Section 5: Telestroke Evaluation

Guidelines Telestroke should include the collection of national quality measures. Continuous quality improvement activities should include: assessment of adoption and use of the telestroke technology; rates of technical and human failures related to the system; and needs for training and maintaining competency. The results of these activities should be shared across the network. 1

Research mainly focuses on monitoring clinical processes and outcomes, including: time from onset to admission, scan, lab values, request for consult, completion of assessment, to tPA treatment; in order to identify the potential for shortening onset-to-treatment time.9 Hypotheses about how telestroke might improve outcome suggest also monitoring system use, impact on decision making, and acceptability. 5, 6, 7, 8, 9, 13

Other telestroke projects detail the implementation tasks and resources to:	Lessons learned from the case study include:
5.1 Monitor clinical processes and outcomes of telestroke	Ongoing multidisciplinary review of telestroke consultations Data recording of the telestroke consultation
5.2 Monitor telestroke system use and impact on decision making	Information about telestroke that was not being collected
5.3 Monitor fidelity, quality, and acceptability	Difficulty of measuring patient satisfaction of the telestroke experience
5.4 System sustainability, expansion, modification

5.1 Monitor clinical processes and outcomes of telestroke

Measure time from onset to: admission, scan, lab values, request for consult, completion of assessment, tPA treatment; to identify potential for shortening onset to treatment time. 9

Evaluation areas	Detail	Example
Clinical and organisational processes and outcomes	Time from stroke event/admission to: triage, scan, assessment, tPA administration Completeness of data tPA rates % treatment with tPA within time limit Transfer frequency/avoidance Mortality Complications Function Length of stay Cost Discharge destination
Telestroke data communication	Flowchart of evaluation data
Telestroke data collection	Collection and analysis strategy
Telestroke commissioning evaluation	Evaluation of the service
Telestroke Governance reports	Activity Conversion rate Number of patients eligible/thrombolysed Gender CT Scan access Demand on radiology Benefits

Lessons learned from the case study:

5.2 Monitor telemedicine system use and impact on decision making

Evaluate how access to specialists is used, and its wider value to users. Monitor the prevalence of system use and non-use for stroke and non-stroke diagnoses. Record the change from suspected stroke to primary diagnosis of stroke. 9

Evaluation areas	Detail	Example
Telestroke system use	Time of use/consult duration Purpose of consultation Documentation transfer TM consultation rates per physician/site/time	Information provided by system provider
Telestroke decision processes	Reasons for TM non-use/delay Information sufficient for decision making? Advice followed? Decision agreement Decision accuracy Change of diagnosis Frequency of stroke diagnosis

Lessons learned from the case study:

Information about telestroke that was not being collected

5.3 Monitor fidelity, quality, and acceptability

Staff may be reluctant to sustain use of a telestroke system if they lack confidence or if the system is time-consuming. 5-6 Monitor the pattern and frequency of use of the system and explore any problems. 7, 8, 9

Evaluation areas	Details and Examples
Fidelity/quality	Technical problems Protocol violations Equipment quality – sound, vision	Provided by system provider and reported in Executive Monthly Report
Satisfaction	Interview schedules for the ASTUTE project
	*Operational lead*	*Clinical user*
	*Patient perspective*	*Patient satisfaction*

Lessons learned from the case study:

Difficulty of measuring patient satisfaction of the telestroke experience

5.4 System sustainability, expansion, and modification

Keep under review the cost-benefit ratio of maintaining a telestroke system versus on-site service development, based on research outcomes for different systems. Consider options for expansion and staffing: the use of stroke nurse practitioners for assessment and delivery of treatment did not present safety or treatment issues in two studies. 7, 12 Stage network expansion processes. 7, 9, 13