Learning from the Lancashire and Cumbria Case Study
Section 1: Telestroke Needs Assessment
- Procuring a telemedicine system
- Developing consensus for telemedicine in stroke
- Developing communication routes for telemedicine in stroke
- Getting agreement for telemedicine in stroke
- Agreeing the finances for telemedicine in stroke
Section 2: Telestroke System Development
- Developing governance procedures for telestroke
- Developing shared clinical resources for telestroke
- Job planning issues and staffing resources for telestroke
- Developing a workable rota for telestroke
- Testing the telestroke equipment and the system
Section 3: Telestroke Clinical and Operational Implementation
- Where should thrombolysis and post-thrombolysis monitoring take place?
- Who should do next day scans and reviews?
- Communicating the telestroke clinical decision securely
- When should decision-support providers be contacted in out-of-hours situations?
- Going live with the rota and the telestroke system
- Ensuring patient privacy and dignity during a telestroke consultation
Section 4: Telestroke Training
- Who should do patient referral assessment?
- Who should do interpretation of CT scans?
- Who should do decision-support provider role?
- Who should do thrombolysis delivery?
- Who should do post-thrombolysis monitoring?
- Who should assess competence for telestroke?
- Building confidence and expertise in telestroke
- Training provision and updating
- Cultural issues between disciplines
- Cultural issues raised by audio-visual communication
Section 5: Telestroke Evaluation
- Ongoing multidisciplinary review of telestroke consultations
- Data recording of telestroke consultation
- Information about telestroke that was not being collected
- Difficulty of measuring patient satisfaction with the telestroke experience
A network telestroke model was chosen rather than a hub and spoke model. A network model was more suitable for the needs of a large rural area with long travel times, and no obvious main provider site. The telestroke service specification was developed by the Lancashire and Cumbria Stroke Network and lead commissioners. Equipment choice was largely influenced by the issue of rurality, with some equipment set-ups not viable because of unreliable internet connections. A managed telestroke system was chosen, because it was seen as more resilient (especially for a network with no main provider).
In the early stages, a lot of time was wasted and the decision to use a single tender was changed as the quote did not fall into the budget. The options were then: restricted tender or competitive dialogue through OJEU (Official Journal of the European Union is the central database for European public sector tender notices); and mini competition or single tender within a “Buying Solutions” (the UK public sector's national procurement portal) Framework. The preferred route for Procurement from the outset would have been to hold a mini competition within Lot 8 (a specific UK Government Framework Agreement for Procurement). This would eliminate the risk of challenge from anyone else, while also allowing a value for money, like-for-like comparison between companies that was fair and equitable. The issues were:
- inviting a single response from one company could cause disagreement;
- either one selected company from a framework or all have to be invited unless there are grounds to exclude, but running a pre-qualification stage would waste time;
- inviting with a very short timescale risks a cry of unfairness from companies who have not yet seen the requirement;
- the requirement has to be put out to all suppliers on the framework to ensure fairness for all companies.
The decision was made to put the requirement out to all suppliers with a three week turn-around timeframe.
Public authority procurement rules are dominated by considerations of fairness and openness and any potential challenges need to be avoided. The product specialist from “Buying Solutions” confirmed the procurement managers’ views as follows:
“There is provision for single tender catalogue ordering and further competition, it is down to the customer to determine capable suppliers. The ITQ function on the Buy in Solutions website provides an easy to use portal for calling suppliers to competition. Buying Solutions advice to its customers is to go to further competition for bespoke requirements or for requirements that cannot be sourced via catalogue or where special terms are required, if for any reason you receive any challenge, then your project may have to start all over again.”
Lessons learned include not giving suppliers a technical specification, but to give them the system specification in plain language; and – involve Procurement from an early stage! Our suggestion is that you seek your own independent legal advice on the options and ensure that the project team are made aware of the issues.
