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Evans NR, Sibson L, Day DJ, Agarwal S, Shekhar R, Warburton EA. Hyperacute stroke thrombolysis via telemedicine: a multicentre study of performance, safety and clinical efficacy. BMJ Open 2022; 12:e057372. [PMID: 35039306 PMCID: PMC8765016 DOI: 10.1136/bmjopen-2021-057372] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Timely thrombolysis of ischaemic stroke improves functional recovery, yet its delivery nationally is challenging due to shortages in the stroke specialist workforce and large geographical areas. One solution is remote stroke specialist input to regional centres via telemedicine. This study evaluates the usage and key metrics of performance of the East of England Stroke Telemedicine Partnership-the largest telestroke service in the UK-in providing hyperacute stroke care. DESIGN Prospective observational study. SETTING The East of England Stroke Telemedicine Partnership provides a horizontal 'hubless' model of out-of-hours hyperacute stroke care to a population of 6.2 million across a 7500 square mile semirural region. PARTICIPANTS All (2709) telestroke consultations between 1 January 2014 and 31 December 2019. MAIN OUTCOME MEASURES Thrombolysis decision, pre-thrombolysis and post-thrombolysis stroke severity (National Institutes of Health Stroke Scale, NIHSS), haemorrhagic complications, and hyperacute pathway timings. RESULTS Over the period, 1149 (42.4%) individuals were thrombolysed. Thrombolysis rates increased from 147/379 (38.8%) in 2014 to 225/490 (45.9%) in 2019. Median (IQR) pre-thrombolysis NIHSS was 10 (6-17), reducing to 6 (2-14) 24-hour post-thrombolysis (p<0.001). Post-thrombolysis haemorrhage occurred in 27 cases (2.3%). Over the period, median (IQR) door-to-needle time reduced from 85 (65-108) min to 68 (55-97.5) min (p<0.01), driven by improved imaging-to-needle times from 52.5 (38-72.25) min to 42 (30.5-62.5) min (p<0.01). However, the same period saw an increase in median onset-to-hospital arrival time from 77.5 (60-109.25) min to 95 (70-135) min (p<0.001). CONCLUSIONS The results from this large hyperacute telestroke cohort indicate two important points for clinical practice. First, telemedicine via a hubless horizontal model provides a clinically effective and safe method for delivering hyperacute stroke thrombolysis. Second, improved door-to-needle times were offset by a concerning rise in prehospital timings. These findings indicate that although telemedicine may benefit in-hospital hyperacute stroke care, improvements across the whole stroke pathway are essential.
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Affiliation(s)
- Nicholas Richard Evans
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lynda Sibson
- Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Diana J Day
- Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Smriti Agarwal
- Department of Stroke Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raj Shekhar
- Department of Stroke Medicine, Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
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Burke NT, Maurice JB, Nasralla D, Potts J, Westbrook R. Recent advances in liver transplantation. Frontline Gastroenterol 2021; 13:57-63. [PMID: 34970429 PMCID: PMC8666869 DOI: 10.1136/flgastro-2020-101425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 10/19/2020] [Accepted: 11/08/2020] [Indexed: 02/04/2023] Open
Abstract
Liver transplant is a life-saving treatment with 1-year and 5-year survival rates of 90% and 70%, respectively. However, organ demand continues to exceed supply, such that many patients will die waiting for an available organ. This article reviews for the general gastroenterologist the latest developments in the field to reduce waiting list mortality and maximise utilisation of available organs. The main areas covered include legislative changes in organ donation and the new 'opt-out' systems being rolled out in the UK, normothermic machine perfusion to optimise marginal grafts, a new national allocation system to maximise benefit from each organ and developments in patient 'prehabilitation' before listing. Current areas of research interest, such as immunosuppression withdrawal, are also summarised.
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Affiliation(s)
- N Thomas Burke
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, London, UK
| | - James B Maurice
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, London, UK
| | - David Nasralla
- Hepatobiliary Surgery, Royal Free London NHS Foundation Trust, London, London, UK
| | - Jonathan Potts
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, London, UK
| | - Rachel Westbrook
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, London, UK
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3
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Patel H, Damush TM, Miech EJ, Rattray NA, Martin HA, Savoy A, Plue L, Anderson J, Martini S, Graham GD, Williams LS. Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program. BMC Health Serv Res 2021; 21:124. [PMID: 33549097 PMCID: PMC7865113 DOI: 10.1186/s12913-021-06123-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support. METHODS We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction. RESULTS Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP. CONCLUSION A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.
