Telestroke for Comprehensive Transient Ischemic Attack Care in Acute Stroke Ready Hospitals

Study Overview
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Brief Summary
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TELECAST-TIA is a prospective single-center study evaluating guideline-based transient ischemic attack (TIA) treatment at an Acute Stroke Ready Hospital (ASRH) pre- and post-initiation of a specialist telestroke inpatient rounding service. TELECAST-TIA will study the following clinical endpoints: diagnostic stroke evaluation, secondary stroke prevention, health screening and evaluation, stroke education, inpatient complications, and stroke recurrence rates. Additional relevant non-clinical data will include patient and provider satisfaction scores, transfer patterns, and a cost analysis.

Detailed Description
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Telestroke is a validated intervention that improves the triage and emergent treatment of acute stroke, specifically related to the use of intravenous thrombolysis. Effective urgent stroke evaluation and secondary stroke prevention is also essential to decrease the risk of recurrent stroke, however, there have been no studies to date examining the use of telestroke to improve delivery of non-emergent inpatient stroke care per American Heart Association (AHA) guidelines. Currently, access to stroke specialist expertise is limited resulting in significant disparities in stroke care. Previous publications have identified that patients in rural areas may receive sub-optimal stroke care that does not follow accepted guideline recommendations. Telestroke is a cost-effective mechanism to deliver specialist stroke care to hospitals that do not have in-person stroke consultation available. The aim of TELECAST-TIA is to determine whether specialist telestroke inpatient rounding improves guideline-based TIA treatment when compared to non-specialist transient ischemic attack treatment. The primary outcome of TELECAST-TIA is a composite score of 3 categories: diagnostic stroke evaluation, secondary stroke prevention, and stroke education. Individual components of the primary outcome were principally derived from AHA stroke guidelines. Additional outcome measures include individual analyses of the components of the primary outcome as well as the complication rate, stroke recurrence rate, transfer rate, patient and provider satisfaction levels, and a cost-analysis. All outcomes will be assessed at 1 year post-implementation, with data accruement starting after a 3-month lead in phase.

Official Title
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Telestroke for Comprehensive Transient Ischemic Attack Care in Acute Stroke Ready Hospitals

Conditions
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Transient Ischemic Attack

Intervention / Treatment
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* Other: Telestroke


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18 and above Patients with the primary diagnosis of transient ischemic attack evaluated at the Fairview Ridges Hospital emergency room Clinical diagnosis of transient ischemic attack by the treating stroke neurology service Exclusion Criteria: Patients less than 18 years old Patients who leave the hospital against medical advice Patients who are felt to have an alternative diagnosis

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Pre-Telestroke<br>Retrospective collection of defined metrics for all TIA patients admitted to the participating ASRH 2 years prior to implementation of an inpatient telestroke service. | |
| Post-Telestroke<br>Prospective collection of defined metrics for all TIA patients admitted to the participating ASRH after implementation of an inpatient telestroke service. | Other: Telestroke<br>* Telestroke is an audiovisual communication network that allows for coordination of stroke care from a distant 'hub' site (the telestroke provider location) to an originating 'spoke' site (patient location) in a HIPAA compliant fashion. In TELECAST-TIA, inpatient telestroke rounding will be used to oversee the urgent diagnostic TIA evaluation, secondary stroke prevention, and stroke education in patients admitted with TIA.<br>* Other names: Telemedicine;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Composite score of TIA treatment (%) | A 19-item global assessment of fundamental TIA treatment primarily informed by AHA guidelines/GWTG criteria, represented in 3 categories: Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, head CT, brain MRI, intracranial vascular imaging, cervical vascular imaging, EKG, telemetry, and outpatient prolonged cardiac monitoring. Secondary prevention (6 items): antiplatelet, anticoagulation, statin, antihypertensives, diabetes management, and carotid revascularization. Stroke education (3 items): tobacco cessation counseling, exercise/lifestyle counseling, and signs of stroke. An item is not scored when not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. | 1 year after implementation of the inpatient telestroke service | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Diagnostic TIA Evaluation | A 10-item global assessment of diagnostic TIA evaluation as well as individual analysis of each item. Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, head CT, brain MRI, intracranial vascular imaging, cervical vascular imaging, EKG, telemetry, and outpatient prolonged cardiac monitoring. An item is not scored when not indicated clinically (for example prolonged cardiac monitoring in a patient with known Afib or an MRI in a patient with an MRI incompatible pacemaker), therefore the composite scores will be reported and analyzed as percentages. | 1 year after implementation of the inpatient telestroke service | 
| Secondary Stroke Prevention | A 6-item global assessment of secondary stroke prevention as well as individual analysis of each item. Secondary stroke prevention (6 items): antiplatelet, anticoagulation, statin, antihypertensives, diabetes management, and carotid revascularization. An item is not scored when not indicated clinically (for example deferring antiplatelet agents if a patient requires anticoagulation), therefore the composite scores will be reported and analyzed as percentages. | 1 year after implementation of the inpatient telestroke service | 
| Stroke Education | A 3-item global assessment of stroke education as well as individual analysis of each item. Stroke education (3 items): tobacco cessation counseling, exercise/lifestyle counseling, and signs of stroke. An item is not scored when not indicated clinically (for example tobacco cessation in a non-smoker), therefore the composite scores will be reported and analyzed as percentages. | 1 year after implementation of the inpatient telestroke service | 
| Composite Stroke Recurrence | The composite rate of recurrent TIA, ischemic, or hemorrhagic stroke at 3 months and one year post-stroke admission. | Measured at 3 months and at 1 year after discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Telestroke, Telemedicine, Secondary stroke prevention