Although seen as a good idea, there was initial nervousness about the development of a telestroke network. At the time, there was no evidence from research to support the idea that it would improve patient care, improve life quality, or reduce social care costs in the longer term. Commissioners were not initially convinced of the value of telestroke because of the low numbers of people who might benefit, but they were influenced by the potential for high cost savings in the longer term. The Strategic (regional) Health Authority and the Lead Provider Trust (Hospital) viewed experience with the telestroke system as useful, to learn about the generalisability of telehealth to other areas of healthcare.
Initially, certain staff groups were less convinced of the value of telestroke. Emergency Department staff saw stroke care as only one of a set of competing priorities; managers did not perceive the value of the payback for their medical consultant’s time spent on the rota. Individual clinicians were also influenced in their perceptions of telestroke by: i) the amount of work involved; ii) their familiarity with technology; iii) the level of research evidence available for the differential benefits of a telestroke system versus investment in local services; and iv) personal factors such as family commitments.
Developing understanding and consensus took a lot of work, mainly by working with individuals to let them experience use of the system. The Lancashire and Cumbria Stroke Network undertook most of this work. Telemedicine insight days and events were also held over two years. Key people at Trust level included the Director of Operations; Procurement Officer; Director of Informatics; Management Lead; the Chief Operations Officers;the Chief Executive Officer who was the Steer for the Telestroke Executive Group; and stroke clinical leads and nursing staff within the relevant areas. The network and lead organisation employed a Project Manager and a Communications Manager. The North West Technical Lead was also a central player in system development, together with the involvement of the Imaging Managers Group.
Lessons learned include ensuring that the lead organisation has the services of a project manager, and even though the Stroke Network can facilitate cross- organisational working - not to under-estimate the sheer amount of work needed to involve everyone.
Most staff groups raised some initial concerns about engagement with telestroke:
- Engagement of staff from Radiology and XRay was difficult at first; due mainly to a lack of information about the potential impact of telestroke on their workload;
- Despite the long history of Information Technology (IT) departments working collaboratively across the North West region, there were differences in the willingness of individual IT departments to be involved in telestroke, with lots of competing priorities for them;
- The interface between emergency department clinicians and acute stroke clinicians is invaluable to a smooth, effective patient pathway, and it was evident at some sites that this communication and engagement was lacking.
Formal communication structures that have been set up include meetings of: the Stroke Clinical Advisory Group; Operational Managers; Continuing Professional Development Leads; and a Stroke Telestroke Board (which is now the Executive Group).
Even though regular meetings were agreed and organised, it has not proved easy to get stroke physicians together across hospitals. There has been poor attendance at joint meetings, including the early monthly review meetings. This could impact on the future sustainability of the service as there was the expectation that the monthly review meetings were the route by which managerial and clinical leads would disseminate information to the relevant sites and staff within their respective organisations.
Despite heroic efforts to involve everybody from the start, at the time the system went live, there were still differences in levels of involvement between participating organisations. Some clinicians felt that they were not initially involved in the decision-making by their own hospitals. Some became more involved and enthusiastic with experience of the system, but some lead clinicians in participating organisations have remained uninvolved in the telestroke rota.
Lessons learned: Management of differences in levels of involvement between organisations needs to been actively undertaken by Operational Managers with input from Medical Directors and Clinical Leads. Establish clear communication routes for all concerned, and ensure everyone knows their roles and responsibilities.
Getting agreement from each organisation worked well in discussion and seemed clear in Executive meetings, but faltered in the working detail. This was particularly so when it came to concrete details, such as arrangements for covering the rota, and when recurrent financing had to be agreed. What had been verbally agreed in principle by organisational leadership could be contested in the details by operational management. For this reason, letters of agreement were drafted to multiple layers in the organisation, including the Chief Executive Officer, the Medical Director, and the Head of Governance, so that agreements and responsibilities were explicit.
