Stroke
Conditions
Keywords
Telestroke, Telemedicine, Stroke, Secondary stroke prevention
Brief summary
TELEstroke for Comprehensive Stroke Care in Acute Stroke Ready HospiTals (TELECAST) is a prospective single-center study evaluating guideline-based acute ischemic stroke care at an Acute Stroke Ready Hospital (ASRH) pre- and post-initiation of a specialist telestroke inpatient rounding service. TELECAST will study the following clinical endpoints: diagnostic stroke evaluation, secondary stroke prevention, health screening and evaluation, stroke education, inpatient complications, and stroke recurrence rates. Additional relevant non-clinical data will include patient and provider satisfaction scores, transfer patterns, and a cost analysis.
Detailed description
Telestroke is a validated intervention that improves the triage and emergent treatment of acute stroke, specifically related to the use of intravenous thrombolysis. Effective urgent stroke evaluation and secondary stroke prevention is also essential to decrease the risk of recurrent stroke, however, there have been no studies to date examining the use of telestroke to improve delivery of non-emergent inpatient stroke care per American Heart Association (AHA) guidelines. Currently, access to stroke specialist expertise is limited resulting in significant disparities in stroke care. Previous publications have identified that patients in rural areas may receive sub-optimal stroke care that does not follow accepted guideline recommendations. Telestroke is a cost-effective mechanism to deliver specialist stroke care to hospitals that do not have in-person stroke consultation available. The aim of TELECAST is to determine whether specialist telestroke inpatient rounding improves guideline-based acute stroke care when compared to non-specialist stroke care. The primary outcome of TELECAST is a composite score comprising 4 categories: diagnostic stroke evaluation, secondary stroke prevention, health screening and evaluation, and stroke education. Individual components of the primary outcome were primarily derived from AHA stroke guidelines. Additional outcome measures include individual analyses of the components of the primary outcome as well as the complication rate, stroke recurrence rate, transfer rate, patient and provider satisfaction levels, and a cost-analysis. All outcomes will be assessed at 1 year post-implementation, with data accruement beginning after a 3-month lead in phase.
Interventions
OTHERTelestroke
Telestroke is an audiovisual communication network that allows for coordination of stroke care from a distant 'hub' site (the telestroke provider location) to an originating 'spoke' site (patient location) in a HIPAA compliant fashion. In TELECAST, inpatient telestroke rounding will be used to oversee the urgent diagnostic stroke evaluation, secondary stroke prevention, health screening & evaluation, and stroke education in patients admitted with stroke.
Sponsors
University of Minnesota
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age 18 and above * Patients with the primary diagnosis of ischemic stroke admitted to Fairview Ridges Hospital * Evidence of stroke on MRI or CT or clinical diagnosis of acute ischemic stroke by the treating stroke service
Exclusion criteria
* Patients less than 18 years old * Patients who leave the hospital against medical advice * Patients with goals of care that impact the stroke evaluation (i.e. comfort measures) * Patients who are felt to have an alternative diagnosis * Patients who are transferred for higher-level stroke care such as endovascular thrombectomy or decompressive craniectomy
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Composite score of inpatient stroke care (%) | 1 year after implementation of the inpatient telestroke service | A 23-item global assessment of fundamental inpatient acute ischemic stroke care primarily informed by AHA guidelines/GWTG criteria comprising 4 categories: * Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, troponin, head CT or brain MRI, intracranial vascular imaging, cervical vascular imaging, EKG, telemetry, and outpatient prolonged cardiac monitoring. * Secondary prevention (6 items): antiplatelet, anticoagulation, statin, antihypertensives, diabetes management, and carotid revascularization. * Health screening & evaluation (4 items): swallow evaluation, cognitive assessment, depression screening, and rehabilitation evaluation. * Stroke education (3 items): tobacco cessation counseling, exercise/lifestyle counseling, and signs of stroke. An item is not scored when not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Diagnostic Stroke Evaluation | 1 year after implementation of the inpatient telestroke service | A 10-item global assessment of inpatient diagnostic stroke evaluation as well as individual analysis of each item. Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, troponin, head CT or brain MRI, intracranial vascular imaging, cervical vascular imaging, EKG, telemetry, and outpatient prolonged cardiac monitoring. An item is not scored when not indicated clinically (for example prolonged cardiac monitoring in a patient with known atrial fibrillation), therefore the composite scores will be reported and analyzed as percentages. |
