Telestroke in Alberta

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Telestroke in Alberta

• Dr Thomas Jeerakathil
• Sharlene Stayberg

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Agenda

• Alberta Provincial Stroke Strategy
• Telestroke in Alberta
• Hyperacute Case Examples

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The Facts About Stroke In Canada

• Stroke is the number 1 cause of acquired
  long-term disability
• Stroke is the 4th leading cause of death
• Most common neurological condition requiring
  admission to hospital
• 20 fatal
• 75 of survivors live with some level of
  disability

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Alberta

• 5,500 new stroke case per year
• 25,000 stroke survivors
• Cost 200-300M per year
• Stroke incidence increases with age
• 1-2 increase in the occurrence of stroke per
  year for the next ten years

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Current State

• Major advances in stroke care over the past
  decade
• Prevention
• Acute management
• Rehabilitation
• Significant gap between what is known about best
  practice and actual practice

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Alberta Provincial Stroke Strategy

• Close the gap between best practice and current
  practice
• Create systems of care that span geopolitical
  boundaries
• Health Regions, Heart and Stroke Foundation and
  AHW working in partnership to enhance service
  delivery across the province
• Alberta Stroke Council reporting to Minister of
  Health
• 20M 2 Year Grant Funding

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Stroke System in Action

• Provincial Network Model
• Optimal stroke care accessible to residents of
  all health regions regardless of where they live
• Enhanced clinical relationships -
  referrals/information flow/knowledge
  transfer/consultation support
• An organized and standardized approach to stroke
  care through the adoption of best practices,
  protocols etc.
• Performance measures to allow continual evolution
  and improvement in service delivery

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APSS - Opportunity

• Inter-regional Collaboration - Coordinate service
  delivery across geopolitical boundaries
• Develop common provincial strategies to
  facilitate access to services and optimal
  evidence based care
• Regions share information about stroke services
  (strengths, gaps, best practices)

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Role of the Key Participants
The Participants

• Regional Health Authorities (9)
• Heart Stroke Foundation of Alberta
• Department of Alberta Health Wellness (Govt)
• Together they form the Alberta Stroke Council

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APSS Process
Components / Inventory (Current State)
Health Regions
Gaps /Issues
Stroke Plans

• Implementation
• Stroke Plans
• Services
• Best Practice
• Protocols
• Education

Best Practices / Recommendations / Protocols /
Resources Performance Measures/ Methodology
Pillars
Current State Provincial Model
Education
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Comprehensive Stroke Centres Other Primary
Stroke Sites Regional Hospital Primary Stroke
Centres
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Comprehensive Stroke Centres Other Primary
Stroke Sites Regional Hospital Primary Stroke
Centres
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Wetaskiwin
Wetaskiwin
Comprehensive Stroke Centres Other Primary
Stroke Sites Regional Hospital Primary Stroke
Centres
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Pillars

• Span prevention, emergency and acute care,
  rehabilitation and community reintegration,
  evaluation and quality improvement
• Best practices Define and disseminate
• Protocols and tools
• Education Resources
• Performance Measures

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APSS Initiatives

• Provincial Health Care Provider Stroke Education
  Strategy
• Provincial Telestroke Working Group facilitate
  telestroke access to education and clinical
  consultation
• Integration of stroke protocols in regional
  Electronic Health Records systems

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Telestroke Working Group

• Regional representatives
• Telehealth
• DI/ IT
• Clinicians
• Stroke Neurologists
• ER physician
• Other Pillar Representative
• Project Manager APSS
• AB DI IM/IT Representative
• AHW Telehealth
• Others as Required
• Technical Consultant, APSS Evaluation
  Representative

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Activities

• Review of compilations of regions service
  telehealth plans, discuss implementation issues
  and requirements
• Funding applications
• Technical analysis recommendations for
  hyperacute
• Review of technical requirements
• Coordination of data collection to minimize
  duplication

