1. Needs Assessment

2. System Development

3. Clinical and Operational Implementation

4. Training

5. Evaluation

Case Study

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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

Length of stay
Discharge destination



Monthly Executive Report

Telestroke data communication Flowchart of evaluation data Telestroke Communication diagram
Telestroke data collection Collection and analysis strategy Data collection and analysis strategy
Telestroke commissioning evaluation Evaluation of the service Performance Monitoring for Commissioners
Telestroke Governance reports

Conversion rate
Number of patients eligible/thrombolysed
CT Scan access
Demand on radiology

Governance Reports

Lessons learned from the case study:

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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

Clinical Review Form

Lessons learned from the case study:

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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

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

Interview questions for Operational Leads

Clinical user

Interview questions for clinical users

Patient perspective

Interview questions for patients

Patient satisfaction

“Patient Questionnaire

Lessons learned from the case study:

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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