• Case Studies: The Telestroke Project

The Telestroke Project: Improving stroke outcomes in regional and rural NSW

One stroke occurs every 19 minutes in Australia and is one of Australia’s leading causes of serious disability.

The good news is that highly effective stroke treatments exist that can dramatically improve patient outcomes. These treatments are collectively called stroke reperfusion therapies, and include endovascular clot retrieval and thrombolysis. 

However, there are challenges that make it hard for everyone to access these therapies, particularly for those living in regional and rural areas:  

Challenge 1: The treatment is time-sensitive – meaning that it needs to be given soon after the stroke occurs to be effective. 

Challenge 2: A stroke specialist is needed to check each patient to determine if they are suitable for this type of treatment. If a patient is found to be suitable, the treatment needs to be administered by a stroke specialist, who typically works in a comprehensive stroke centre found in major city hospitals.

In regional NSW, only the John Hunter Hospital in Newcastle has the specialist staff to provide endovascular clot retrieval, preventing many regional and rural patients from accessing this life-changing treatment. 

NSW Regional Health Partners supported a project to improve accessibility to world class stroke care for those living in regional and rural NSW.

NSWRHP partner organisations HMRI, the University of Newcastle, Hunter New England Local Health District, Mid-North Coast Local Health District and Central Coast Local Health District, working together with NSW Ambulance and consumer organisations, conducted a translational research project to: 

  1. Train paramedics to determine the type of stroke a patient has experienced
  2. Use videoconferencing and advanced computed tomography (CT) imaging in rural and regional hospitals to determine the treatment required, and  
  3. Test, evaluate and refine a transport-decision support tool (the ‘Hunter 8’) with an embedded telehealth communication pathway to improve communication between the team members. 

This project has supported the rapid identification of rural and regional stroke patients who require endovascular clot retrieval to be transported directly to the John Hunter Hospital, bypassing their closest hospital when needed, enabling them to receive world class stroke care. 

The Telestroke program was a success!

The three interventions together have led to: 

Improved health outcomes

  • More patients were accurately identified as requiring specialist treatment. 
  • Very few patients missed out on receiving appropriate treatment.

Improved health services

  • More than 1800 patients at 16 rural sites in NSW have been assessed.
  • More than 300 patients receiving reperfusion therapies.
  • Videoconferencing and advanced imaging are not routinely used by paramedics, regional rural hospitals and comprehensive stroke centres to make transport and treatment decisions.
  • Increased staff confidence and skills

Improved policy

  • The Telestroke project is being rolled out state-wide by the newly founded NSW Telestroke Network. 
  • The Hunter-8 stroke assessment tool has been integrated into the NSW Referral Guide ‘Eligibility for endovascular clot retrieval’ as the gold-standard pre-hospital triage assessment tool. The Hunter-8 tool is currently being trialled in Brisbane. 
  • Consensus guidelines now emphasise that ambulance services should transfer suspected stroke patients to hospitals capable of delivering reperfusion therapy with pre-notification. 

Increased value

  • The health economic analysis of the pilot study found the Telestroke Network was highly likely to be cost effective. 
  • NSW Health is in the process of refining cost estimates for the Telestroke network. The economic model will then be re-run to assess cost effectiveness. 

This project was supported by the Australian Government’s Medical Research Future Fund (MRFF) as part of the Rapid Applied Research Translation program.

Publications

Gangadharan, S., Lillicrap, T., Miteff, F., Garcia-Bermejo, P., Wellings, T., O’Brien, B., Evans, J., Alanati, K., Levi, C., Parsons, M. W., Bivard, A., Garcia-Esperon, C., & Spratt, N. J. (2020). Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network. Frontiers in Neurology, 11. https://doi.org/10.3389/fneur.2020.00628

Garcia‐Esperon, C., Soderhjelm Dinkelspiel, F., Miteff, F., Gangadharan, S., Wellings, T., O´Brien, B., Evans, J., Lillicrap, T., Demeestere, J., Bivard, A., Parsons, M., Levi, C., Spratt, N. J., Peake, R., Hughes, J., Dark, L., Ryan, N., Shepherd, M., Ali, O., & Wills, J. (2019). Implementation of multimodal computed tomography in a telestroke network: Five‐year experience. CNS Neuroscience & Therapeutics, 26(3), 367–373. https://doi.org/10.1111/cns.13224

References

Demeestere J, Sewell C, Rudd J, Ang T, Jordan L, et al. (2017). The establishment of a telestroke service using multimodal CT imaging decision assistance: “Turning on the fog lights”. J Clin Neurosci.37:1-5. doi: 10.1016/j.jocn.2016.10.018

Garcia-Esperon C, Ostman C, Walker FR, Chew BLA, Edwards S, et al (2022) The Hunter-8 Scale prehospital triage workflow for identification of large vessel occlusion and brain haemorrhage, prehospital emergency care. doi: 10.1080/10903127.2022.2120134

Garcia-Esperon C, Soderhjelm Dinkelspiel F, Miteff F, Gangadharan S, Wellings T et al (2020).  Implementation of multimodal computed tomography in a telestroke network: Five-year experience. CNS Neurosci Ther. 26(3):367-373. doi: 10.1111/cns.13224

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