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Affiliation(s)
- Himalaya Patel
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA.
| | - Teresa M Damush
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring for Quality Improvement (PRIS-M) QUERI Center, Indianapolis, Indiana, USA
| | - Edward J Miech
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring for Quality Improvement (PRIS-M) QUERI Center, Indianapolis, Indiana, USA
| | - Nicholas A Rattray
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring for Quality Improvement (PRIS-M) QUERI Center, Indianapolis, Indiana, USA
| | - Holly A Martin
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring for Quality Improvement (PRIS-M) QUERI Center, Indianapolis, Indiana, USA
| | - April Savoy
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Laurie Plue
- VA Office of Specialty Care Services, Neurology, San Francisco, California, USA
| | - Jane Anderson
- VA Office of Specialty Care Services, Neurology, San Francisco, California, USA
| | - Sharyl Martini
- VA Office of Specialty Care Services, Neurology, San Francisco, California, USA
| | - Glenn D Graham
- VA Office of Specialty Care Services, Neurology, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, California, USA
| | - Linda S Williams
- Center for Health Information and Communication (CIN 13-416), Health Services Research and Development (HSR&D) Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring for Quality Improvement (PRIS-M) QUERI Center, Indianapolis, Indiana, USA
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Abstract
PURPOSE Until now, the use of telemedical applications in orthopedics was limited to sparsely populated countries. However, due to the SARS-CoV-2 pandemic, interest in orthopedics in these procedures has increased significantly. The aim of this systematic review was to find out to what extent there is scientific evidence for the use of telemedicine in the orthopedic field. METHODS A systematic literature search was carried out in various databases on randomized controlled trials (RCTs) on telemedical applications in orthopedics. RESULTS Altogether, 14 articles were identified that reported about a total of eight RCTs of telemedical applications in orthopedics. Two RCTs were about a patient-to-doctor video consultation and six RCTs were about telerehabilitation after knee and hip arthroplasty (4 × knee arthroplasty, one hip and knee arthroplasty, one hip arthroplasty). For the majority of outcome parameters evaluated, there were no significant differences between the study groups. The cost effectiveness of videoconsultations depended on the workload (number of patient consultations) as well as the effectiveness of telerehabilitation on the distance of the patient's home to the health care center (30 km round-trip). CONCLUSION There is sufficient evidence to recommend the use of telemedical methods in orthopedics. However, more research is necessary to further expand the possibilities of telemedical methods with regard to physical examination.
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Hamm JM, Greene C, Sweeney M, Mohammadie S, Thompson LB, Wallace E, Schrading W. Telemedicine in the emergency department in the era of COVID-19: front-line experiences from 2 institutions. J Am Coll Emerg Physicians Open 2020; 1:1630-1636. [PMID: 33392572 PMCID: PMC7771749 DOI: 10.1002/emp2.12204] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/21/2020] [Accepted: 07/08/2020] [Indexed: 12/15/2022] Open
Abstract
During the COVID-19 pandemic, one of the major changes that has occurred in emergency medicine is the evolution of telemedicine. With relaxation of regulatory and administrative barriers, the use of this already available technology has rapidly expanded. Telemedicine provides opportunity to markedly decrease personal protective equipment (PPE) and reduce healthcare worker exposures. Moreover, with the convenience and availability of access to medical care via telemedicine, a more fundamental change in healthcare delivery in the United States is likely. The implementation of telemedicine in the emergency department (ED) in particular has great potential to prevent the iatrogenic spread of COVID-19 and protect health care workers. Challenges to widespread adoption of telemedicine include privacy concerns, limitation of physical examination, and concerns of patient experience. In this clinical review, we discuss ED telemedicine applications, logistics, and challenges in the COVID-19 era as well as recent regulatory and legal changes. In addition, examples of telemedicine use are described from 2 institutions. Examples of future applications of telemedicine within the realm of emergency medicine are also discussed.
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Affiliation(s)
- Joel M. Hamm
- Department of Emergency MedicineUniversity of KentuckyLexingtonKentuckyUSA
| | - Chris Greene
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Mike Sweeney
- Department of Emergency MedicineUniversity of KentuckyLexingtonKentuckyUSA
| | - Setareh Mohammadie
- Department of Emergency MedicineUniversity of KentuckyLexingtonKentuckyUSA
| | - Linda B. Thompson
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Eric Wallace
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Walter Schrading
- Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Kakkar G, Zirpe KG, Sapra H, Dixit S, Chugh C, Nagaiyan S, Kumar P. Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India. Indian J Crit Care Med 2020; 24:757-762. [PMID: 33132556 PMCID: PMC7584840 DOI: 10.5005/jp-journals-10071-23511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
COVID-19 disease caused by the SARS coronavirus has caused significant morbidity and mortality around the world ever since it was first declared as a pandemic by the World Health Organization (WHO) in March 2020. Acute neurological manifestations of this disease have also started emerging and being recognized around the world and acute ischemic stroke (AIS) or thrombotic stroke is becoming one of the major neurological illnesses related to COVID-19. The management of AIS is time-critical and major advances in its management over the recent years, such as bridging thrombolysis and mechanical thrombectomy (MT), are multidisciplinary activities requiring robust coordination and management in the acute setting. All these advances are severely challenged in the COVID-19 pandemic where severe pressures exist on the clinical resources and logistics required to deliver an effective stroke service. This is further compromised by legal and preventive measures during this pandemic like local lockdowns. Reporting of minor or initial symptoms has also been compromised due to the fear of approaching healthcare settings which are perceived as high-risk zones to catch the infection. The purpose of this document is to highlight these challenges and provide a guiding framework for the management of AIS under three principles: (a) Delivering an effective service, (b) Preventing infections within the healthcare setting, and (c) Optimizing resource utilization. How to cite this article: Kakkar G, Zirpe KG, Sapra H, Dixit S, Chugh C, Nagaiyan S, et al. Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India. Indian J Crit Care Med 2020;24(9):757-762.
