Acute Telestroke Implementation to increase treatment rates and improve outcomes for rural and regional stroke patients (‘At It’ study)

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What is the problem?

Stroke is common in Australia, with 60,000 new strokes yearly. Studies show these numbers are disproportionately distributed across Australia, with stroke rates 30% higher in rural areas.

Stroke is most commonly caused by blockage of an artery in the brain resulting in brain injury. Fast treatment with ‘clot busting’ drugs (thrombolysis with intravenous tissue plasminogen activator –tPA within 4.5 hours of onset) and/or endovascular clot removal (ECR) can save brain function. Stroke reperfusion therapies are highly effective treatments producing major reductions in disability. Two recent clinical trials have shown a major benefit from clot retrieval in patients selected using advanced imaging. This applies to only a minority of stroke patients (around 10%) but these are the ‘big strokes’ that cause around half of the population disability burden of stroke.

Patients in rural and regional Australia have had limited opportunity to receive ECR, as, until recently, it was believed to be effective only if undertaken within 6 hours of onset of stroke symptoms, and it is only performed in major hospitals. Use of tPA in rural and regional patients has also been much lower than it should be.

About the research translation program

Rapid treatment of stroke is critical. Having a well-designed and streamlined process to deliver tPA and identify patients for ECR is crucial and has very strong evidence of a large impact on patient outcome.

Recent pivotal trials have shown that ECR can be undertaken up to 24 hours post stroke onset in advanced imaging selected patients, with significant benefit. This increases the scope for ECR for rural and regional patients, previously excluded by the six-hour window. The John Hunter Hospital Neurology team is collaborating with NSW Ambulance to trial a revised pathway for suspected stroke, with the aim of incorporating this latest evidence into practice.

The research project has implemented an acute 24/7 telestroke service in seven district hospitals in northern NSW. The service is providing neurologist videoconferencing and advanced CT imaging-supported stroke treatment that enables ECR eligible patients to be accurately identified and quickly transferred from rural and regional areas. Paramedics are being trained to identify potential candidates so that eligible patients can immediately be taken to the most appropriate centre, and out-of-area transfers are restricted to those most likely to benefit. The advanced imaging and stroke neurologist-supported decision-making available through this service is also facilitating the appropriate use of tPA in rural and regional centres.

What will be the impact?

This project is expected to increase the use of tPA in the participating rural centres and provide access to ECR for rural patients for the first time. The project is already delivering improved patient outcomes for treatment-eligible patients, establishing long-term sustainable improvements in therapy, and providing a model for other rural regions; a template for a state-wide service being developed through this project is expected to commence in March 2020.

Delivering reperfusion therapies to currently underserviced locations is also expected to reduce the overall costs to the community by preventing both lost work opportunity and reducing care costs (estimated at 2.1 billion per annum nationally).

Preliminary results from paramedics’ use of the Hunter 8 Stroke Score, designed to assess stroke severity, is showing a higher than expected rate of identification of large vessel occlusion strokes in the field, enabling rapid access to ECR for those patients.

Additionally, the project has increased telestroke consultations by almost 500%. This has increased the number of patients receiving tPA but reduced the rate of tPA in these centres. That is, more patients who are suitable for tPA are receiving this treatment, and fewer patients who are not suitable. At three months, patient outcomes are in line with large comprehensive stroke centres.

For more information, contact Neil Spratt – Neil.Spratt@health.nsw.gov.au