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Telestroke Questionnaire

• Regional telehealth plans re stroke
• When plan to migrate to a telehealth model for
  hyperacute, other planned uses of telehealth re
  APSS, initial plans for overlay applications
• Technical plans
• Proposed solution (technology requirements,
  technical approach for sharing images,
  integration with regional systems)
• Implementation issues
• Barriers, tools that can share, how privacy and
  security issues are being addressed, clinical
  workflow
• Regional funding requirements

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Learnings - Questionnaires

• Telehealth will support enhance delivery of
  stroke services, within and between regions
• Supports all Pillars
• Variable readiness
• Telestroke/ Overlay
• Different telestroke service priorities
• Different resource requirements
• Different technical solutions planned
• The most technically complex service is
  hyperacute and involves DI and videoconferencing
  components. Other services use videoconferencing.

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Canada Health Infoway Investment

• Scope telehealth components equipment,
  planning, implementation, change management, etc
• Leverages APSS funding and other regional and AHW
  investments
• Multiphased provincial scale project reflecting
• variable readiness to proceed stroke (e.g. re
  hyperacute,
• variable readiness to proceed with overlay
  applications

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Timelines
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Telestroke Services

• Pillar I Health Promotion and Disease Prevention
• Primary prevention sessions focused on
  established disease risk factors for stroke and
  other cardiovascular disease
• Secondary prevention clinic consultations for
  high risk individuals
• Pillar 2 Emergency Response and Acute Care
• Hyperacute stroke triage
• Hyperacute care follow-up consultations
• Other acute stroke services
• Pillar 3 Rehabilitation and Community
  Reintegration
• Rehabilitation consultations for assessment and
  treatment
• Discharge / transitional planning sessions

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Telestroke Services Contd

• Other Stroke Services (impacts multiple pillars)
• Telementoring for staff
• Public education sessions
• Patient education sessions
• Telestroke rounds and other provider education
  sessions
• Initial Overlay Services piloting of the
  overlay
• Trauma consultations (1 region)
• Occupational therapy consultations (1 region)

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Integration/ Coordination

• Clinicians delivering hyperacute consultation
  services will depend on technologies that fall
  within the domain of the Alberta DI Information
  Management/ Information Technology (AB DI IM/IT)
  project (e.g. digitally moving CT images).
• APSS Telestroke Working Group will retain a close
  association and awareness of progress in the AB
  DI IM/IT project.
• Manager of the AB DI IM/IT project is a member of
  the Telestroke Working Group.
• PACS specialist also a member of Working Group
• Technical consultant works with RSHIP project

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Hyperacute Services

• Clinical Needs
• The first is a CT head scan (and image review by
  a stroke neurologist or a radiologist) to rule
  out other possible causes for the patients
  condition and/or maintain the patients
  eligibility for tPA.
• The second is an interactive visual
  request/response session between a trained
  clinician (casualty officer and/or stroke
  neurologist) and the patient that adheres to an
  internationally recognized protocol and degree of
  stroke scale (National Institutes of Health
  Stroke Scale).

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Remote/Local Requirements - Hyperacute

• Multiple ways to complete clinical assessment
• Completely locally, using local expertise,
  (telehealth not required)
• Completely remotely, using an on-call stroke
  neurologist and possibly radiologist
• A mixture of local and remote expertise (e.g.
  remote review of the CT head images by either a
  stroke neurologist or radiologist, combined with
  on-site neurological assessment by trained
  clinician),
• Approach varies dependant on local staffing.
• Recommended approach for regional centers
  accommodate all options. This doesnt preclude
  implementation of PACS component first.

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Requirements - Hyperacute

• Both technologies will require, (and potentially
  use), the same high bandwidth wide area network
  infrastructure that connects the remote trauma
  site (PSC) to the Edmonton or Calgary Stroke
  Center (CSC).
• The devices and components that enable the
  telehealth connection and the devices and
  components that enable the PACS connectivity are
  vastly different, and totally incompatible.
• The only possible common component would be the
  display station at the CSC that the stroke
  neurologist would use.

