Johannes Schenkel

Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany.

BACKGROUND Telemedical networks are a new approach to improve stroke care in community settings. We aimed to assess the effects of a stroke network with telemedical support in Germany on quality of care, according to acute processes and long-term outcome. METHODS Five community hospitals without pre-existing specialised stroke care were included in a network with telemedical support by two academic hospitals. In a non-randomised, open intervention study, five community hospitals without specialised stroke care served as the control group, matched individually to the network hospitals by predefined characteristics. Stroke patients admitted consecutively to one of the participating hospitals between July 7, 2003, and March 31, 2005, were included in the study. Patients in network and control hospitals were assessed in the same manner and were followed up for vital status, living situation, and disability at 3 months. Poor outcome was defined by death, institutional care, or disability (Barthel index <60 or modified Rankin scale >3). Predefined indicators for quality of acute stroke care were achieved. FINDINGS A total of 5696 patients with a sudden, non-convulsive loss of neurological function who were diagnosed with having suspected stroke were admitted to the ten hospitals participating in the study. After exclusion, 3122 were included in the final analysis, of whom 1971 (63%) were treated in the network hospitals. All indicators related to quality of acute stroke care were more commonly met in the network than in the control hospitals. After 3 months, 44% of patients treated in network hospitals versus 54% treated in control hospitals had a poor outcome (p<0.0001). In multivariate regression analysis, treatment in network hospitals independently reduced the probability of a poor outcome (odds ratio 0.62, 95% CI 0.52-0.74; p<0.0001). INTERPRETATION Telemedical networks with academic stroke centres offer new and innovative approaches to improve acute stroke care at community level for stroke patients living in non-urban areas.

Telemedicine for Safe and Extended Use of Thrombolysis in Stroke The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria

Background and Purpose— Systemic thrombolysis represents the only proven therapy for acute ischemic stroke, but safe treatment is reported only in established stroke units. One major goal of the ongoing Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria is to extend the use of tissue plasminogen activator (tPA) treatment in nonurban areas through telemedic support. Methods— The stroke centers in Munich-Harlaching and in Regensburg established a telestroke network to provide consultations for 12 local hospitals in eastern Bavaria. The telemedic system consists of a digital network that includes a 2-way video conference system and CT/MRI image transfer with a high-speed data transmission up to 2 Mb/s. Each network hospital established specialized stroke wards in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 hours per day. Results— A total of 106 systemic thrombolyses were indicated via teleconsultations between February 1, 2003, and April 7, 2004. During the first 12 months, the rate of thrombolyses was 2.1% of all stroke patients. Mean age was 68 years, and median National Institutes of Health Stroke Scale score was 13. Mean delay between onset and hospital admission was 65 minutes, and door-to-needle time was on average 76 minutes, which included 15 minutes for the teleconsultation. Symptomatic hemorrhage occurred in 8.5% of patients, and in-hospital mortality was 10.4%. Conclusions— The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas.

Comparison of tissue plasminogen activator administration management between Telestroke Network hospitals and academic stroke centers: the Telemedical Pilot Project for Integrative Stroke Care in Bavaria/Germany.

Background and Purpose— Systemic thrombolysis is the only therapy proven to be effective for ischemic stroke. Telemedicine may help to extend its use. However, concerns remain whether management and safety of tissue plasminogen activator (tPA) administration after telemedical consultation are equivalent in less experienced hospitals compared with tPA administration in academic stroke centers. Methods— During the second year of the ongoing Telemedical Pilot Project for Integrative Stroke Care, all systemic thrombolyses in stroke patients of the 12 regional clinics and the 2 stroke centers were recorded prospectively. Patients’ demographics, stroke severity (National Institutes of Health Stroke Scale), frequency of administration, time management, protocol violations, and safety were included in the analysis. Results— In 2004, 115 of 4727 stroke or transient ischemic attack patients (2.4%) in the community hospitals and 110 of 1889 patients in the stroke centers (5.8%) received systemic thrombolysis. Prehospital latencies were shorter in the regional hospitals despite longer distances. Door to needle times were shorter in the stroke centers. Although blood pressure was controlled more strictly in community hospitals, symptomatic intracerebral hemorrhage rate (7.8%) was higher (P=0.14) than in stroke centers (2.7%) but still within the range of the National Institute of Neurological Disorders and Stroke trial. In-hospital mortality rate was low in community hospitals (3.5%) and in stroke centers (4.5%). Conclusions— Although with a lower rate of systemic thrombolysis, there was no evidence of lower treatment quality in the remote hospitals. With increasing numbers of tPA administration and growing training effects, the telestroke concept promises better coverage of systemic thrombolysis in nonurban areas.

