Remote Assessment for IV Thrombolysis of Ischemic Stroke
Remote Assessment for IV Thrombolysis of Ischemic Stroke
Northumbria Healthcare NHS Foundation Trust is an acute and elective healthcare provider for one of the largest geographical areas in England. Three district general hospitals provide healthcare to 550 000 people living in Northumberland and North Tyneside. A single stroke service comprising six stroke physicians admits approximately 1000 patients a year across three ED sites, each with a specialist acute stroke unit. Given the large distances between sites, it was not possible to establish (a) a local service where all patients who were potentially eligible for thrombolysis were reviewed by a specialist in person outside office hours or (b) a service which ensured timely transfer of patients to a centralised stroke unit. In 2007, a telephone-based telemedicine service was established to provide a 24 h specialist opinion to all three sites during the ED assessment of patients who might be suitable for thrombolysis.
Medical and nursing staff from each ED attended a standardised training session for familiarisation with a protocol including initial stroke identification by Recognition Of Stroke In the Emergency Room (ROSIER) Score, awareness of the National Institute of Health Stroke Scale (NIHSS) for measurement of neurological deficit, recognition of patients suitable for thrombolysis according to standard criteria, request for urgent brain imaging, appropriate timing of stroke physician contact, thrombolysis delivery and monitoring of patients immediately afterwards. This process was described in a structured thrombolysis pathway document specifically aimed at identifying and managing patients suitable for intravenous thrombolysis treatment. The treatment algorithm is summarised in figure 1.
(Enlarge Image)
Figure 1.
Northumbria ED stroke thrombolysis protocol.
Thrombolysis treatment decisions were made only by a stroke physician. If potential thrombolysis candidates were identified in any ED between 08:00 and 18:00 h on weekdays then the ED registrar or consultant contacted a site-based stroke physician about the possibility of an urgent specialist review in person. At all other times, or if the local stroke physician was not quickly available at any time owing to scheduled commitments, patients with thrombolysis potential were discussed by telephone with the stroke physician on-call (SPOC) providing advice for all three sites. The SPOC remotely viewed brain imaging over a secure internet-based digital imaging system and made a treatment decision based upon the structured clinical information provided by the ED medical staff. They did not speak to, or remotely view, the patient. All treated patients were moved to a suitable setting for close observation and reviewed within 24 h by a stroke physician. Feedback was provided to ED staff via newsletter about adherence to the protocol and treatment outcomes. All patients had a repeat brain imaging at 24–48 h. Anonymous details of patients treated with thrombolysis were recorded on the Safe Implementation of Treatments in Stroke (SITS) database. For audit purposes, an internal record was also made of the mode of thrombolysis assessment—that is, purely by telephone or whether a stroke physician was present at any time before the treatment decision was made. There was no systematic record kept of patients who were assessed for thrombolysis but not treated.
Using SITS records between 6 September 2007 and 1 October 2010, we retrospectively examined the details of patients given thrombolysis for acute stroke when a stroke physician was present and those in the same service when the SPOC made a treatment decision by telephone. Outcome measures were 90 day combined death and dependency based upon a split of 0–2 on the modified Rankin Scale (mRS) for a good outcome and 3–6 for a poor outcome, including death, day 7 change from baseline NIHSS, presence of haemorrhage on second scan (symptomatic and asymptomatic) and inpatient mortality. Symptomatic haemorrhage was defined by a deterioration of at least four points on the NIHSS with a responsible haemorrhagic change on repeat brain imaging. If data were incomplete, hospital records were reviewed by a clinician. All information collected had local data protection approval. Ethical approval was not required.
Methods
Northumbria Healthcare NHS Foundation Trust is an acute and elective healthcare provider for one of the largest geographical areas in England. Three district general hospitals provide healthcare to 550 000 people living in Northumberland and North Tyneside. A single stroke service comprising six stroke physicians admits approximately 1000 patients a year across three ED sites, each with a specialist acute stroke unit. Given the large distances between sites, it was not possible to establish (a) a local service where all patients who were potentially eligible for thrombolysis were reviewed by a specialist in person outside office hours or (b) a service which ensured timely transfer of patients to a centralised stroke unit. In 2007, a telephone-based telemedicine service was established to provide a 24 h specialist opinion to all three sites during the ED assessment of patients who might be suitable for thrombolysis.
Medical and nursing staff from each ED attended a standardised training session for familiarisation with a protocol including initial stroke identification by Recognition Of Stroke In the Emergency Room (ROSIER) Score, awareness of the National Institute of Health Stroke Scale (NIHSS) for measurement of neurological deficit, recognition of patients suitable for thrombolysis according to standard criteria, request for urgent brain imaging, appropriate timing of stroke physician contact, thrombolysis delivery and monitoring of patients immediately afterwards. This process was described in a structured thrombolysis pathway document specifically aimed at identifying and managing patients suitable for intravenous thrombolysis treatment. The treatment algorithm is summarised in figure 1.
(Enlarge Image)
Figure 1.
Northumbria ED stroke thrombolysis protocol.
Thrombolysis treatment decisions were made only by a stroke physician. If potential thrombolysis candidates were identified in any ED between 08:00 and 18:00 h on weekdays then the ED registrar or consultant contacted a site-based stroke physician about the possibility of an urgent specialist review in person. At all other times, or if the local stroke physician was not quickly available at any time owing to scheduled commitments, patients with thrombolysis potential were discussed by telephone with the stroke physician on-call (SPOC) providing advice for all three sites. The SPOC remotely viewed brain imaging over a secure internet-based digital imaging system and made a treatment decision based upon the structured clinical information provided by the ED medical staff. They did not speak to, or remotely view, the patient. All treated patients were moved to a suitable setting for close observation and reviewed within 24 h by a stroke physician. Feedback was provided to ED staff via newsletter about adherence to the protocol and treatment outcomes. All patients had a repeat brain imaging at 24–48 h. Anonymous details of patients treated with thrombolysis were recorded on the Safe Implementation of Treatments in Stroke (SITS) database. For audit purposes, an internal record was also made of the mode of thrombolysis assessment—that is, purely by telephone or whether a stroke physician was present at any time before the treatment decision was made. There was no systematic record kept of patients who were assessed for thrombolysis but not treated.
Using SITS records between 6 September 2007 and 1 October 2010, we retrospectively examined the details of patients given thrombolysis for acute stroke when a stroke physician was present and those in the same service when the SPOC made a treatment decision by telephone. Outcome measures were 90 day combined death and dependency based upon a split of 0–2 on the modified Rankin Scale (mRS) for a good outcome and 3–6 for a poor outcome, including death, day 7 change from baseline NIHSS, presence of haemorrhage on second scan (symptomatic and asymptomatic) and inpatient mortality. Symptomatic haemorrhage was defined by a deterioration of at least four points on the NIHSS with a responsible haemorrhagic change on repeat brain imaging. If data were incomplete, hospital records were reviewed by a clinician. All information collected had local data protection approval. Ethical approval was not required.
