Telestroke Building Equity?
Written by Jan Hallam
Friday, 27 October 2017
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Those at the sharp edge of stroke treatment around the world are hailing the technique of endovascular clot retrieval (ECR), or endovascular thrombectomy as a game-changer for a select group of patients with acute ischaemic stroke due to large vessel occlusion. Some have dubbed it the Lazarus phenomenon because some stroke sufferers are seemingly ‘brought back from the dead’ – or at least from a life of permanent and major disability.
Alongside thrombolysis, ECR has given an extra spring in the step of stroke units everywhere – but there’s the rub. Everywhere is, in reality, only within a workable ‘retrieval’ distance from a multidisciplinary stroke unit capable of doing this complex but minimally invasive surgery. In WA, there are two such units – a 24/7 seven-day a week team at Sir Charles Gairdner Hospital and a five-day a week team at Fiona Stanley Hospital. St John of God Midland has a stroke service but does not do ECR.
In the August 2017 edition of Stoke, a journal of the American Heart Association, three Melbourne stroke interventionists discussed equity, access and standards of endovascular thrombectomy in their state of Victoria, which has been in the vanguard of stroke treatment in Australia.
Prof Stephen Davis, A/Prof Bruce Campbell and Prof Geoffrey Donnan wrote that these procedures required teams of highly trained health professionals where “clearly, procedural volume and complexity correlate with efficacy and safety.”
201711-Telestroke-Consult-FSH Oct17Telestroke consult at Fiona Stanley Hospital in progress.Stroke workforce issues
They went on to acknowledge there was a shortage of neurointerventionists. “Given the need for speedy recanalisation of large artery occlusion and the current workforce problems, we agree that training of a significant proportion of stroke physicians to undertake interventional work should be priority.”
So, while those who live in the metropolitan areas of Australia can enjoy 21st century medicine, what happens to those who don’t? This is a particularly fraught question for WA, which has vast areas to cover with little or no chance of fulfilling the desired “procedural volume and complexity to correlate with efficacy and safety”.
This is where telehealth medicine is playing an important role.
Stroke physician and geriatrician Dr Andrew Wesseldine, who is the WA State Stroke Director, said the service had been evolving over the past 3½ years and with the growth of WACHS telemedicine network and the establishment of the acute teams at SCGH and FSH, Telestroke was having a positive impact on the lives of rural patients.
“Stroke is still an uncommon condition presenting to rural EDs and the field has seen extraordinary developments in acute treatment over the past decade, which make it very challenging for people who are not experts to manage these situations,” Andrew told Medical Forum.
“It’s not possible to have a SCGH or a FSH stroke unit in Geraldton or Albany, but we can bring the stroke doctor to the patient. The key has been communication that is contemporaneous, accurate, useful and delivered as often as possible by a stroke clinician to help the rural doctor or nurse with the care, decision-making and treatment strategies of their stroke patient. That’s at the heart of the Telestroke concept.”
Teleheath builds bridges
“Teleheath will be a bridge for future delivery of thrombolysis for a rural patient. It’s certainly been used in Victoria in that regard.”
Andrew said the landmark paper from the Netherlands on endovascular thrombectomy, MR CLEAN, in late 2014, which successfully trialled retrieval of clots from the large vessel in the brain via the femoral artery, had been part of treatment in WA at the Neurological Intervention and Imaging Service of WA (NIISwa) for some time. It has had ramifications for rural stroke patients as well.
However, he stressed that the procedure was not suitable for every stroke patient.
“We screen eight to treat one, so there are a lot who are not eligible, but that’s the nature of stroke. It is a heterogeneous condition which is why it’s so challenging. However, for those who are treated, the number needed to treat to achieve a good outcome is only 2.8. This is one of the most cost-effective treatments in medicine,” he said.
“Each week, we are retrieving these kinds of acute stroke patients from all around the state with the assistance of our great RFDS and St John Ambulance. WA has a dedicated core of stroke carers, nurses, ED physicians, medicos and I’m not saying these words lightly. These are incredible people.”
“They are all pulling into gear on an event that might occur in say Broome once a month. But if they pull into gear on the right patient, we are talking an absolutely remarkable outcome.”
Andrew said it was remarkable to consider the number of people involved in the Telestroke process.
Meet the team
“You’re talking about the nurse or doctor who calls from the ED, then you have the retrieval services, Ambulance, RFDS or both, the cath lab nurses at Charlies who come in at two in the morning and the specialist neurointerventionist and all the people in between – the registrars, consultants on the ground.”
The effect of the endovascular treatment was demonstrated recently with the treatment of a 16-year-old boy from Manjimup, whose CT scans were assessed via Telestroke and he was flown to Perth, paralysed down one side and unable to speak. He walked and talked his way out of hospital 48 hours later.
“It is not just the skill of those involved. It’s the fact everyone in the care of the individual was communicating effectively about an uncommon problem with a treatment that could only be delivered in a metropolitan hospital because of the scarcity of people with the necessary skills.”
“We are very lucky, with a population of our size, to have two multidisciplinary units. Victoria has two. So there’s been a remarkable change in stroke care in WA and for those of us who have been around doing stroke medicine for 20 years or more, it is just transformative.”
Andrew said that underpinning these developments was Telestroke as a tool to educate, train, assist and, build communication networks.
“Everything about the project is about the patient, and I am really proud of that. When we compare ourselves nationally we are punching well above our weight.”
Counting the seconds
“The key to this is to work on the systems to keep learning and getting better. Right now it is not a system you can activate from a GP’s surgery. Patients, particularly if they are hundreds of kilometres away need a CT scan for diagnosis. In rural Victoria, CT scanners have been put into ambulances to aid in a speedy diagnosis.”
“Telestroke continues to drive skills capacity in regional areas. We have been doing a lot of work in EDs and with the Emergency Telehealth Service so we can become a cohesive communication network.”
“But if you are talking time on the stroke clock, this has only happened at a minute to midnight. These systems of care are currently being shaped and put into practice all around the world and we have had to do the same thing. We are very lucky to have groups like WACHS and a supportive Director General and people in between who support this for WA patients.”
 “The initial time window was six hours but recent studies have suggested that selected patients outside of that window may benefit but there is not rule book to determine who they are.”
Support around the clock
“What we have said to rural doctors, if you have a stroke patient that is acute, in other words within the past 12 hours, Telestroke can help determine the treatment pathway. What has become clear is the necessity of consultant support 24/7. There are a number of states that don’t have this coordinated service but we don’t apologise for putting WA stroke patients in the centre of the conversation.”
Currently international trials are underway for neuroprotective drugs which could potentially buy the stroke patient and the care teams, time.
“However, in any world we live in, stroke prevention is the most important thing. We want to stop strokes from occurring by treating blood pressure, high cholesterol, diabetes and sleep apnoea. We want to get people with Atrial Fibrillation on to the right drugs. With all the amazing things happening in the treatment of strokes, it’s important to never lose sight of the absolute critical nature of primary care and that interface with the patient.”
Telestroke is a fine example of technology being used to help teams separated by vast distances to pull together for their patients and Andrew is encouraged by the willingness of everyone in stroke care to be involved.
“There are new things happening all the time and national networks are growing to share knowledge but for everyone involved who know what a stroke means to a person’s life, it’s motivation enough.”
On October 21 and 22, the DoH sponsored a stroke symposium for rural clinicians to meet metropolitan stroke specialists and to go through training scenarios. Andrew said he hoped this would be an annual event and another step in expanding stroke services for those in rural areas.
“It’s so important for rural doctors and nurses to feel comfortable asking questions of the stroke team. Questions are critical to good patient care.”