Long-Term Effects of Specialized Stroke Care With Telemedicine Support in Community Hospitals on Behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS)

Background and Purpose— Stroke unit treatment is effective in reducing death and dependency after stroke but is not available in many, particularly rural, areas. The implementation of a stroke network with telemedicine support was associated with improved outcome at 3 months. We report follow-up results at 12 and 30 months after acute stroke. Methods— Telemedical Project for Integrative Stroke Care (TEMPiS) consists of the set-up of specialized local stroke wards, continuous medical education, and telemedical consultation for patients with acute stroke by 2 stroke centers. In a prospective, nonrandomized, intervention study, 5 community hospitals participating in the network were compared with 5 matched control hospitals without specialized stroke facilities or telemedical support. All patients with consecutive ischemic or hemorrhagic stroke admitted between July 2003 and March 2005 were evaluated. Outcome “death and dependency” was defined by death, institutional care, or disability (Barthel index <60 or Rankin scale >3). Results— We followed-up 3060 patients (1938 in TEMPiS and 1122 in control hospitals). Follow-up rates were 97.2% after 12 months and 95.9% after 30 months for death or institutional care, and 96.5% after 12 months and 95.7% after 30 months for death and dependency. In multivariable regression analysis, there was no significant effect of the TEMPiS intervention for reduced “death or institutional care” at 12 months (OR, 0.89; 95% CI, 0.75–1.07; P=0.23) and 30 months (OR, 0.93; 95% CI, 0.78–1.11; P=0.40) but a significant reduction of “death and dependency” at 12 months (OR, 0.65; 95% CI, 0.54–0.78; P<0.01) and 30 months (OR, 0.82; 95% CI, 0.68–0.98; P=0.031). Conclusions— Implementing a system of specialized stroke wards, continuing education, and telemedicine in community hospitals offers long-term benefit for acute stroke patients.

Can Telemedicine Contribute to Fulfill WHO Helsingborg Declaration of Specialized Stroke Care

Background: Providing stroke unit treatment for all stroke patients is a cross-national goal as stated in the WHO Helsingborg Declaration. In order to achieve specialized stroke care for a large area, two stroke centers and 12 community hospitals established an integrative stroke network. This evaluation was performed to analyze achieved advances in stroke management. Methods: Core network elements are: (1) establishing stroke wards in all hospitals; (2) continuous training in stroke treatment; (3) telemedicine service staffed by a 24 h/day ‘strokologist’ with capability for high-speed videoconferencing and transfer of CT/MRI images. Data were prospectively documented in the databank of the telestroke service, in the Bavarian Stroke Registry and in the controlling departments. Results: In 2003, 4,179 stroke patients were admitted to the regional network hospitals. Between February 2003 and January 2004 a total of 2,182 teleconsultations were conducted. 250 teleconsultations yielded a nonvascular diagnosis. Indicators for stroke management quality improved compared with other hospitals without stroke unit: the frequency of CT/MRI within 3 h was 59% compared to 46%, frequency of speech therapy 36% (21%), and of occupational therapy 38% (12%). Eighty-six (2.1%) of the patients received systemic thrombolysis compared to 10 patients in the preceding year. Mean length of in-hospital stay decreased from 12.4 in 2002 to 9.7 days in 2003. Conclusions: This stroke network concept leads to a substantial improvement of stroke management. Telemedicine contributes to an early etiological assessment and fills the gap of specialized stroke expertise in neurologically underserved areas.

