ASTUTE: Acute Stroke Telemedicine: Utility Training and Evaluation Implementing Telemedicine in Acute Stroke and the development of a Standardised Telemedicine Tookit Lancashire Teaching Hsopitals NHS Foundation Trust Poster from the 'Delivering NHS services, seven days a week' event held in Birmingham on 16 November 2013 More information about this event can be found at http://www.nhsiq.nhs.uk/news-events/events/nhs-services-seven-days-a-week.aspx

1. ASTUTE: Acute Stroke Telemedicine: Utility Training and Evaluation
Implementing Telemedicine in Acute Stroke and the development of a Standardised Telemedicine Tookit
CE Lightbody1, A McLoughlin1&2 , J Fitzgerald1, JME Gibson1, JJ McAdam1, K Blacker3, P Davies4, E Day3, H Emsley2, G Ford5, B French1, A Gibson1,
1, C May6, M O’Donnell7, C Price8, C Sutton9, CL Watkins1 1Clinical Practice Research Unit, University of Central Lancashire; 2Lancashire Teaching Hospitals NHS Foundation Trust;
MJ Leathley
3Cardiac
and Stroke Networks in Lancashire and Cumbria; 4North Cumbria University Hospitals NHS Trust; 5Institute for Ageing & Health, Newcastle University; 6School of Health Sciences, University of Southampton;
7Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust, 8Northumbria Healthcare NHS Trust; 9 Lancashire Clinical Trials Unit, University of Central Lancashire.
BACKGROUND
Patient outcomes in acute stroke are improved by timely access to specialist
consultation and treatment. Telemedicine may ensure earlier and wider access
to stroke-specialist consultation and enhance emergency assessment and
treatment. To facilitate NHS implementation of telemedicine in acute stroke,
we examined existing networks to inform development of standardised
systems for new networks in a four-phase project.
PHASE 1- Toolkit Development
We constructed an on-line Standardised Telemedicine Toolkit (STT). The STT
details implementation tasks and challenges for development of a
telemedicine system. Material for the STT came from 3 main sources:
Systematic review, Content analysis of existing implementation resources,
and a UK telemedicine project case study.
The STT is at http://www.astute-telestroke.org.uk/.
PHASE 2- Exploration of staff, patient, and carer views of the
acceptability of the STT.
Semi-structured interviews were undertaken with staff (n=19) and patients
and/or carers (n=24) who had recently experienced a telemedicine
consultation. Structured questionnaires (n=169) returned from patients who
received telemedicine across the network were also analysed.
Staff - Key challenges were: concerns that subtle factors could be missed;
standardisation of procedures across sites; issues of trust, confidence and
skills between sites; feedback on patient outcomes.
Benefits included the opportunity to engage in expert teaching of junior
medical staff via the telemedicine process.
Patients and Carers - Themes included: information and understanding of
telemedicine; telemedicine process; support during the process; evaluation of
telemedicine. Telemedicine appeared to be
well-accepted and understood by patients and carers. Staff interpersonal skills
and teamwork contributed to overcoming concerns about “remote”
consultation.
Questionnaires- Feedback was generally positive: patients reported that
telemedicine was a good way to get immediate expert treatment. Negative
experiences included communication; training with equipment; uncertainty of
what was happening. To address this, scripts for staff were included in the
STT.
PHASE 3- Testing feasibility of clinical decision making in
telemedicine.
Twenty-six telemedicine consultations were recorded, edited and presented
with accompanying case histories. The correct ‘gold standard’ diagnoses were
16 strokes and 10 non-strokes. Staff were asked to assess a sample of 6 of the
26 consultations and to rate how confident they were with each of their
diagnosis decisions. 40 raters: 13 stroke physicians, 15 nurses, 3 ED
consultants, 8 registrars and 1 neurologist; ED consultants, registrars and
neurologist were combined as an ED group. The median number of raters for
each consultation was 8.
Data were analysed using Cohen’s kappa (K) with 95% confidence interval
(CI) calculated using bias-corrected bootstrapping in STATA with 10000
replicates. Sensitivity and specificity were estimated.
Agreement was ‘fair’ overall and was similar for all groups, although CIs
were wide. There was no significant difference between nurses’, stroke
physicians’, or ED doctors’ agreement or accuracy of diagnosis when rating
the telemedicine consultations.
PHASE 4- Exploration of mode of assessment on door-to-needle time and
patient outcome.
SINAP (Stroke Improvement National Audit Programme) data from hospitals
in Lancashire and Cumbria, and the DASH (Developing and Assessing
Services for Hyperacute stroke) database, funded by NIHR, were utilised.
Only patients admitted out of hours and given thrombolysis were included in
the analysis, whether assessed via telemedicine, or face-to-face.
Cox regression modelling was used to investigate factors, including mode of
assessment, affecting door-to-needle time; given the known differences
between speed of assessment at different hospitals, adjustment for hospital
was also performed to reduce confounding.
281 patients had thrombolysis out of hours either by telemedicine (n=101) or
face to face (n=138). Groups had similar age, sex and FAST positive
status. The main analysis excluded those assessed via telephone (n=42) and
with missing/incorrect sequences of times, reducing the sample to 223 (94
telemedicine, 129 face to face). Age significantly affected door-to-needle time
(p=0.002) with increasing age being associated with a shorter time (sex
[p=0.85] and being ‘FAST positive’ [p=0.34] were non-significant).
Adjusting for age and hospital, the effect of mode (telemedicine vs face to
face) on door-to-needle time was non-significant (hazard ratio=1.33; CI 0.862.08, p=0.21). Hospital had a strong and highly significant (p<0.001) effect on
door-to-needle time.
There was no significant difference in length of stay on the stroke unit
(telemedicine [n=75]: mean [sd] 22.8 [26.6] days; face to face [n=119]: mean
[sd] 19.0 [22.9] days; p=0.29) or complication rates (telemedicine 13/101
[13%]; face to face12/128 [9%]; p=0.40) between those assessed by
telemedicine and face to face.
When adjusted for age and hospital, the mode of thrombolysis decisionmaking did not have a statistically significant effect on the door-to-needle
time, although the estimated hazard ratio was consistent with quicker
assessment when telemedicine was used. The difference in complication rates
was not statistically significant, but the study was not powered to detect
absolute differences of the magnitude observed.
EXPECTED IMPACT
Telemedicine in acute stroke was acceptable to patients and staff. Patients are
receiving timely access to stroke-specialist assessment and treatment via
telemedicine without outcomes, experiences and satisfaction being
significantly affected. The STT has had 234 hits since Feb 2013,
nationally/internationally, suggesting it is a useful resource. We are exploring
the utility of the STT in other settings.
For further information, please e-mail: celightbody@uclan.ac.uk
This poster summarises independent research funded by the National Institute for Health Research
(NIHR) under its Research for Patient Benefit Programme (Grant Reference Number PB-PG-120818280). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR
or the Department of Health.