Telestroke for Comprehensive Stroke Care in Acute Stroke Ready Hospitals

Study Overview
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Brief Summary
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TELEstroke for Comprehensive Stroke Care in Acute Stroke Ready HospiTals (TELECAST) is a prospective single-center study evaluating guideline-based acute ischemic stroke care at an Acute Stroke Ready Hospital (ASRH) pre- and post-initiation of a specialist telestroke inpatient rounding service. TELECAST 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 is to determine whether specialist telestroke inpatient rounding improves guideline-based acute stroke care when compared to non-specialist stroke care. The primary outcome of TELECAST is a composite score comprising 4 categories: diagnostic stroke evaluation, secondary stroke prevention, health screening and evaluation, and stroke education. Individual components of the primary outcome were primarily 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 beginning after a 3-month lead in phase.

Official Title
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Telestroke for Comprehensive Stroke Care in Acute Stroke Ready Hospitals

Conditions
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Stroke

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 ischemic stroke admitted to Fairview Ridges Hospital Evidence of stroke on MRI or CT or clinical diagnosis of acute ischemic stroke by the treating stroke service Exclusion Criteria: Patients less than 18 years old Patients who leave the hospital against medical advice Patients with goals of care that impact the stroke evaluation (i.e. comfort measures) Patients who are felt to have an alternative diagnosis Patients who are transferred for higher-level stroke care such as endovascular thrombectomy or decompressive craniectomy

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 ischemic stroke 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 ischemic stroke 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, inpatient telestroke rounding will be used to oversee the urgent diagnostic stroke evaluation, secondary stroke prevention, health screening & evaluation, and stroke education in patients admitted with stroke.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Composite score of inpatient stroke care (%) | A 23-item global assessment of fundamental inpatient acute ischemic stroke care primarily informed by AHA guidelines/GWTG criteria comprising 4 categories: Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, troponin, head CT or 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. Health screening & evaluation (4 items): swallow evaluation, cognitive assessment, depression screening, and rehabilitation evaluation. 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 Stroke Evaluation | A 10-item global assessment of inpatient diagnostic stroke evaluation as well as individual analysis of each item. Diagnostic evaluation (10 items): neurologist evaluation, LDL, HgA1c, troponin, head CT or 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 atrial fibrillation), 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 | 
| Health Screening & Evaluation | A 4-item global assessment of health screening and evaluation as well as individual analysis of each item. Health screening & evaluation (4 items): swallow evaluation, cognitive assessment, depression screening, and rehabilitation evaluation. An item is not scored when not indicated clinically, 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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Stroke, Telestroke, Telemedicine, Secondary stroke prevention