Regional NSW gets better, faster stroke care

A 24-hour a day, seven-day a week service providing improved emergency care for stroke patients in rural and regional areas has flourished from its pilot origins and is expanding across New South Wales.

The Acute Telestroke Service is being more widely implemented after a study at seven northern NSW hospitals demonstrated that by providing a rural or remote stroke patient with an urgent telehealth assessment, their outcomes are significantly improved.

Thanks to its use of videoconferencing and advanced computed tomography (CT) imaging in rural hospitals, city-based neurologists can now identify patients requiring endovascular clot retrieval. These patients can then be flown to major centres for the procedure.

The pilot study of the telestroke service was led by neurologists from Gosford Hospital and the John Hunter Hospital in Newcastle and funded by NSW Regional Health Partners with money from the Medical Research Future Fund.

“I think this is a world first for rural hospitals to do this sort of imaging,” says chief investigator, University of Newcastle Professor Neil Spratt.

“In our treatment model the neurologist looks at the patient over the camera and looks at the imaging over the internet and then talks to the treating doctor and makes decisions about whether they think the patient may be suitable for treatment with clot dissolving medication.”

“In some cases, we will then decide to fly the patient as quickly as we can to Newcastle so we can treat them by pulling the clot out.”

Project chief investigator, Professor Neil Spratt, University of Newcastle

The service is now being extended to 23 locations in regional New South Wales, co-ordinated by the Prince of Wales Hospital in Sydney.

The new treatment model reflects research evidence that a tenth of the most severe strokes account for about 50 per cent of the associated disability.

“The kind of strokes we select for clot retrieval, we are talking patients that otherwise without any intervention, around 80 per cent of them would have significant disability or require a nursing home scenario,” says John Hunter Hospital stroke neurologist Dr Carlos Garcia-Esperon.

“So we are talking about catastrophic strokes, not minor strokes.”

However, even in the aftermath of catastrophic strokes, clot retrieval restores more than one-in-three patients to their normal lives. Many of the rest avoid the dire health outcomes and severe disabilities that would otherwise await them.

Dr Garcia-Esperon calls clot retrieval “one of the most powerful therapies that we have in modern medicine”.

Most rural parts of NSW are not home to neurologists, and district hospitals cannot perform endovascular clot retrieval which is a highly specialised procedure offered in a few tertiary hospitals, such as the John Hunter and Sydney’s Royal Prince Alfred, Liverpool or Prince of Wales hospitals. Delivery requires trained specialists in neuro-intervention working in high volume centres.

So the Acute Telestroke Service virtually connects local doctors and paramedics with specialists in stroke diagnosis and treatment.

Tamworth Stroke Care Coordinator Rachel Peake says the time sensitivity of stroke as a medical emergency means that determining a patient’s stroke type and treatment options quickly is crucial.

“CT perfusion scanning, which is at these telestroke sites, has made for much more appropriate patient selection. I think that’s helped, along with the triage tools they have used,” says Ms Peake.

“The right patients are getting assessed in a very timely manner, and they are getting decision-to-treatment time clarified early.”

Dr Garcia-Esperon cites the recent case of a woman from Moree in her 70s who suffered a massive stroke. She presented to hospital and, via teleconference, was started on clot-busting medication at the rural hospital. After she was flown to Newcastle, the woman underwent successful clot retrieval procedure.

“The whole scenario took around seven-and-a-half hours, which can sound like a lot,” he said

“But the patient needs to be identified by NSW Ambulance from home to the hospital. We arrange the imaging and make a decision.

“Moree is far away, so definitely you need a fixed wing aircraft, which needs to land at Williamtown airport. An ambulance needs to be waiting for the patient and come to John Hunter, where we are ready to do the case.”

Dr Garcia-Esperon recently presented data for 136 patients from around Australia and New Zealand who had undergone similar long transfers.

“The evidence shows that with good imaging selection, patient outcomes are as good as in the large clinical trials.”

“As a result, the stroke community is Australia and New Zealand have been very quick to adopt this approach.”