The use of telemedicine in combination with a new stroke-code-box significantly increases t-PA use in rural communities

AbstractBackground: The benefit of tissue plasminogen activator (t-PA) is strongly associated with the time to treatment. In Bavaria, Germany, only half of the population has the opportunity to be transferred to 1 of the 19 stroke units within the critical time window of less than 3 hours. The aim of this study was to investigate the benefit of a new stroke-code-box for t-PA thrombolysis combined with a telemedicine network system to increase the use of acute stroke thrombolysis. Methods: Two specialized stroke centers in Germany established a 24-hour telemedicine network (Telemedicine Pilot Project of an Integrated Stroke Care [TEMPiS]) to advise 12 community hospitals in eastern Bavaria. These clinics are linked via telemedicine in a 24-hour/7-day service network that allows patients to be examined by experts via a video-conference system Additionally, a special stroke-code-box for acute t-PA thrombolysis was designed to reduce time in the application and documentation process. Results: In the 12-month period before implementation of the TEMPiS network system, 10 patients had received systemic thrombolysis. In our 6-month study period (from July to December 2003) and after implementation of a stroke-code-box for t-PA thrombolysis within the telestroke network, 164 patients with acute stroke were presented with t-PA treatment indications. Of this patient population, 27.4% (45 of 164) received t-PA. Conclusions: Stroke care, including t-PA thrombolysis in non-urban areas, is feasible using a modern stroke unit concept within a telestroke network. With the expertise of specialized stroke centers accessed via telemedicine and the design of a stroke-code-box for t-PA thrombolysis, nearly one-third of patients presented with a possible indication for systemic thrombolysis can be treated with t-PA, thereby increasing the options for a successful stroke treatment.

Admission Facility Is Associated With Outcome of Basilar Artery Occlusion

Background and Purpose— Basilar artery occlusion (BAO) is a stroke subtype with poor prognosis, but recanalizing therapies have been reported to be effective. We investigated whether initial admission to telemedically linked general hospitals with subsequent stroke-center transfer is related to poorer outcome than direct admission to stroke centers. Methods— All BAO cases of 3 stroke centers in Munich and 1 center in Regensburg between March 1, 2003 and December 31, 2004 were included, either if patients were directly admitted to stroke centers (n=23) or had initial admission to general hospitals of the telemedical network for integrative stroke care (TEMPiS) and secondary transfer to stroke centers (n=16). BAO was defined as angiographically (CTA, MRI or conventional angiography) confirmed occlusion of the basilar artery. Baseline parameters and therapeutic procedures were recorded. One-year follow-up was conducted prospectively. Results— Differences in baseline parameters were not statistically significant. Time from onset to first angiography was significantly longer in patients with secondary transfer (mean: 355±93 minutes versus 222±198 minutes; P<0.01), mainly attributable to transfer duration (mean:156±73 minutes). In-hospital mortality (22% versus 75%; P<0.01) and 1-year-mortality (30% versus 81%; P<0.01) were lower for patients with direct admission to stroke centers. Fifty-two percent of directly admitted patients versus 13% of patients with secondary transfer (P=0.02) were living at home after 1 year. Conclusions— BAO patients who were admitted primarily to community hospitals had a worse prognosis. Patients with typical symptoms should have direct access to stroke centers, or may need bridging therapies.

Is Mobile Teleconsulting Equivalent to Hospital-Based Telestroke Services?

Background and Purpose— Telemedicine is increasingly used to provide acute stroke expertise for hospitals without full-time neurological services. Teleconsulting through mobile laptop computers may offer more flexibility compared with hospital-based services, but concerns about quality and technical reliability remain. Methods— We conducted a controlled trial, allocating hospital-based or mobile teleconsulting in a shift-by-shift sequence and evaluating technical parameters, acceptability, and impact on immediate clinical decisions. Both types of telemedicine workstations were equipped with DICOM (Digital-Imaging-and-Communications-in-Medicine) viewer and videoconference software. The laptop connected by asymmetrical broadband UMTS (Universal-Mobile-Telecommunication-Systems) technology with a one-way spoke-to-hub video transmission, whereas the hospital-based device used landline symmetrical telecommunication, including a 2-way videoconference. Results— One hundred twenty-seven hospital-based and 96 mobile teleconsultations were conducted within 2 months without any technical breakdown. The rates per allocated time were similar with 3.8 and 4.0 per day. No significant differences were found for durations of videoconference (mean: 11±3 versus 10±3 minutes, P=0.07), DICOM download (3±3 versus 4±3 minutes, P=0.19), and total duration of teleconsultations (44±19 versus 45±21 minutes, P=0.98). Technical quality of mobile teleconsultations was rated worse on both sides, but this did not affect the ability to make remote clinical decisions like initiating thrombolysis (17% versus 13% of all, P=0.32). Conclusions— Teleconsultation using a laptop workstation and broadband mobile telecommunication was technically stable and allowed remote clinical decision-making. There remain disadvantages regarding videoconference quality on the hub side and lack of video transmission to the spoke side.

