Section 3: Telestroke Clinical and Operational Implementation
Guidelines suggest that telestroke services need to provide the elements of emergency stroke diagnosis and treatment to a specified level of quality. An organised stroke unit or equivalent should be available for specialised post-thrombolysis monitoring and care. Telestroke consultation should be readily and rapidly available, with medical advice provided in a manner similar to on-site consultations. Documentation of the telestroke consultation should be completed within a reasonable time and transmitted to the patient referring site, but should remain accessible to the decision-support provider. Protocols for telemedicine for stroke should be standardised across sites. Patients and their families should be made aware that telestroke consultation will occur and that they will be asked for permission. 1
Research details potential barriers to telestroke system use in practice:
- Lack of familiarity with the telestroke system can result in low rates of use; 9
- The telestroke system may not be used because it is perceived by clinicians to cause treatment delay, and because of a lack of cultural norms for system use; 5, 6
- Patients may not be presented for telestroke consultation because referring clinicians think that the diagnosis is clear, but this certainty is not borne out by comparison of diagnostic rates; 9
- Technical problems happen, albeit rarely. The most common issues include delays, problems with sound or image quality, or problems with access. 8, 11, 13
| Other telestroke projects detail the implementation tasks and resources to: | Lessons learned from the case study include: |
|---|---|
| 3.1 Develop clinical procedures for telestroke | Where should thrombolysis and post-thrombolysis monitoring take place? Choice needs to suit the resources, preference and history of each site. Who should do next day scans and telestroke outcome reviews? Decision-support providers don’t need to be involved, but do like feedback on patient outcome. Communicating the telestroke clinical decision securely and reliably is complex to organise and ensure in a networked system. |
| 3.2 Develop operational and technical procedures for telestroke | When should decision-support providers be contacted in out-of-hours situations? Monitor how much time people spend on-call and their need for compensatory rest. Going live with the rota and the telestroke system Develop a system to ensure switchboards are using up-to-date rotas. |
| 3.3 Develop guidance for patient involvement in telestroke | Ensuring patient privacy and dignity during a telestroke consultation Patient consent is necessary to use audio-visual recording of the telestroke consultation for audit, evaluation, or training. |
3.1 Develop clinical procedures for telestroke
There should be efficient stroke code policies, and clear parameters for telestroke system use to define criteria for telestroke presentation. 5, 6, 11 There is a suggestion that during telestroke system implementation all patients should be presented via telestroke so that using the telestroke system is a routine and familiar procedure, the time taken is reduced, and accuracy of diagnosis is checked. 9
| Implementation task | Details and Examples | |
|---|---|---|
Pathways, procedures, protocols for telestroke |
Prehospital protocol
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Protocol: acute stroke A+E/triage/referral
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Checklist: exclusion criteria/decision to give tPA
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CT scan protocol
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Stroke thrombolysis pathway
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Stroke thrombolysis flowchart
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Thrombolysis pathway from ED
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Thrombolysis pathway from Medical Assessment Unit
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Thrombolysis pathway from ward
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Nursing care plan for thrombolysis
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Thrombolysis dosage/administration
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Staff groups’ responsibilities for thrombolysis
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| Recording and monitoring | Pre thrombolysis brief clerking record/A&E screen
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Full clerking record
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CT scan report This is available electronically via the PACS system |
ROSIER
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NIHSS
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Telestroke consultation notes
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Joint assessment checklist
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Review/follow up checklist/record
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Thrombolysis complications
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Observation record
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Pathway variations recording sheet
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Thrombolysis timing sheet
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Signature record
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Lessons learned from the case study:
- Where should thrombolysis and post-thrombolysis monitoring take place?
- Who should do next day scans and telestroke outcome reviews?
- Communicating the telestroke clinical decision securely
3.2 Operational and technical procedures
When operational, people need to have confidence that the system will work reliably. Monitor technical failures; have a system for rapid access to technical support; develop a detailed troubleshooting guide; and have a plan for what to do if the system fails. 8
| Implementation task | Details and Examples | |
|---|---|---|
| System “go live” briefs | Director of Operations brief
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Radiology brief
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Switchboard brief
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Ambulance Service brief
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Staff Bulletin
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| Telestroke system use | Operational policy
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Survey for rota
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Rota
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| Fault management and contingency planning | ASDL Fault Management  |
Telecart Fault Management  |
Scanner Failure Protocol
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Contingency planning
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Lessons learned from the case study:
- When should decision-support providers be contacted in out-of-hours situations?
- Going live with the rota and the telestroke system
3.3 Develop guidance for patient involvement in telestroke
Patients may need preparation for participation in telestroke. 8
| Implementation task | Details and Examples |
|---|---|
| Patient information for telestroke | Generic example
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| Patient consent | Initial consent is obtained verbally - written consent is later sought for access to notes or to recording.
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Lessons learned from the case study:
