Telestroke Services Give Hospitals an Effective Model for Improving Clinical Outcomes

August 13, 2021 - One of the early front-runners in proving the value of telehealth is through telestroke services, where the technology has literally saved lives.

Healthcare providers have used telemedicine to treat stroke patients for more than three decades, beginning with the strategy of using an audio-visual platform to allow a neurologist to see a patient showing signs of a stroke. These platforms took the form of a hub-and-spoke telemedicine network, with specialists at a large health system or hospital occupying the hub and connecting to smaller, more remote hospitals and clinics, or spokes.

Today’s networks are more sophisticated, but the model is still the same. Neurologists are in short order and high demand, and a telemedicine platform is an easy means of allowing them to extend their reach and treat more patients, especially those who can’t easily access emergency in-person care. Networks have sprung up in many states, within large health systems with multiple sites as well as via partnerships that allow hospitals to market their services to other hospitals and clinics.

Measuring Success in Minutes

The strategy behind telestroke is to identify whether someone is experiencing a stroke as quickly as possible, so that treatment can begin. The treatment often consists of administering tissue plasminogen activator (tPA), a clot-dissolving drug first developed for treatment of heart attacks in the 1980s and then fine-tuned for stroke treatment in the early 1990s. The key to success in treatment, however, lies in administering tPA as quickly as possible, to counter the effect of blood loss to the brain. The shorter time period between stroke and treatment, the less permanent damage to the brain.

This is where telehealth comes into play. A telemedicine platform that allows specialists to see a patient remotely, including viewing images, can speed up the time to treatment. The challenge lies in ensuring that the technology is good enough to allow for an accurate diagnosis.

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In 2016, Kaiser Permanente released results of a study involving more than 2,500 patients treated for stroke symptoms between 2013 and 2015 in its 14-hospital network in southern California. That study, the largest of its kind at that time, saw a 75 percent increase in the timely use of tPA after a telehealth consult. Patients receiving a telehealth consult were given a diagnostic imaging test 12 minutes sooner, and the drug was administered 11 minutes sooner – reducing the door-to-needle time to less than an hour.

“These findings have important implications for future delivery of stroke care,” the researchers concluded. “Particularly in hospitals with limited local resources and/or limited access to neurologic expertise, telestroke is an important tool to aid in the evaluation and treatment of potential stroke. We specifically found that unwarranted hospital variability in stroke care could be eliminated through a standardized telestroke program. Additionally, telestroke may aid in triage and transfer decisions and in identifying patients potentially eligible for endovascular intervention or patients who might otherwise benefit from transfer to a stroke center.”

That study didn’t address clinical outcomes, but it did get the experts to sit up and take notice. Later in 2016, the American Heart Association and American Stroke Association unveiled the first standards for telestroke services. The document targeted four aspects of the telemedicine platform: process measures, including time to consult and time to treatment; information on where patients are transferred to and why; outcomes such as mortality, clinical status, hemorrhage rates and patient satisfaction; and communication quality. A short while later, the American Telemedicine Association added telestroke to its library of practice guidelines to ensure “standardization around the assessment, diagnosis, management and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies.”

In 2017, Kaiser Permanente released the results of a second telestroke study, conducted in 21 hospitals in its northern California network, which found that 87 percent of stroke patients in those hospitals were treated within 60 minutes – the recommended “door-to-needle” time put forth by the American Heart Association and American Stroke Association. Nationally, less than 30 percent of stroke patients are treated within this window.

More importantly, 73 percent of stroke patients in those hospitals were treated within 45 minutes and 41 percent were treated within 30 minutes; the average “door-to-needle” time was 34 minutes.

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“Processes that used to happen sequentially during a stroke alert, one after another, are now happening at the same time, allowing us to quickly, safely and confidently provide evaluation and treatment with intravenous r-tPA to stroke patients who can benefit,” Jeffrey Klingman, MD, chairman of the Chiefs of Neurology for Kaiser Permanente Northern California and a co-author of the study, said.

Dozens of studies have been conducted since then, all connecting the value of a telehealth consult to quicker diagnosis and treatment, which in turn improves clinical outcomes. Nearly every program can tell a story – often more than one – of a patient experiencing a stroke who was diagnosed and treated with tPA through a telestroke consult quickly enough to save his or her life.

But there are other, downstream benefits as well. Small, rural hospitals that take part in a telestroke program can keep and treat more of their own patients, reducing costly transports and building their value to the community. And they can build off that platform to offer other telehealth services, adding to their resources and keeping even more patients in the community.

Hub health systems, meanwhile, can reduce traffic in their ED and ICU through a telestroke program, reducing their own inpatient expenses. They can also use the platform as a new business line, marketing the service to other hospitals and clinics, and build off that platform and their specialist base to offer other telehealth programs.

As with any telehealth program, there are challenges. A telestroke program won’t just spring up and save lives and money on its own. The technology behind the platform has to be reliable and exact, giving specialists the right data to make a definitive diagnosis. The connection between hub and spoke can’t be sketchy. And the workflows have to be designed carefully, to ensure that a specialist is available and can treat a patient as quickly as possible.

Critics also note that a telehealth platform can be overused if the right protocols aren’t in place to manage the program. The ability to summon an expert on demand is great, but it can be abused to the point that it creates unnecessary expenses, stresses the delivery system and causes providers to think the effort isn’t worth the outcomes. Telestroke programs have to designed and managed with efficiency in mind, and guardrails to prevent overuse.

New Platforms and Possibilities

The next frontier for telestroke services is mobile health.

The concept is simple. If telehealth improves outcomes for people who are experiencing a stroke, why not bring the technology right to them, wherever they’re located, rather than waiting for them to reach a hospital or clinic?

Several programs have launched in recent years that use specially designed mobile health units to rush to the location of a potential stroke victim, much like an ambulance would be dispatched to the scene of an accident. The programs, launched in major cities like New York, Cleveland and Atlanta by local health systems, aim to speed up diagnosis and potentially begin treatment before the patient has reached the hospital.

"We will be able to give patients the same medication at their homes that they would receive in an emergency department," David Fiorella, a neurointerventionist at Stony Brook University Hospital and director of the cerebrovascular program at the university's Cerebrovascular & Comprehensive Stroke Center, said in 2018 as the Long Island health system was preparing to launch a $2.2 million mobile telestroke program – beginning with two vehicles stationed at exists along the Long Island Expressway.

In 2019, NewYork-Presbyterian Hospital released the results of a study that indicated its mobile telestroke program, launched in 2016 in a partnership with the Fire Department of New York, shaved an extra 30 minutes off of average treatment time.

“Given the public health implications of faster stroke treatment, these results suggest that mobile stroke units may represent a potentially beneficial addition to stroke systems of care in dense cities,” Matthew E. Fink, MD, the study’s lead author, a chair of neurology and the Louis and Gertrude Feil Professor in Clinical Neurology at Weill Cornell Medicine in New York and neurologist-in-chief at NewYork-Presbyterian/Weill Cornell Medical Center, said in the study.

That type of success has prompted some health systems to expand the strategy. In 2021, the University of Minnesota Department of Medicine unveiled plans to deploy mobile health units with telemedicine equipment designed to treat heart attack patients at the scene.

"With our mobile teams and cardiac arrest toolkits, we are able to deliver the expertise and equipment needed to stabilize people suffering cardiac arrest within as little as 30 minutes," said Jason Bartos, president of UM’s Minnesota Mobile Resuscitation Consortium (MMRC) and an assistant professor at the University of Minnesota Medical School. "The ability to deliver these life-saving capabilities so quickly and reach patients across the Twin Cities is a game changer in the treatment of cardiac arrest."

But while these programs can boost clinical outcomes, they’re very costly and complex, undertaken only by large health systems with large budgets in metropolitan areas that see enough strokes and heart attacks in a year to justify the expense. Some critics even complain that the money spent on these programs would be better spent elsewhere, on technology in the hospital or programs that aim to reduce strokes and heart attacks before they happen.

The future of these mobile telestroke programs lies in less expansive, more sophisticated technology that might be included in every ambulance, EMS and police vehicle, allowing any first responder to connect with specialists on demand for a quick and accurate diagnosis.

That type of innovation might even happen in the consumer-facing connected health market, through smartwatches, wearables, even sensor-embedded jewelry and clothing that can track the wearer’s biometric data and detect early signs of a stroke. Imagine a wearable that spots those signs, alerts the wearer and also connects with the nearest hospital, transmitting data that will allow care providers to diagnose and plan treatment. The wearable might even summon transportation for the user and direct that cab, emergency vehicle or, perhaps, Uber driver to the hospital (it might also contact the wearer’s family and alert the primary care provider and health plan, but that’s a story for another day).

For now, the ability to use telemedicine equipment and mHealth devices to bring care to someone exhibiting signs of a stroke makes telestroke oen of the more established connected health services, benefitting both urban and rural care providers and quite literally saving lives.