Evaluation of Telestroke Services

Transcription

1

2 Evaluation of Telestroke Services 2013 Telestroke Summit Heart and Stroke Foundation of New Brunswick and the Canadian Stroke Network Dr. Patrice Lindsay Director Best Practices and Performance, Stroke Heart and Stroke Foundation, Canada 2

3 3 Disclaimer Dr. Patrice Lindsay I am a NURSE I am employed by the Heart and Stroke Foundation In the last two years, I have not had a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of Telestroke and this presentation. I have received travel and accommodation reimbursement from Allergen for presentations on the Post-Stroke Checklist, developed independently by an international group of stroke specialists. 3

4 Objectives Critically appraise a proposed evaluation strategy for telestroke Discuss required components for comprehensive evaluation of Telestroke Gain consensus on key performance indicators by participants 4

5 CTAC Framework Patient-centred, crosscontinuum 5 priority areas that emerged from report Policy and advocacy Delivery Models Best Practices and Implementation Technology Performance and Evaluation 5

6 Monitoring Quality of Telestroke Care Purpose - Why measure? For whom? What will be done with information? Key Performance Indicators Relevance, Feasibility, Actionability Data Collection Privacy, Quality, Accessibility, Cost Quality Improvement Plans Responsibility, Communication, Implementation 6

7 Canadian Best Practice Telestroke Definitions 7

8 Core Components of Telestroke Patient Presentation/Referral Reaccessing system Follow-up Management Hyperacute Acute Care Prevention Rehabilitation Education Monitoring Assessment and Diagnosis Decision to initiate Telestroke Patient-Clinician Interactions 8

9 Canadian Best Practices in Telestroke 7.1 Telestroke networks should be implemented wherever acute care facilities do not have on-site stroke care expertise to provide 24/7 acute stroke assessment and treatment with tissue plasminogen activator in accordance with current treatment guidelines [Evidence Level C]. 9

10 7.1.1 Organization of Telestroke Delivery for Hyperacute Stroke Management Standardized protocols should be established to ensure a coordinated and efficient approach to telestroke service delivery in the hyperacute phase of stroke to facilitate delivery of thrombolytic therapy in referring sites 533, 534 [Evidence Level B]. Continuously available at the referring and consulting sites [Evidence Level C]. Clearly defined criteria and protocols at the referring and consulting sites Two-way audiovisual communication should be in place to enable remote clinical assessment of the patient [Evidence Level A]. The consultant should be a physician with specialized training in stroke management All laboratory and diagnostic results required by the consultant should be made available during the telestroke consultation [Evidence Level B]. Standardized documentation should be completed by both the referring site and the consulting site [Evidence Level C]. At the completion of the consultation, the consulting physician should provide a consultation note to the referring site to be included in the patient medical record [Evidence Level C]. 10

11 7.1.3 Staff Training and Ongoing Education Service providers should be trained in using the telestroke system and understand their roles and responsibilities. o Telestroke training and education should be ongoing to ensure competency [Evidence Level C]. Referring physicians should know the inclusion and exclusion criteria for thrombolytic therapy and they should be familiar with the NIH Stroke Scale (NIHSS) so that they are able to assist the telestroke consultant with the video neurological examination. Ideally referring physicians should be certified in the NIHSS [Evidence Level B]. Consulting physicians should have expertise and experience in managing stroke patients [Evidence Level C]. 11

12 Telestroke Quality and Performance Monitoring Structure Technology training and competence Connectivity quality Access and consistency Uptake of Telestroke across sites and across continuum Process Assessment and diagnosis accuracy Appropriateness of referrals, consult:intervention ratios Efficiency and TS response times, DTN times Missed referral opportunities Re-accessing consultants Volumes and consult duration time Outcomes Impact of referrals on patient management Provider and patient perceptions Longer term follow-up outcomes Economic benefits 12