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Affiliation(s)
- Gaurav Kakkar
- Department of Neuroanaesthesia and Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India
| | - Kapil G Zirpe
- Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Neurocritical Care, Medanta–The Medicity, Gurugram, Haryana, India
| | - Subhal Dixit
- Department of CCM, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Chandril Chugh
- Department of Interventional Neurology, Max Superspecialty Hospital, Delhi, India
| | - Sridhar Nagaiyan
- Department of Critical Care, Kauveri Hospital, Chennai, Tamil Nadu, India
| | - Prashant Kumar
- Department of Anaesthesiology and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Qureshi AI, Abd-Allah F, Al-Senani F, Aytac E, Borhani-Haghighi A, Ciccone A, Gomez CR, Gurkas E, Hsu CY, Jani V, Jiao L, Kobayashi A, Lee J, Liaqat J, Mazighi M, Parthasarathy R, Steiner T, Suri MFK, Toyoda K, Ribo M, Gongora-Rivera F, Oliveira-Filho J, Uzun G, Wang Y. Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel. Int J Stroke 2020; 15:540-554. [DOI: 10.1177/1747493020923234] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Foad Abd-Allah
- Department of Neurology, Kasralainy school of Medicine, Cairo University, Cairo, Egypt
| | - Fahmi Al-Senani
- Neurology Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Emrah Aytac
- Department of Neurology, University of FIRAT, Elazig Turkey
| | | | - Alfonso Ciccone
- Department of Neurosciences, Hospital Carlo Poma, ASST di Mantova, Mantua, Italy
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, MO, USA
| | - Erdem Gurkas
- Stroke Center, Department of Neurology, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE, USA
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Jahanzeb Liaqat
- Pakistan Emirates Military Hospital (J.L.), Rawalpindi, Pakistan
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain
| | - Fernando Gongora-Rivera
- Servicio de Neurología, Hospital Universitario José Eleuterio González de la Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México; Instituto de Neurología y Neurocirugía, Hospital Zambrano Hellion, Tecnológico de Monterrey, San Pedro, Nuevo León, México
| | | | - Guven Uzun
- Beverly Hills Pain Institute and Neurology, Beverly Hills, CA, USA
| | - Yongjun Wang
- Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China
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O'Cathail M, Sivanandan MA, Diver C, Patel P, Christian J. The Use of Patient-Facing Teleconsultations in the National Health Service: Scoping Review. JMIR Med Inform 2020; 8:e15380. [PMID: 32175911 PMCID: PMC7105931 DOI: 10.2196/15380] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/13/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The National Health Service (NHS) Long-Term Plan has set out a vision of enabling patients to access digital interactions with health care professionals within 5 years, including by video link. OBJECTIVE This review aimed to examine the extent and nature of the use of patient-facing teleconsultations within a health care setting in the United Kingdom and what outcome measures have been assessed. METHODS We conducted a systematic scoping review of teleconsultation studies following the Joanna Briggs Institute methodology. PubMed, Scopus, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were searched up to the end of December 2018 for publications that reported on the use of patient-facing teleconsultations in a UK health care setting. RESULTS The search retrieved 3132 publications, of which 101 were included for a full review. Overall, the studies were heterogeneous in design, in the specialty assessed, and reported outcome measures. The technology used for teleconsultations changed over time with earlier studies employing bespoke, often expensive, solutions. Two-thirds of the studies, conducted between 1995 and 2005, used this method. Later studies transitioned to Web-based commercial solutions such as Skype. There were five outcome measures that were assessed: (1) technical feasibility, (2) user satisfaction, (3) clinical effectiveness, (4) cost, (5) logistical and operational considerations. Due to the changing nature of technology over time, there were differing technical issues across the studies. Generally, teleconsultations were acceptable to patients, but this was less consistent among health care professionals. However, among both groups, face-to-face consultations were still seen as the gold standard. A wide range of clinical scenarios found teleconsultations to be clinically useful but potentially limited to more straightforward clinical interactions. Due to the wide array of study types and changes in technology over time, it is difficult to draw definitive conclusions on the cost involved. However, cost savings for health care providers have been demonstrated by the goal-directed implementation of teleconsultations. The integration of technology into routine practice represents a complex problem with barriers identified in funding and hospital reimbursement, information technologies infrastructure, and integration into clinicians' workflow. CONCLUSIONS Teleconsultations appear to be safe and effective in the correct clinical situations. Where offered, it is likely that patients will be keen to engage, although teleconsultations should only be offered as an option to support traditional care models rather than replace them outright. Health care staff should be encouraged and supported in using teleconsultations to diversify their practice. Health care organizations need to consider developing a digital technology strategy and implementation groups to assist health care staff to integrate digitally enabled care into routine practice. The introduction of new technologies should be assessed after a set period with service evaluations, including feedback from key stakeholders.
