1. SAVING TIME, SAVING BRAIN A study into the assessment of out-of-hours stroke patients Louise Dawson, Julia Fordham & Lizzie Griffiths Foundation Doctors, Dorset County Hospital

3. INTRODUCTION Ischaemic stroke is common and can be fatal Time is brain In large vessel ischaemic stroke, on average 1.9 million neurons are lost per minute Ischaemic brain ages 3.6 years per hour Thrombolysis with alteplase improves morbidity and mortality % alive and independent at final follow up Thrombolysed within 6hrs: 46% with thrombolysis (vs 42% without) Thrombolysed within 3hrs: 40% with thrombolysis (vs 31% without)

4. CURRENT PRACTICE NICE recommends thrombolysis with alteplase within 4.5 hrs stroke onset (within certain criteria) with 24/7 access for all patients Sentinel Stroke National Audit Programme (SSNAP) organisational report: 89% of hospitals offer stroke thrombolysis 74% of hospitals offer 24/7 thombolysis Telemedicine systems for assessment of acute strokes has been approved for use by NHS In 2011, 30 of 168 acute trusts in England were using telemedicine for acute stroke management

5. CURRENT PRACTICE….AT DORSET COUNTY HOSPITAL For out-of-hours stroke thrombolysis calls, consultant cover is provided by 11 consultants 5 Emergency Medicine 1 Stroke 5 other medical Telemedicine assessment is always available for the on-call consultant 3 consultants use (occasionally or always) this when off site The others drive in from home to assess the patient

6. TELEMEDICINE….SO WHAT’S THAT THEN? In the hospital High resolution camera and microphone in ED in full view of patient At home Laptop with live audiovisual linking of patient examination, directed by consultant at home & live discussion with colleagues Rapid access to CT head images & report

7. TELEMEDICINE….SO WHAT’S THAT THEN?

8. AIM OF STUDY Establish whether use of telemedicine (vs face-to-face) examination of stroke patients reduced time from admission to thrombolysis Investigate the causes of delays in time from admission to thrombolysis Determine the need for further training or facilitation of the use of telemedicine for stroke assessment

9. GOLD STANDARDS Consensus There should be no difference in time from admission to stroke thrombolysis between the different methods of assessment

10. STUDY METHOD Retrospective study All out-of-hours, thombolysed stroke patients from July 2010 to October 2013 Data from hospital records and SITS International (Safe Implementation of Treatment in Stroke) Time from admission to CT and to thrombolysis was recorded Comparison made between those assessed via telemedicine vs face-to-face evaluation

11. RESULTS 51 OOH strokes were thrombolysed in total 9 patients assessed via telemedicine: 8 by the Stroke consultant 1 by an elderly care physician 37 patients assessed via face-to-face evaluation 5 excluded Incomplete data available

12. RESULTS Time (mins)Admission to CTAdmission to thrombolysis Telemedicine3061 Face-to-face4179

13. STANDARDS ACHIEVED? In this study, assessment via telemedicine was associated with a reduction in the time from hospital admission to thrombolysis in out-of-hours stroke patients.

14. FURTHER WORK…QUESTIONNAIRES Consultants covering the OOH stroke on call rota: 5 out of 11 responded 3 had been trained in telemedicine use: of these all felt it was easy to use and 2 thought they could make a safe decision with it 4 always waited for CT head report prior to making thrombolysis decision 2 felt waiting for the report delayed time to thrombolysis 1 thought using telemedicine would reduce delay to thrombolysis 1 thought telemedical evaluation could be detrimental Only 1 felt that they would want to use telemedicine in the future

15. FURTHER WORK…QUESTIONNAIRES Consultants coving the OOH stroke on call rota Ideas for improvements: Draw up alteplase as soon as CT report available Educate nurses to initiate arrangements for CT sooner Access to GP patient records for completing assessment of suitability for thrombolysis Put the CT in the back of the ambulance Early call to consultant on call Bedside INR testing

16. FURTHER WORK…QUESTIONNAIRES Radiology consultants covering OOH stroke on call rota 4 consultants out of 8 responded 3 consultants reviewed CT images from home, 1 always came in to hospital Range of estimate of time to review images: 3-15 mins Range of estimate of time to written report: 5-15 mins 2 always spoke directly to the medical consultant on call to give their report

17. FURTHER WORK…QUESTIONNAIRES Radiology consultants covering OOH stroke on call rota Ideas for improvements Direct line to medical consultant instead of via hospital switch listening to lengthy diarrhoea message! Improve stability of software: multiple ‘crashes’ when trying to produce report Faster broadband

18. FURTHER WORK…PENDING Analysis of case notes Identify specific points of delay in out-of-hours thrombolysis Rule out confounding factors Continuation of data collection Change in method of reporting CT images needs monitoring Reaudit – when appropriate

19. CONCLUSION Use of telemedicine in this study was associated with a reduction in the time from admission to thrombolysis out-of-hours Also identified: Infrequent use of telemedicine within Dorset County Hospital. Consultant uncertainties regarding effective use of telemedicine reflected as poor usage of system. Potential delays in receiving timely thrombolysis at Dorset County Hospital. Potential methods that will improve time to thrombolysis. “Saving Time, Saving Brain”

20. REFERENCES Saver JL (2006). Time is brain – quantified. Stroke Jan;37(1):263-6. Epub 2005 Dec 8. Davis S, Holmes M, Simpson E et al. Alteplase for the treatment of acute ischaemic stroke (review of technology appraisal 122), May 2012. NICE guidance Alteplase for treating acute ischaemic stroke (review of technology appraisal guidance 122). National clinical guideline for stroke Fourth edition September 2012 Prepared by the Intercollegiate Stroke Working Party.

21. QUESTIONS?