13 Detailed Telestroke Indicators (2010) Percentage of patients who arrive at a designated referring hospital with stroke symptoms who receive access to stroke expertise through telestroke as the proportion of total stroke cases treated at the referring site and the proportion of patients with acute ischemic stroke arriving at the hospital within 3.5 hours. Time to initiation of Telestroke consult from stroke symptom onset (last time patient was known to be normal) arrival in emergency department completion of the CT scan Number of Telestroke referrals where stroke specialists were inaccessible or access was delayed due to multiple conflicting calls (telestroke and other) technical difficulties preventing video-transmission Proportion of telestroke cases where an urgent follow-up is required with the stroke specialist due to complications or unexpected events. Percentage of telestroke consults who are treated with tpa. Proportion of stroke patients managed with telestroke who received tpa, who had a symptomatic secondary intracerebral hemorrhage, systemic hemorrhage, died in hospital, were discharged to long-term care vs. home or to rehabilitation. Percentage of patients managed with Telestroke where the Telestroke consultant s note is found in the patient s chart. 13

14 Data Sources Currently no systematic way of collecting comprehensive telestroke data Most telestroke programs collect some structural and technical information on number of connections, duration, service interruptions Process information on what actually took place during the telestroke session is usually local, more difficult to access, and not standardized or consistent for cross program comparisons Need to balance feasibility of attaining data with importance of having it Billing codes and ICD codes not standardized for telestroke Tracking telestroke processes and outcomes for rehab even more challenging 14

15 Quality Data Access Identify limited number of core indicators Define data elements required for measurement Build data elements into regular work flow and documentation processes where possible Work in partnership for data collection with IT, clinicians and decision support The mere existence or absence of documentation is a key performance indicator unto itself Focus on driving quality improvement Do not measure just because you can, without meaning and action planning Address access, privacy and data quality issues Think about this early in the process of establishing a telestroke program and ensure process I place before service delivery starts 15

16 Data Analysis Ontario Telestroke Program Silver, Khan,

17 Ontario Telestroke Evaluation Results We were able to match 452 of 635 Criticall records using probabilistic linkage, with the majority of the remainder of records being non-stroke activations and ineligible patients. An additional 107 consultations not listed in the Criticall database were included. Silver, Khan, 2011 Figure 1. Over 30% of Telestroke activations resulted in tpa administration between April 1, 2006 and March 31,

18 Patient Characteristics Characteristic All Telestroke All OSA Telestroke tpa OSA tpa P-value* Number (audit sample) Female (%) Mean age (years) Medical history (%) Stroke type (%) Prior stroke/tia Diabetes Hypertension Current smoker Hyperlipidemia Atrial fibrillation Myocardial infarction Ischemic Stroke Transient ischemic attack ICH IVH SAH Non-stroke Unable to determine Transported by ambulance (%) Arrival within 2.5 hrs of symptom onset (%) Silver, Khan, 2011 *P-value comparison between Telestroke and OSA patients who received tpa. 18

19 Ontario Delivery of Care and Outcomes: Telestroke Indicator Telestroke (N=171) OSA (N=129) P-value CT Scan within 25 minutes (%) tpa administered within 1 hr (%) Median Door to Needle (min) Median NIHSS prior to tpa Secondary hemorrhage within 36 hrs (%) Symptomatic secondary hemorrhage (%) Systemic bleed (%) Outcomes Rankin 0 to 2 (%) Rankin 3 to 5 (%) Median Length of Stay (days) Risk-adjusted In-hospital Mortality* (%) Risk-adjusted In-hospital Mortality* Odds Ratio Risk-adjusted 30-day Mortality * (%) Silver, Khan, 2011 Risk-adjusted 30-day Mortality* Odds Ratio *Adjusted for age, sex and initial stroke severity 19

20 Discharge Destination % Telestroke OSA Home Rehab Long-term Care* Figure 2. Excludes patients discharged to another acute care facility. *Long-term care includes Complex Continuing Care and Retirement home Silver, Khan,

21 APSS Jeerakathil,

22 Results Telestroke Non-telestroke Comp Stroke Centre Primary Stroke Centre (73%) 119 (100%) 117 (27%) Age (y) male (%) Jeerakathil,

23 Neurological worsening with intracranial hemorrhage v 3 there were no significant differences between TS and nonts for any comparisons 0.0 Non-telestroke Telestroke ICH+Petechial all 4 years ICH 2009/10 ICH 2010/11 Jeerakathil,

24 APSS Door to needle time for patients treated with telestroke vs non-telestroke interquartile range Jeerakathil,

25 Adjusted 30 day in-hospital mortality in telestroke vs nontelestroke patients Jeerakathil,

26 We will measure and evaluate telestroke services and care delivery!! 26