice guidelines + staff awareness of documentation