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Affiliation(s)
- Micheal O'Cathail
- School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Department of Oncology & Radiotherapy, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - M Ananth Sivanandan
- Department of Oncology & Radiotherapy, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Claire Diver
- School of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Poulam Patel
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Judith Christian
- Department of Oncology & Radiotherapy, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,School of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
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Ohannessian R, Schott AM, Colin C, Nighoghossian N, Medeiros de Bustos E, Moulin T. Acute telestroke in France: A systematic review. Rev Neurol (Paris) 2020; 176:316-324. [PMID: 32147201 DOI: 10.1016/j.neurol.2019.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/12/2019] [Accepted: 11/18/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute telestroke is the use of telemedicine to improve acute stroke care. It has demonstrated to be a safe and effective medical practice. Since 2011, acute telestroke has been promoted by the Ministry of Health in France, and in 2018 many regions were in the process or completion of implementing telestroke. The objective of this study was to describe acute telestroke implementation in France. METHODS A systematic review was conducted using PubMed and ScienceDirect databases. Articles and abstracts in English and French, published between January 1st, 2000 to April 30th, 2018 were used. Studies conducted in France and that had presented an outcome evaluation of a regional acute telestroke activity were included. No meta-analysis was conducted. RESULTS A total of 24 studies (14 in French, 10 in English) were included, with 13 published articles (7 indexed on PubMed) and 11 abstracts. Among the 13 published articles, there were seven observational retrospective studies, one quasi-experimental before-after study, one experimental randomised controlled trial, and four medico-economic studies. All telestroke network models of care were drip-and-ship with hub and spoke organisation. The case-control studies did not show a difference with or without telemedicine. The territorial thrombolysis rate was measured in two regions, with an increase in Franche-Comté from 0.2% (2004) to 9.9% (2015), and a relative increase of 76% in Nord-Pas-de-Calais between 2009-2010 and 2012. CONCLUSION Implementation of acute telestroke in France had a positive clinical and public health impact but the evaluation remained limited and needs to be supported.
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Affiliation(s)
- R Ohannessian
- CIC-1431 Inserm département de Neurologie, EA 481 laboratoire de neurosciences intégratives et cliniques université de Franche-Comté, UBFC, CHRU de Besançon, Besançon, France; Télémédecine 360, TLM360, Paris, France.
| | - A-M Schott
- HESPER EA 7425, université Lyon, université Claude Bernard Lyon 1, 69008 Lyon, France; Pôle IMER, hospices civils de Lyon, 69003 Lyon, France
| | - C Colin
- HESPER EA 7425, université Lyon, université Claude Bernard Lyon 1, 69008 Lyon, France; Pôle IMER, hospices civils de Lyon, 69003 Lyon, France
| | - N Nighoghossian
- Unité neurovasculaire, hôpital Pierre-Wertheimer, hospices Civils de Lyon, 69677 Bron cedex, France
| | | | - T Moulin
- Department of Neurology, University Hospital of Besançon, Besançon, France; French Society of Telemedicine, Paris, France
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Sharma R, Zachrison KS, Viswanathan A, Matiello M, Estrada J, Anderson CD, Etherton M, Silverman S, Rost NS, Feske SK, Schwamm LH. Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes. Circ Cardiovasc Qual Outcomes 2020; 13:e005903. [PMID: 32126805 PMCID: PMC7374496 DOI: 10.1161/circoutcomes.119.005903] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network. METHODS AND RESULTS We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τβ nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03). CONCLUSIONS Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.
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Affiliation(s)
- Richa Sharma
- Dept of Neurology, Yale University School of Medicine
| | | | - Anand Viswanathan
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Marcelo Matiello
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Juan Estrada
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Christopher D. Anderson
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Mark Etherton
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Scott Silverman
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Natalia S. Rost
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | | | - Lee H. Schwamm
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
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11
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Alasheev AM, Hubert GJ, Santo GC, Vanhooren GT, Zvan B, Campos ST, Abilleira S, Corea F. Recommendations on telestroke in Europe. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:33-41. [DOI: 10.17116/jnevro202012003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Hubert GJ, Santo G, Vanhooren G, Zvan B, Tur Campos S, Alasheev A, Abilleira S, Corea F. Recommendations on telestroke in Europe. Eur Stroke J 2018; 4:101-109. [PMID: 31259258 DOI: 10.1177/2396987318806718] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/20/2018] [Indexed: 11/17/2022] Open
Abstract
Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. The aim of this article is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organisation on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organisation stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organisation stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).