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Computed Tomography - Hyperacute

• Basic CT technology is adequate CT angiogram may
  have future benefit but not necessary for
  hyperacute telestroke intervention
• Display monitor
• with 8 bits (256 levels) of gray scale. 1.3 or 2
  mega-pixel resolution
• Scroll feature.
• Gray scale windowing (dynamic display range) and
  leveling (central display intensity).
• Magnification of selected parts of an image
  and/or Zoom plus Panning of the entire displayed
  image.
• Distance measurement, angle measurement.

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TeleHealth Components Hyperacute

• Either mobile or fixed configuration can work.
• Multiple vendors meet criteria AB - multivendor
  environment
• High quality video camera, positioned at face
  level (patient sitting or supine).
• Camera needs to have remotely operated zoom as
  well as remote panning and tilting capability.
• Adequate room lighting, particularly for the
  facial area. There should be local (room) control
  of the individual light sources, including
  dimming capabilities.
• High quality (directional?) microphone and
  speakers for good sound quality.
• Background noise suppression (if possible).
• Within 2 years, HD (high definition) video
  systems will be standard, and will necessitate
  the use of higher network bandwidth (likely gt 1
  Mbps).

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Approaches for Sharing of CT Images

• Tactical
• Solutions dependant on availability
• Timelines of AB IM/IT DI project do not align
  with APSS
• Creativity (existing networks, abandoned
  networks, SuperNet)
• Med-term Tactical
• Recommendation is use of AB IM/IT DI project
  infrastructure with images sent from local PACS
  station to telestroke/ unverified folder at RSHIP
  Shared Data Center
• Long-term
• AB IM/IT DI project will have full data
  concurrency for PACS images by approximately 2009

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PCHR
Current Configurations, Protocols
NLHR
CH PACS Hub
CH UnV Folder
AHR
SuperNet and Other Networks
ECHR
DTHR
CHR PACS Hub
CHR CSC
Web Server
Web Server
PHR
SARP
ChinHR
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PCHR
Proposed Configurations, Protocols
NLHR
CH PACS Hub
Supernet
AHR
RSHIP PACS Hub
DTHR
ECHR
CHR PACS Hub
PHR
Chinook HR
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Some Next Steps

• Finalize all funding agreements
• Regions continue to implement telehealth services
• Finalize technical analysis/ recommendations
• Provincial DI architecture group June discussion
  of technical options
• Establish new network connections
• Confirmation/ address network, NAT issues
• Finalize data collection processes
• identify training requirements
• Identification of additional overlay services

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• CLINICAL EXAMPLES

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Patient 1

• 70ish male enjoying his coffee at a local
  restaurant in rural Alberta fell off of his
  chair
• Unable to rise
• EMS transported patient to a non-tPA hospital
• ED physician noted right sided weakness, visual
  loss, inability to speak acute stroke
• Transfer to a Telestroke Centre hospital
• Contact with UAH telestroke physician

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Patient 1 (cont.)

• Patient assessed via videoconference and PACS
  images reviewed by stroke physician
• NIHSS 14
• Decision for intravenous tPA
• Clinical improvement
• At 1 month NIHSS 3

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Wetaskiwin
Wetaskiwin
Comprehensive Stroke Centres Other Primary
Stroke Sites Regional Hospital Primary Stroke
Centres
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Patient 2

• 70ish male resident of a lodge
• Family unavailable for history or PMH
• Witnessed to have speech problems (?sudden)
  using one side less than the other
• Confused behaviour, deficits fluctuating
• ? Stroke related language disturbance
• Assessed at Telestroke Hospital simultaneously by
  stroke neurologist and ED physician
• CT reviewed by PACS

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Patient 2

• On videoconferencing the visual appearance
  suggested delirium and not stroke
• Delirium-related speech confusion without
  neologisms or paraphasic errors
• No other focal neurological features
• The appearance would be difficult to describe
  over the phone and distinguish from isolated
  aphasia
• Decision stroke mimic
• Final diagnosis kidney infection.

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Technology and information for decision-making
Information for decision making
PACS/CT Transmission
/- Local Radiology expertise
PACS/CT Transmission Phone
Phone Local Radiology Expertise
Videoconferencing
Phone
Technology