However, even with this level of formal agreement in place, the working details of issues such as medical consultant job planning were not easily resolved across multiple organisations, and took numerous meetings. Guidance on the different job planning options was provided to try to help, but some job planning issues are still not resolved in some organisations, even after the system has gone live.
Lessons learned include getting early sign-up from Chief Executives in participating organisations; funders (Primary Care Trusts); and clinicians. Job plans need to be clarified in the early stages so that medical consultants are committed from the outset.
One organisation needed to be responsible for procuring the telemedicine system, to assure adherence to legal, financial and contractual rules. Financial issues included meeting the regulations for reclaiming VAT (Value Added Tax); and concerns that there would be capital charges from capital spend (which was avoided by having a managed service contract and leased equipment).
Procurement was delayed on the issue of whether the Primary Care Trust (PCT) should pay, or whether the money should come out of the acute care tariff. At the time, there was nervousness around reorganisation of the PCTs in the UK, so people were reluctant to sign up for recurrent costs.
The main lesson learned was to confirm financial agreements in writing right from the start. Our implementation dates were far too optimistic, and agreeing the finances has been the biggest hold up throughout.
There needed to be a governance structure that all organisations were confident in. The policy had to be clear about who was responsible for the patient. There was some nervousness expressed that the patient referrer retained responsibility for patient care, and that any litigation would fall on the middle grade clinician at the local site for thrombolysing or not thrombolysing. A covering letter was sent out from the Strategic Health Authority (regional) Medical Director with the draft governance policy, addressing concerns.
The lesson learned was to address clinicians’ concerns about governance at a strategic level.
Pathways needed to be analysed in terms of what was already done, and then re-designed as a master pathway. The pathway analysis and process mapping showed that there were local issues that needed adaptation of the master pathway, such as platelets that were not stored on site. Pathways for each site also needed to take into consideration the different routes into thrombolysis, such as what to do if a stroke happened on the ward, or in the hospital somewhere (one of the first people to be thrombolysed was a member of hospital staff who became ill while at work). Variants of the thrombolysis pathway were made for the emergency department, medical assessment unit, and ward.
Agreement was needed from all the clinicians involved that they are willing to use the standardised policies and recording forms. Policies had to be submitted for review at each site, as there was no central system for agreeing changes to the paperwork. The documents took numerous drafts and had to be sent to each site for adaption and review, before being sent to the formal panels at each site for acceptance and validation. The stroke clinical lead from each site plus a member of the project team had to present the documents at the formal meetings which in some cases meant having to attend as many as four meetings per site e.g. patient risk groups, clinical governance groups, patient safety reviews,executive governance board.
The lesson learned was not to underestimate the time it takes to develop and agree standardised policies and paperwork. The lead provider organisation is now responsible for ensuring that document version control is upheld, and they lead on any revisions.
Implementation of a telestroke system increases the volume of work overall, so there is also the requirement to ensure adequate staffing resources, such as:
- adequate consultant cover during the day to manage follow up;
- the need for adequate nursing staff on the emergency department and/or stroke units to manage post-thrombolysis monitoring and care;
- rota manager;
- staff resources for data collection.
Medical consultant job planning was a major issue. Despite organisational level agreement, individual clinicians and their managers struggled to adapt workloads to cover the additional sessions. For people working at maximum capacity, something else had to be dropped. Managers did not perceive the added value gained by participation in the telestroke rota. While the medical consultants acting as decision-support providers were supportive of telestroke, this does not alter the fact that telestroke means additional disruption to their weekends and night-times. There was a feeling that their commitment and enthusiasm for telestroke could be taken advantage of by organisations, and individuals were worried about the workload. Job planning guidance was provided, but even as the system went operational, some job planning issues were still not resolved.
The lesson learned is to evaluate the costs and benefits of involvement in telestroke from the perspective of the different stakeholders.