| Secondary Stroke Prevention | 1 year after implementation of the inpatient telestroke service | A 6-item global assessment of secondary stroke prevention as well as individual analysis of each item. Secondary stroke prevention (6 items): antiplatelet, anticoagulation, statin, antihypertensives, diabetes management, and carotid revascularization. An item is not scored when not indicated clinically (for example deferring antiplatelet agents if a patient requires anticoagulation), therefore the composite scores will be reported and analyzed as percentages. |
| Health Screening & Evaluation | 1 year after implementation of the inpatient telestroke service | A 4-item global assessment of health screening and evaluation as well as individual analysis of each item. Health screening & evaluation (4 items): swallow evaluation, cognitive assessment, depression screening, and rehabilitation evaluation. An item is not scored when not indicated clinically, therefore the composite scores will be reported and analyzed as percentages. |
| Stroke Education | 1 year after implementation of the inpatient telestroke service | A 3-item global assessment of stroke education as well as individual analysis of each item. Stroke education (3 items): tobacco cessation counseling, exercise/lifestyle counseling, and signs of stroke. An item is not scored when not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. |
| Composite Stroke Recurrence | Measured at 3 months and at 1 year after discharge | The composite rate of recurrent TIA, ischemic, or hemorrhagic stroke at 3 months and one year post-stroke admission. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Telestroke feasibility | 1 year after implementation of the inpatient telestroke service | Descriptive data related to the feasibility of telestroke implementation will be collected. This includes time from admission to when the patient is seen, duration of telestroke screen time, and physician, patient, and nursing satisfaction. |
| Hospital Length of Stay | 1 year after implementation of the inpatient telestroke service | The number of days of hospitalization for patients admitted with a primary diagnosis of stroke. |
| Composite score of fundamental inpatient stroke care at the CSC hub site (%) | 2 years retrospective data and 1 year prospective data after implementation of the inpatient telestroke service at the participating ASRH | A 23-item assessment of fundamental inpatient stroke care (see primary outcome) at the CSC hub site. This data will serve to compare the delivery of inpatient stroke care via inpatient telestroke vs. stroke care delivered in person at the hub site. An item is not scored if it is not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. |
| 14. Composite score of fundamental inpatient stroke care at non-telestroke ASRHs (%), including Fairview Hospitals: Range, Grand Itasca, Lakes, and Northland | 2 years retrospective data and 1 year prospective data after implementation of the inpatient telestroke service at the participating ASRH | A 23-item assessment of fundamental inpatient stroke care (see primary outcome) at ASRHs within the same stroke network that do not have an inpatient telestroke service. These scores will serve as temporal controls for the primary outcome. An item is not scored if it is not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. |
| Acute Stroke Care | 1 year after implementation of the inpatient telestroke service | Appropriate and timely delivery of acute stroke interventions per AHA guidelines. |
| Transfer patterns | 1 year after implementation of the inpatient telestroke service | Transfer rate and discharge destinations. We will also study the impact of changing transfer patterns on baseline patient demographics of the inpatient stroke service at the participating ASRH. |
| Inpatient complications | 1 year after implementation of the inpatient telestroke service | Inpatient complications include: hemorrhagic transformation, UTI, PE, pneumonia, DVT, falls, stage II or greater decubitus ulcers, and mortality. |
| Provider and patient satisfaction | 1 year after implementation of the inpatient telestroke service | Provider and patient satisfaction with the telestroke service will be assessed with a questionnaire administered to providers and patients receiving the service. |
| Cost analysis | 1 year after implementation of the inpatient telestroke service | A cost analysis incorporating the spoke site and the central (hub) site will be performed. Data collected will include hospital cost of admission, hospital admission reimbursement, transfer costs, and operational costs. |
Countries
United States
Outcome results
None listed