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Affiliation(s)
- Gordian J Hubert
- Department of Neurology, TEMPiS network, Munich Clinic, Munich, Germany
| | - Gustavo Santo
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Geert Vanhooren
- Department of Neurology, AZ Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - Bojana Zvan
- TeleKap network, Ljubljana University Medical Center, Ljubljana, Slovenia
| | | | - Andrey Alasheev
- Sverdlovsk Regional Clinical Hospital #1, Yekaterinburg, Russia
| | - Sònia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Francesco Corea
- Stroke and Neurology Clinic, San Giovanni Battista Hospital, Foligno, Italy
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13
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Ekeland AG, Hansen AH, Bergmo TS. Clinical Videoconferencing as eHealth: A Critical-Realist Review and Qualitative Meta-Synthesis. J Med Internet Res 2018; 20:e282. [PMID: 30361197 PMCID: PMC6231801 DOI: 10.2196/jmir.8497] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 03/22/2018] [Accepted: 07/28/2018] [Indexed: 12/19/2022] Open
Abstract
Background Earlier work has described videoconferencing technologies, peripheral equipment, organizational models, human relations, purposes, goals and roles as versatile, multifaceted, and those used differently in different clinical practices. Knowledge about benefits and challenges connected to specific characteristics of services are lacking. A 2005 systematic review of published definitions of electronic health (eHealth) identified 51 unique definitions. In addition, the “10 E’s of eHealth” was developed. In 2015, the question “What Is eHealth: Time for an Update?” was posed. Objective Considering videoconferencing as eHealth, the objective of the paper is twofold: to demonstrate and cluster (different) clinical videoconferencing practices and their situated implications and to suggest interpretive concepts that apply to all clusters and contribute to generative learning of eHealth by discussing the concepts as add-ons to existing descriptions of eHealth in the “10 E’s of eHealth.” Methods We performed a literature search via the National Center for Biotechnology Information, encompassing PubMed and PubMedCentral, for quality reviews and primary studies. We used the terms “videoconferencing” and “clinical practices.” The selection process was based upon clearly defined criteria. We used an electronic form to extract data. The analysis was inspired by critical and realist review types, grounded theory, and qualitative meta-synthesis. Results The search returned 354 reviews and primary studies. This paper considered the primary studies, and 16 were included. We identified the following 4 broad clusters: videoconferencing as a controlled technological intervention within existing health care organizations for expert advice, controlled mixed interventions with experimental organizational arrangements, videoconferencing as an emerging technosocial service involving dialogue and empowerment of patients, and videoconferencing as a controlled intervention to improve administrative efficiency. The analysis across the clusters resulted in a proposal to add the following 4 D’s to the existing 10 E’s: (inter)-dependent, differentiated across services and along temporal lines, dynamic in terms of including novel elements for meeting incremental needs, and demanding in terms of making new challenges and dual results visible and needing fresh resources to meet those challenges. For a normative discussion about what eHealth should be according to authors’ conclusions, results suggested ethical, in that users interests should be respected, and not harmful in terms of increasing symptom burden. Conclusions Services were enacted as dynamic, differentiated concerning content and considerations of quality and adaptive along temporal lines. They were made to work from an ongoing demand for fresh resources, making them interdependent. The 4 D’s—Dynamic, Differentiated, Demanding, and (inter) Dependent—serve as pragmatic add-ons to the “10 E’s of eHealth.” Questions concerning outcome of specified balances between standardization and customization in clinical settings should be addressed in future research along with the emerging dual character of outcome: services being considered both “good” and “bad.”
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Affiliation(s)
- Anne Granstrøm Ekeland
- Norwegian Centre for eHealth Research, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Helen Hansen
- Centre for Quality Improvement and Development, University Hospital of North Norway, Tromsø, Norway.,Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Trine Strand Bergmo
- Norwegian Centre for eHealth Research, University Hospital of North Norway, Tromsø, Norway
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14
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Carvalho VS, Picanço MR, Volschan A, Bezerra DC. Impact of simulation training on a telestroke network. Int J Stroke 2018; 14:500-507. [DOI: 10.1177/1747493018791030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Stroke is a leading cause of morbidity and mortality in Brazil, where there are significant imbalances in access to specialized stroke care. Telemedicine networks allow patients to receive neurological evaluation and intravenous thrombolysis in underserved areas, where performance measures are challenging. Aims To describe the impact caused by adequate stroke care training, using realistic simulation, in a developing country telestroke network. Methods Retrospective observational study comparing the number of all stroke diagnoses, thrombolysis rate, door-to-needle time and symptomatic intracranial hemorrhage after intravenous thrombolysis, during one year providing just algorithms and orientation in stroke care to spoke facilities (phase 1), with the results achieved along one year after the beginning of ongoing live training sessions (phase 2). Results The mean number of patients diagnosed with stroke increased from 7.5 to 16.58 per month ( P = 0.019) rising from 90 patients during phase 1 to 199 in phase 2. There was a reduction in the mean door-to-needle time from 137.1 to 95.5 min (−41.58; 95% CI −62.77 to −20.40). The thrombolysis and symptomatic intracranial hemorrhage rates had a non-significant decrease from 21.31% to 18.18% (OR 0.82; 95% CI 0.39 to 1.71) and 12.5% to 7.69% (OR 0.58; 95% CI 0.046 to 7.425), respectively. Conclusions Realistic simulation stroke care training provided by stroke centers to spoke facilities seems to significantly reduce door-to-needle time and enhance adherence in a telestroke network.
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Affiliation(s)
| | - Miguel R Picanço
- Department of Neurology, Hospital Pró-Cardíaco, Rio de Janeiro, Brazil
| | - André Volschan
- Department of Education and Research, Hospital Pró-Cardíaco, Rio de Janeiro, Brazil
| | - Daniel C Bezerra
- Department of Neurology, Hospital Pró-Cardíaco, Rio de Janeiro, Brazil
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15
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Tai D, Dhar A, Yusuf A, Marshall A, O'Beirne J, Patch D, Tsochatzis E, Alexander G, Portal J, Thalheimer U, Thorburn D, Kallis Y, Westbrook R. The Royal Free Hospital ‘hub-and-spoke network model’ delivers effective care and increased access to liver transplantation. Public Health 2018; 154:164-171. [DOI: 10.1016/j.puhe.2017.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/09/2017] [Accepted: 10/19/2017] [Indexed: 01/16/2023]
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16
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Nguyen-Huynh MN, Klingman JG, Avins AL, Rao VA, Eaton A, Bhopale S, Kim AC, Morehouse JW, Flint AC. Novel Telestroke Program Improves Thrombolysis for Acute Stroke Across 21 Hospitals of an Integrated Healthcare System. Stroke 2017; 49:133-139. [PMID: 29247142 PMCID: PMC5753819 DOI: 10.1161/strokeaha.117.018413] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/08/2017] [Accepted: 11/15/2017] [Indexed: 12/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Faster treatment with intravenous alteplase in acute ischemic stroke is associated with better outcomes. Starting in 2015, Kaiser Permanente Northern California redesigned its acute stroke workflow across all 21 Kaiser Permanente Northern California stroke centers to (1) follow a single standardized version of a modified Helsinki model and (2) have all emergency stroke cases managed by a dedicated telestroke neurologist. We examined the effect of Kaiser Permanente Northern California’s Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke program on door-to-needle (DTN) time, alteplase use, and symptomatic intracranial hemorrhage rates. Methods— The program was introduced in a staggered fashion from September 2015 to January 2016. We compared DTN times for a seasonally adjusted 9-month period at each center before implementation to the corresponding 9-month calendar period from the start of implementation. The primary outcome was the DTN time for alteplase administration. Secondary outcomes included rate of alteplase administrations per month, symptomatic intracranial hemorrhage, and disposition at time of discharge. Results— This study included 310 patients treated with alteplase in the pre–EXpediting the PRrocess of Evaluating and Stopping Stroke period and 557 patients treated with alteplase in the EXpediting the PRrocess of Evaluating and Stopping Stroke period. After implementation, alteplase administrations increased to 62/mo from 34/mo at baseline (P<0.001). Median DTN time decreased to 34 minutes after implementation from 53.5 minutes prior (P<0.001), and DTN time of <60 minutes was achieved in 87.1% versus 61.0% (P<0.001) of patients. DTN times <30 minutes were much more common in the Stroke EXpediting the PRrocess of Evaluating and Stopping Stroke period (40.8% versus 4.2% before implementation). There was no significant difference in symptomatic intracranial hemorrhage rates in the 2 periods (3.8% versus 2.2% before implementation; P=0.29). Conclusions— Introduction of a standardized modified Helsinki protocol across 21 hospitals using telestroke management was associated with increased alteplase administrations, significantly shorter DTN times, and no increase in adverse outcomes.
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Affiliation(s)
- Mai N Nguyen-Huynh
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.).
| | - Jeffrey G Klingman
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Andrew L Avins
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Vivek A Rao
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Abigail Eaton
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Sunil Bhopale
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Anne C Kim
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - John W Morehouse
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
| | - Alexander C Flint
- From the Division of Research, Kaiser Permanente Northern California, Oakland (M.N.N.-H., A.L.A., A.C.F., A.E.); Departments of Neuroscience (A.C.F., V.A.R.) and Emergency Medicine (S.B.), Kaiser Permanente, Redwood City, CA; Departments of Neurology (M.N.N.-H., J.G.K.) and Radiology (A.C.K.), Kaiser Permanente, Walnut Creek, CA; and Department of Emergency Medicine, Kaiser Permanente, Oakland, CA (J.W.M.)
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17
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Blanc-Labarre C, Delpont B, Hervieu-Bègue M, Osseby GV, Ricolfi F, Thouant P, Giroud M, Béjot Y. [Acute management of ischemic stroke in 2017]. Rev Med Interne 2017; 39:408-413. [PMID: 28867531 DOI: 10.1016/j.revmed.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/24/2017] [Indexed: 01/19/2023]
Abstract
Acute management of ischemic stroke is a burning topic in 2017 since stroke represents the leading cause of acquired handicap in adults. Over the last past years, major improvement took place, especially with the demonstration of the efficacy of mechanical thrombectomy, thus needing to better organize care pathways, and optimize access to neurologists and interventional neuroradiology platforms. Intensive care stroke units remain the pivotal place of patients' management. A multidisciplinary coordination is required, with continuous teaching of all the actors involved in stroke management, so as to increase the number of patients who could benefit from available active treatments.