A one in fifteen rota was chosen, with six to eight weeks notice for changes such as annual leave or study leave. For emergency changes the minimum time frame is 24 hours. However, some Trusts with more resource are contributing more to the network, raising the issue of how to ensure a balance of effort between sites. The number of consultants to work on the rota was estimated from the stroke activity on that site. Those sites with fewer patients provide two consultants (acting as decision-support providers) and cover two slots on the rota. All other sites provide three consultants and cover three slots of the rota. It is up to the local site to cover any shortage of consultant cover in the interim if one is off sick or if there is a short term problem.
The project manager role ended when the system went live. From that point on, the Telestroke Administrator is seen as a key role for the telestroke network. The post holder has been trained in IT issues; is a ‘Train the Trainer’ for the telestroke cart and laptop; and has administrator rights to the generic NHS e-mail accounts at each of the sites (used to send consultation reports). They are expected to look at the generic e-mail boxes to pull information from the Telestroke assessments and input all the relevant information from these into monitoring databases. This information is then used on a monthly and quarterly basis to generate a report for the relevant parties.
The lesson learned is to have contingency plans for the rota. The Telestroke Administrator works 8am-4pm, so each local Trust has to take responsibility if something happens out of hours. A local manager contingency plan is available for all sites and for escalation to a lead provider manager should the rota not be covered.
Technical testing of the telestroke carts was done remotely with a local IT presence. Technical testing of the laptops was performed in 2 stages:
- Alpha testing, which was done by remote testing from the commercial firm managing the system to the laptop, checking connectivity and set-up;
- Beta testing, which was performed by the clinician from home. They had to be able to dial up to each cart; get the staff at the local sites to assess them for audio and visual quality; test camera function; access NHS e-mail to complete documentation and forward it to the test site; and access Burnbank to view test CT images.
Repeated telestroke walkthroughs prior to going live were invaluable in checking assumptions about how things were going to work. Walkthroughs highlighted areas of good practice and gaps in the process, and displayed areas of contention that previously were not transparent. Walkthroughs also identified areas for improved communication and further training opportunities, and sometimes highlighted that training had not been as effective as previously thought. There was an optimal size for a successful walkthrough - one walkthrough with about 30 people was too unwieldy, but the politics of the organisation at the time did not allow for a smaller group.
Live mock-ups provided additional information because they were in real-time with staff who would be working in the out-of-hours situation. These mock-ups demonstrated areas of good practice; the levels of engagement of both medical and nursing staff (in particular lack of ownership around the telecart); and issues around retrieval of activity-monitoring data from generic NHS e-mail boxes at the individual sites.
The lessons learned from the walkthroughs were to:
- Develop a walkthrough check-list and send to the operational manager prior to the event;
- Ensure that the correct staff are invited to the event, i.e. those people who will be able to influence a decision: IT lead; Estates manager; emergency department manager, medical consultant (stroke lead if possible), and senior nursing staff (Matron, shift co-ordinators); clinical lead for stroke, nursing staff from stroke ward; operational manager for stroke to lead the process. However, don’t have too many people on each walkthrough;
- Ensure feedback from the event and an action plan are disseminated to all named staff and to all other relevant parties;
- Ensure any actions generated by walkthrough to be documented, and given to a named person within an established timeframe;
- Ensure progress of actions is monitored prior to and on the day the timeframe is completed.
There was some debate about whether thrombolysis should take place in emergency department, or on the stroke unit. This was influenced by local circumstances in each organisation, including: where thrombolysis was already embedded; staffing logistics; and the availability of beds on the stroke unit. The issue of availability of skilled staff for post-thrombolysis monitoring also varied between sites, and at different times of day. There was some disagreement between stroke physicians and emergency department staff, with different views expressed on the benefits of shorter door-to-needle times, versus safety.
The lesson learned was that choice of site for thrombolysis and post-thrombolysis monitoring can’t be standardised and needs to suit the resources, preferences, and history of each organisation.
