1. Needs Assessment

2. System Development

3. Clinical and Operational Implementation

4. Training

5. Evaluation

Case Study

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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:

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

Out of Hours Pre-hospital protocol

Protocol: acute stroke A+E/triage/referral

Thrombolysis Protocol diagram

Checklist: exclusion criteria/decision to give tPA

Thombolysis exclusion checklist

CT scan protocol

CT Scan Interpretation out of hours

Stroke thrombolysis pathway

Thrombolysis clinical documentation

Stroke thrombolysis flowchart

Thrombolysis Flowchart

Thrombolysis pathway from ED

Thrombolysis pathway from A&E

Thrombolysis pathway from Medical Assessment Unit

Thrombolysis pathway from MAU

Thrombolysis pathway from ward

Thrombolysis pathway from ward

Nursing care plan for thrombolysis

Integrated care plan

Thrombolysis dosage/administration

Thrombolysis dosage chart

Staff groups’ responsibilities for thrombolysis

Staff responsibilities for thrombolysis

Recording and monitoring

Pre thrombolysis brief clerking record/A&E screen

Pre-thrombolysis A&E screen

Full clerking record

Thrombolysis Clerking Record

CT scan report

This is available electronically via the PACS system


Rosier Checklist


NIHSS record

Telestroke consultation notes

Consultation Notes

Joint assessment checklist

Joint Decision Making Checklist

Review/follow up checklist/record

24hr Clinical Report

Thrombolysis complications

Thrombolysis Complication & Interventions

Observation record

Thrombolysis Observation Record

Pathway variations recording sheet

Thrombolysis Variations from Pathway recording sheet

Thrombolysis timing sheet

Thrombolysis Timing Sheet

Signature record

Thrombolysis Staff Signature Record


Lessons learned from the case study:

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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

Director of Operations briefing

Radiology brief

Radiology briefing

Switchboard brief

Switchboard briefing

Ambulance Service brief

Ambulance briefing

Staff Bulletin

Staff Bulletin

Telestroke system use

Operational policy

Operational Policy

Survey for rota

Survey for consultant rota


Draft consultant rota

Fault management and contingency planning

ASDL Fault Management

ADSL Fault reporting

Telecart Fault Management

System Fault Reporting

Scanner Failure Protocol

CT Scanner Failure Protocol

Contingency planning

Contingency Planning

Lessons learned from the case study:

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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

Patient information leaflet   Patient information leaflet

Patient consent

Initial consent is obtained verbally - written consent is later sought for access to notes or to recording.


Lessons learned from the case study:

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