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Affiliation(s)
- C Blanc-Labarre
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - B Delpont
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - M Hervieu-Bègue
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - G-V Osseby
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - F Ricolfi
- Service de Neuroradiologie, CHU de Dijon-Bourgogne, Dijon, France
| | - P Thouant
- Service de Neuroradiologie, CHU de Dijon-Bourgogne, Dijon, France
| | - M Giroud
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Y Béjot
- Service de neurologie générale, vasculaire et dégénérative, registre dijonnais des AVC Dijon, EA7460, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France.
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18
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Porter J, Hall RE, Kapral MK, Fang J, Khan F, Silver FL. Outcomes following telestroke-assisted thrombolysis for stroke in Ontario, Canada. J Telemed Telecare 2017; 24:492-499. [PMID: 28691864 DOI: 10.1177/1357633x17717601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Since 2002, the Ontario Telestroke Program has provided hospitals in under-served regions of the province the opportunity to offer intravenous thrombolysis with tissue plasminogen activator (IV tPA) to eligible patients. The purpose of this study was to determine whether telestroke-assisted IV tPA patients had similar risks of 7- and 90-day mortality, symptomatic intracerebral haemorrhage (sICH), and poor functional outcome compared to patients who received IV tPA with on-site expertise. Methods Data from two audits of patients with acute ischaemic stroke hospitalized in Ontario, Canada in 2010 and 2012 were analysed. We modelled the risk of all-cause death within 7 and 90 days of receiving IV tPA using proportional hazards adjusting for hospital type, patient characteristics, and whether IV tPA was administered as part of a telestroke consultation. Outcomes of sICH and modified Rankin Scale ≥ 3 at discharge were modelled using generalized estimating equations adjusting for the same variables used in the mortality model. Results There was no difference in 7- or 90-day mortality among those who received IV tPA with telestroke ( n = 214) compared to those without ( n = 1885) (7-day adjusted hazard ratio (aHR) 1.29 (95% confidence interval (CI) 0.68, 2.44); 90-day aHR 1.01 (95% CI 0.67, 1.50)). Complications were similar between groups, with an adjusted odds ratio (aOR) for sICH of 0.71 (95% CI 0.29, 1.71) and an aOR of 0.75 (95% CI 0.46, 1.23) for poor functional ability at discharge. Discussion Patients receiving IV tPA supported by telestroke had similar outcomes to those managed with on-site expertise.
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Affiliation(s)
- Joan Porter
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Ruth E Hall
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada.,2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,3 Ontario Stroke Network, Toronto, Canada
| | - Moira K Kapral
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada.,2 Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,4 Department of Medicine, University of Toronto, Toronto, Canada.,5 Division of General Medicine and Toronto General Research Institute, University Health Network, Toronto, Canada
| | - Jiming Fang
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Ferhana Khan
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Frank L Silver
- 1 Institute for Clinical Evaluative Sciences, Toronto, Canada.,4 Department of Medicine, University of Toronto, Toronto, Canada.,6 Krembil Neuroscience Program, University Health Network, Toronto, Canada
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19
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Wade V, Stocks N. The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review. Heart Lung Circ 2016; 26:331-337. [PMID: 27993487 DOI: 10.1016/j.hlc.2016.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 10/07/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022]
Abstract
Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.
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Affiliation(s)
- Victoria Wade
- Discipline of General Practice, School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia.
| | - Nigel Stocks
- Discipline of General Practice, School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia
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20
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Wechsler LR, Demaerschalk BM, Schwamm LH, Adeoye OM, Audebert HJ, Fanale CV, Hess DC, Majersik JJ, Nystrom KV, Reeves MJ, Rosamond WD, Switzer JA. Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 48:e3-e25. [PMID: 27811332 DOI: 10.1161/str.0000000000000114] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. METHODS A literature search was undertaken to examine the current status of telestroke and relevant quality indicators. The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. RESULTS Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation.
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Deldar K, Bahaadinbeigy K, Tara SM. Teleconsultation and Clinical Decision Making: a Systematic Review. Acta Inform Med 2016; 24:286-292. [PMID: 27708494 PMCID: PMC5037984 DOI: 10.5455/aim.2016.24.286-292] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/15/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations. METHOD The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library. RESULTS 174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles. CONCLUSION The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired.