There was debate about whether the decision-support provider should be involved in the 24 hour post-thrombolysis review. Stroke physicians were generally in agreement, but others thought that this should not be necessary, because it should be no different to normal procedures for follow up of daytime thrombolysis. However, in the early stages of system use, clinicians acting as decision-support providers have expressed a desire for feedback on the outcome of the patients they have seen.
The lesson learned was that while continued involvement of the decision-support provider is not necessary after the consultation, next-day feedback on patient outcome is valuable to them.
The telestroke technical system chosen by the Lancashire and Cumbria Telestroke Network does not have automatic data transfer. A system was therefore needed to ensure the timely, reliable, and secure transfer of written documentation on the clinical assessment and recommendations. A number of possible solutions were considered. The end decision was to establish generic telestroke e-mail accounts at each site, with a group of staff at each site identified as the most appropriate people to access this. These groups had to register an account at NHS mail and they were then added to the generic accounts. After the consultation the decision-support provider completes the Joint Decision Making Form plus the NIHSS documentation and forwards them to the relevant site. Staff at the patient referral site then access their account, download the documentation, and file it in the patient’s records. However, at the time of going live the system still had teething problems such as things being posted to the wrong site, or staff unable to download the documentation.
The lesson learned is to carefully consider and plan for the complexity of maintaining secure, timely, and reliable communication between sites in a networked telestroke system.
There was some deliberation about exactly when decision-support providers should be contacted in out-of-hours situations. This depended to some extent on the CT scan resources at the patient referral site. If CT resources were some distance away from the emergency department or if the scan was not immediately available, the decision-support provider could be woken up, only to be waiting 15 to 20 minutes before being able to do an assessment. There were differences in decision-support provider preference: some wanting to be contacted early; others preferring to wait for the scan to be available. A survey was conducted, and the results were that the decision-support provider would be contacted and informed of the patient prior to the scan so that they could assess the patient if they had time.
Another problem that developed in the early stage of system use is that the telestroke system is being used for general advice, and not just for assessment. This was expected to some extent, but it soon became apparent that the telestroke process would take some bedding-in time, especially during junior doctor rota changes.
The lesson learned was to monitor issues around job-planning in relation to compensatory rest, intensity and frequency of on-call. An activity monitoring form was designed to capture the types of advice given and the time and duration of calls, which the decision-support provider completes at the end of his on-call.
Despite all the planning, preparation, and briefings - teething problems still occurred when the telestroke system went live. On one of the first nights, the connectivity to Burnbank (CT image portal) from one of the sites went down, and the decision-support provider had to contact the on-call radiologist at that site for a verbal report of the CT images of the patient being accessed. This tested the contingency plan, which worked well!
Also, in the early stages the wrong decision-support providers were called on occasion, because out-of-date rotas were still in circulation. One call went through to the Cardiac and Stroke Network answerphone. This was a switchboard issue - one site was centralising switchboards from three down to one site and the operators misheard.
The lesson learned is to develop a system with the switchboard managers to ensure that the operators are using up-to-date rotas, and that they are kept informed of changes.
One decision-support provider was unsure whether the ability to remain sensitive and responsive to maintaining patient privacy and dignity would be the same using a telestroke system, as it would be in a face-to-face consultation.
A patient information leaflet has been developed with help from the Stroke Association, to increase patients’ and carers’ understanding of the Telestroke Service. A patient experience form has also been developed with the aid of the Stroke Association to give feedback on the service (see evaluation section).
There is also the issue of the recording of the telestroke consultation. Advice and recommendations from the UK General Medical Council have been implemented into the governance and operational policies. Verbal consent will be gained from the patient by the decision-support provider to record the session for the purposes of audit and evaluation. If the patient lacks capacity to give verbal consent, then the recording cannot take place.
The lesson learned was that written consent is required from the patient to use an audiovisual recording of a consultation for training purposes, which should be obtained as soon as possible.
As well as the considerations of time needed for transfer between units and the requirements of bed management, there were issues of staff competence and availability to consider in deciding who should undertake the assessment. On some sites, stroke nurse specialists normally undertook assessments, and guided the patient through the system. This was considered to be ideal, but was not feasible to maintain out of hours. Other sites had a preference for an emergency department middle grade doctor or registrar to undertake assessment. However, there was concern about the involvement of registrars in view of their diverse workload and training needs.
Radiologists were concerned that there would be an explosion of work with the advent of telestroke. One solution was to train stroke physicians to read head CT scans. There was no conflict over this solution for ruling out haemorrhage, but there were issues around what the radiologist remit would be, and how they would work.
In the main, this was limited to consultant stroke physicians, neurologists, and emergency or elderly medicine physicians because of the requirement for competency in stroke thrombolysis. There was some discussion about whether registrars could be involved, but it was acknowledged that they would still need to be supervised, and that equipment would need to be installed into their homes, which would then require renewal every six months at rota changes. A decision was made that anyone on the telestroke decision-support provider rota had to have a substantive post at their own Trust and have experience in performing stroke thrombolysis.
Prescribing of the thrombolysis drug Alteplase is the responsibility of the physician at the local site who collaborates with the decision-support provider as to dosage (the patient should ideally be weighed as the drug is weight dependent). The responsibility for thrombolysis delivery varies between sites: either emergency department medical staff or stroke physicians take responsibility, but there is no reason why nursing staff with IV certification could not deliver the drug.
Emergency department nurses are familiar with monitoring during thrombolysis. However, the delivery of Alteplase takes at least an hour - resulting in a staff nurse being unavailable for other duties in the emergency department. There has been lots of discussion about emergency department nurses/medical staff workload and capacity and breach of the four hour target, but the decision to use the emergency department for thrombolysis delivery was a popular choice. The bolus dose and full infusion is given in the emergency department and then the patient is transferred to an area for a further post-thrombolysis monitoring. Each hospital may have a different pathway so the patient might be transferred to areas such as High Dependency, Coronary Care, or Acute Stroke Unit for the 24 hour monitoring period.
Thrombolysis is mainly given in the emergency department, although two of our sites give it on the Acute Stroke Unit, where the patient remains for post-thrombolysis monitoring.
There was a suggestion that stroke consultants on each site would be responsible for competency assessment, but this was perceived to be unworkable. The Network Clinical Leads signed off the clinicians on the telestroke rota who held records of attendance for the required qualifications. Competency assessment at local sites has mainly been delivered by the stroke specialist nurses at the sites or the stroke champions, and through training provided by the Regional Stroke Network and equipment manufacturers. Ongoing competency assessment will be done by the same individuals, but this is not as robust as we would like.
Some consultants were reluctant to participate in telestroke due to lack of confidence about thrombolysing. Clinicians with less experience of thrombolysis were provided with specific opportunities to get involved in thrombolysis prior to joining in on the telestroke rota. This was done by attendance at stroke thrombolysis masterclass days, CT training, and for some, placements at centres that thrombolyse on a regular basis. Some clinicians were very worried about the technology and had to be intensively supported through early experiences with the system. A learning curve is anticipated while people gain familiarity and confidence with the system, and ongoing review is seen as crucial in ensuring that people are comfortable with what they are being required to do.
Ensuring that all staff had initial training was challenging. Middle grade doctors needed to be targeted for neurological assessment and thrombolysis training, but not all organisations had a “Train the Trainers” system, and it was difficult to get staff released from their clinical duties.
Training in CT scan interpretation had to be repeated because people lost confidence very quickly if they were not using the skills regularly. Training was needed for bed managers. Training emergency department receptionists was difficult because of winter pressures, and training of junior staff and radiographers was slow to be completed.
Technical equipment providers had to run training on multiple occasions, to cater for shift patterns.. There is as yet no procedure in place for training Information technology support staff, for flagging up the training needs of new staff, or how to manage training updating and the ongoing assessment of competency. It is hoped that the rota manager will take some role in keeping records and flagging up training needs.