Telemedically Provided Stroke Expertise beyond Normal Working Hours

Background: State-of-the-art stroke management requires neurological expertise for the recognition of complex cerebrovascular syndromes or stroke-mimicking symptoms and initiation of proven acute therapies. Many community hospitals struggle to fulfill these premises particularly at evening/nighttimes or weekends. Telemedicine can improve that situation by offering rapid access to neurological expertise, but it has not been shown to what extent it is used beyond working times. Methods: The Telemedical Project for Integrated Stroke Care is a telemedical network of 2 stroke centers and 12 regional general hospitals with newly established stroke wards in Bavaria. This analysis comprises all teleconsultations from 1st February 2003 to 15th December 2006. The consultations were prospectively documented and categorized according to predefined indications and direct impact on clinical decisions. The teleconsultations were analyzed concerning whether they were requested during regular working time or during off-time (at evening/nighttimes or weekends). Results: A total of 10,239 teleconsultations were carried out in 8,326 patients. The 6,679 patients with cerebrovascular diagnosis comprised 51% of all admitted stroke cases between 2003 and 2006. During off-time 6,306 consultations (62%) were requested; 1,598 teleconsultations yielded nonstroke diagnoses, with 68% beyond working hours. Of all presented stroke patients 567 (8.5%) received systemic thrombolysis, with 58% off-time. Interhospital transports were initiated in 1,050 patients (10.5% of all), mainly for specific diagnostic workup or interventional treatments. Sixty percent of these transfers were launched off-time. Conclusions: The majority of teleconsultations were requested beyond normal working times and a significant proportion had an immediate impact on clinical decisions.

Initiation of Oral Anticoagulation after Acute Ischaemic Stroke or Transient Ischaemic Attack: Timing and Complications of Overlapping Heparin or Conventional Treatment

Background: Oral anticoagulation is highly effective for secondary prevention of cardioembolic strokes in patients with atrial fibrillation (AF). There are no studies investigating timing and complications of different strategies for initiation of oral anticoagulation after acute stroke or transient ischaemic attack (TIA). Methods: Patients of ten community hospitals participating in the prospective evaluation of medical effects of the Telemedical Project for Integrative Stroke Care (TEMPiS) were included. This observational evaluation was restricted to ischaemic stroke or TIA patients with AF who were started on Phenprocoumon treatment during in-hospital stay. Antithrombotic co-medication was dichotomized in heparin bridging (weight or partial thromboplastin time-adjusted heparin) or conventional treatment (antiplatelets and/or low-dose heparin or nil). Besides treatment-relevant extracranial bleeding, major complications were documented according to the European Atrial Fibrillation Trial definitions including vascular death, ischaemic or haemorrhagic stroke, systemic embolism, and myocardial infarction. Results: Between July 2003 and March 2005, 4,082 ischaemic stroke or TIA patients were admitted. AF was recorded in 961 patients (23.5%), of whom 376 (39.1%) received oral anticoagulation. In 229 of these patients oral anticoagulation was started in hospital, 150 (65.5%) with heparin bridging and 79 (34.5%) with conventional treatment. Patients with heparin bridging were younger, and had a longer in-hospital stay after adjustment for potential confounders (p = 0.01). Major complications were infrequent in both groups (2.0 vs. 2.5%; p = 1.0) as well as extracranial bleeding (3.3 vs. 1.2%; p = 0.43). Conclusions: Initiation of oral anticoagulation after acute ischaemic stroke yielded low complication rates independent of antithrombotic co-medication. Heparin bridging was associated with a longer stay in acute care hospitals.