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Affiliation(s)
- Kolsoum Deldar
- Student Research Committee, Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Kambiz Bahaadinbeigy
- Medical Informatics Research Center, Institute of Futures Studies in Health, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Seyed Mahmood Tara
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
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Legris N, Hervieu-Bègue M, Daubail B, Daumas A, Delpont B, Osseby GV, Rouaud O, Giroud M, Béjot Y. Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety. Eur J Neurol 2016; 23:1433-40. [PMID: 27194487 DOI: 10.1111/ene.13054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/21/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the context of the development of telemedicine in France to address low thrombolysis rates and limited stroke infrastructures, a star-shaped telestroke network was implemented in Burgundy (1.6 million inhabitants). We evaluated the safety and effectiveness of this network for thrombolysis in acute ischemic stroke patients. METHODS One hundred and thirty-two consecutive patients who received intravenous thrombolysis during a telemedicine procedure (2012-2014) and 222 consecutive patients who were treated at the stroke center of Dijon University Hospital, France (2011-2012) were included. Main outcomes were the modified Rankin scale (mRS) score and case fatality at 3 months. Comparisons between groups were made using multivariable ordinal logistic regression and logistic regression analyses, respectively. RESULTS Baseline characteristics of telethrombolysis patients were similar to those of patients undergoing thrombolysis locally except for a higher frequency of previous cancer and pre-morbid handicap, and a trend towards greater severity at admission in the former. The distribution of mRS scores at 3 months was similar between groups, as were case-fatality rates (18.9% in the telethrombolysis group versus 16.5%, P = 0.56). In multivariable models, telethrombolysis did not independently influence functional outcomes at 3 months (odds ratio for a shift towards a worse outcome on the mRS, 1.11; 95% confidence interval, 0.74-1.66, P = 0.62) or death (odds ratio, 0.86; 95% confidence interval, 0.44-1.69, P = 0.66). CONCLUSION The implementation of a regional telemedicine network for the management of acute ischemic stroke appeared to be effective and safe. Thanks to this network, the proportion of patients who benefit from thrombolysis will increase. Further research is needed to evaluate economic benefits.
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Affiliation(s)
- N Legris
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - M Hervieu-Bègue
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - B Daubail
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - A Daumas
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - B Delpont
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - G-V Osseby
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - O Rouaud
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - M Giroud
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Y Béjot
- Dijon Stroke Registry, EA4184, Department of Neurology, University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
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A one-to-one telestroke network: the first Italian study of a web-based telemedicine system for thrombolysis delivery and patient monitoring. Neurol Sci 2016; 37:725-30. [DOI: 10.1007/s10072-016-2569-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 03/22/2016] [Indexed: 11/25/2022]
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Akbik F, Hirsch JA, Chandra RV, Frei D, Patel AB, Rabinov JD, Rost N, Schwamm LH, Leslie-Mazwi TM. Telestroke-the promise and the challenge. Part one: growth and current practice. J Neurointerv Surg 2016; 9:357-360. [PMID: 26984868 DOI: 10.1136/neurintsurg-2016-012291] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/20/2016] [Indexed: 11/04/2022]
Abstract
Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the first of a detailed two part review, and explores the growth and current practice of telestroke, including the specific role it plays in the assessment and management of patients after emergent large vessel occlusion.
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Affiliation(s)
- F Akbik
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J A Hirsch
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - R V Chandra
- Department of Neuroendovascular, Monash University Hospital, Melbourne, Australia
| | - D Frei
- Department of NeuroInterventional Surgery, Radiology Imaging Associates/RIA Neurovascular, Swedish Medical Center, Englewood, Colorado, USA
| | - A B Patel
- Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J D Rabinov
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - N Rost
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - L H Schwamm
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - T M Leslie-Mazwi
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
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Amadi-Obi A, Gilligan P, Owens N, O'Donnell C. Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment. Int J Emerg Med 2014; 7:29. [PMID: 25635190 PMCID: PMC4306051 DOI: 10.1186/s12245-014-0029-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 06/19/2014] [Indexed: 12/22/2022] Open
Abstract
The right person in the right place and at the right time is not always possible; telemedicine offers the potential to give audio and visual access to the appropriate clinician for patients. Advances in information and communication technology (ICT) in the area of video-to-video communication have led to growth in telemedicine applications in recent years. For these advances to be properly integrated into healthcare delivery, a regulatory framework, supported by definitive high-quality research, should be developed. Telemedicine is well suited to extending the reach of specialist services particularly in the pre-hospital care of acute emergencies where treatment delays may affect clinical outcome. The exponential growth in research and development in telemedicine has led to improvements in clinical outcomes in emergency medical care. This review is part of the LiveCity project to examine the history and existing applications of telemedicine in the pre-hospital environment. A search of electronic databases including Medline, Excerpta Medica Database (EMBASE), Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant papers was performed. All studies addressing the use of telemedicine in emergency medical or pre-hospital care setting were included. Out of a total of 1,279 articles reviewed, 39 met the inclusion criteria and were critically analysed. A majority of the studies were on stroke management. The studies suggested that overall, telemedicine had a positive impact on emergency medical care. It improved the pre-hospital diagnosis of stroke and myocardial infarction and enhanced the supervision of delivery of tissue thromboplasminogen activator in acute ischaemic stroke. Telemedicine presents an opportunity to enhance patient management. There are as yet few definitive studies that have demonstrated whether it had an effect on clinical outcome.
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Affiliation(s)
- Ahjoku Amadi-Obi
- Clinical Research Department, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland ; Emergency Department, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - Peadar Gilligan
- Emergency Department, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - Niall Owens
- School of Medicine, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Cathal O'Donnell
- National Ambulance Services, Oak House, Millennium Park, Naas, County Kildare, Ireland
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Sibson L. The use of telemedicine technology to support in pre-hospital patient care. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/jpar.2014.6.7.344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Lynda Sibson
- independent nusres consultant; lecturer, FD Paramedic Studies, Coventry University; telemedicine project manager, Addenbrooke's Hospital, Cambridge
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