A core issue for clinicians is that the benefits and limitations of telestroke communication compared to face-to-face communication are unknown. There is the possibility that it may restrict subtle nuances of skilled assessment built over years of experience, which subsequently limits the optimal treatment of the patient. There may also be issues related to preserving privacy and dignity that are less well able to be controlled than in face-to-face consults.
Cultural issues of telestroke communication are raised for everyone involved. It is unlikely that the staff involved in a telestroke assessment will know each other. This can be daunting, and is very stressful for some people. If the system is always active, people might feel that they are being watched. These issues need careful attention during training if people are to feel comfortable.
Wider cultural issues are raised by changing the work relationships between professional groups. There are likely to be some issues of confidence, for example - stroke physicians and neurologists have very different backgrounds and approaches to assessment. Some nervousness was expressed by the radiologists about the stroke physicians interpreting head CT scans. The decision-support provider is very dependent on the bedside referrer, who may have little experience in stroke assessment. Highly skilled staff need to work with and have confidence in others participating in telestroke, whose skills may be less developed e.g. junior doctors on short rotations.
It is envisaged that everyone will link up monthly by cart or laptop to discuss cases. Ongoing multidisciplinary review is part of the telestroke specification document. It is a way of assessing the delivery of the service and the continuous professional development of the clinicians on the rota. It is also to be used as an audit tool and feedback mechanism for the clinicians to look at the efficiency of their local pathway and to examine their own clinical expertise in the interpretation and assessment of CT scans. Clinicians acting as decision-support providers intend to invite consultant neuro-radiologists to multidisciplinary review to discuss the scans and any possible ways to improve their skill in this field, and to determine if they have interpreted any incorrectly.
A digital recording device is built into the technical system. Initially, this needed verbal consent, with an explanation that we would only use the recording for audit and education of the decision-support providers on the rota. The recording was an issue with the video bridge being a major problem for connectivity to the carts from the consultants' laptops. As numerous suggestions were made, the service started without a recording option. New advice from the GMC advised that reordings should only be done if they are to be used as a primary part of the patient's care,for connectivity to the carts from the decision-support providers' laptops.
New guidelines from the UK General Medical Council now advise that recordings should only be done if they are to be used as a primary part of the patient’s care. However, the planned recordings for this service only had a secondary purpose of audit and education. If the recordings are to be used for training purposes then a written consent is required from the patient, which would need to be procured as soon as the patient was well enough. If the patient lacked capacity then the decision was made that no recording would be performed.
Because the recording has an influence on laptop connectivity, a new mechanism is now needed to allow the decision-support provider to start a recording after permission was granted (this is still being worked out). If recordings are taken, a data storage agreement also has to be in place. This specifies what will happen to the videos; who has responsibility for storing them; and for how long. This cannot be done until a process for recording is in place.
The decision-support providers complete the joint decision making form for each consultation. This is sent to the NHS telestroke e-mail account at the relevant patient referral site. The telestroke administrator has access to all these sites so can retrieve them easily and the on-call episode form gets sent directly to the Telestroke Administrator.
We realised early on that the joint decision making form (which was our main method of data collection) was not capturing some information that would be useful. An on-call episode form was also designed to collect information for each on-call episode on: what went well and what went wrong; what decision-support providers were being consulted for; and how long they were being on-call during out-of-hours.
Drawing up a patient satisfaction survey was not easy. The final form was based on a number of other evaluations mainly from the Scottish Centre for Telehealth and East of England Telemedicine for Stroke, and was sent to the Stroke Association for advice on composing an aphasia friendly feedback form.
A pilot and review of the form is in process. Comments made so far include:
- whether an aphasia friendly format will be seen as demeaning to those patients who do not suffer from aphasia?
- whether the form will need translating into other languages across the telestroke network?