The East of England Stroke Telemedicine Service - providing a 24

1. February 2012 The East of EnglandStroke Telemedicine Service- providing a 24/7 stroke thrombolysis service -

2. Stroke Thrombolysis A stroke is the brain equivalent of a heart attack Stroke caused caused by thrombosis (clot) or haemorrhage Stroke results in a loss of brain function due to a disturbance of the blood vessels in the brain Thrombolytic agents can help dissolve the thrombosis and prevent future disability Time is brain! Just to provide a very brief clinical context of stroke thrombolysis. Stroke is one of the top three causes of death in England and a leading cause of adult disability. There are approximately 110,000 strokes and a further 20,000 transient ischaemic attacks (TIAs) occur in England every year. At least 300,000 people in England living with moderate to severe disabilities as a result of stroke. Stroke care costs the NHS about �2.8 billion a year in direct care costs � more than the cost of treating coronary heart disease Stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism, or due to a haemorrhage. Some of the most visual physical effects are that of hemiparesis, slurred speech & confusion. Untreated, these symptoms persist and are the largest cause of disability in the UK In the case of a thrombosis, a thrombolytic agent can be administered intravenously to dissolve the clot and thereby alleviate the symptoms, with patients often returning to normal function. However the thrombolytic agent needs to be administered within a specific timeframe for maximum effectiveness. Just to provide a very brief clinical context of stroke thrombolysis. Stroke is one of the top three causes of death in England and a leading cause of adult disability. There are approximately 110,000 strokes and a further 20,000 transient ischaemic attacks (TIAs) occur in England every year. At least 300,000 people in England living with moderate to severe disabilities as a result of stroke. Stroke care costs the NHS about �2.8 billion a year in direct care costs � more than the cost of treating coronary heart disease Stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism, or due to a haemorrhage. Some of the most visual physical effects are that of hemiparesis, slurred speech & confusion. Untreated, these symptoms persist and are the largest cause of disability in the UK In the case of a thrombosis, a thrombolytic agent can be administered intravenously to dissolve the clot and thereby alleviate the symptoms, with patients often returning to normal function. However the thrombolytic agent needs to be administered within a specific timeframe for maximum effectiveness.

3. East of England Stroke Thrombolysis Service Service commenced November 2010 following successful pilot project 7 Level 1 & 8 Level 2 hospitals Level 1 hospitals � utilise telemedicine to support a local rota & access to local expert advice Level 2 hospitals access the regional rota and a Stroke Consultant Out of Hours (OOH) Telemedicine service uses videoconferencing software on a telemedicine �cart� in the Emergency Department (ED) Stroke Consultants have similar software on their laptops Contractual agreements signed by CEO.

4. Geographical Barriers

5. A Regional Service Two levels of service: Level 1: telemedicine equipment & support (�6,000) Level 2: telemedicine equipment, access to regional rota & support (�20,000) Regional Rota: 10 Stroke Consultants OOH cover 24/7/365 Telemedicine Stroke Consultants in substantive posts with appropriate training & expertise Support Service Management Hardware Software Licenses N3 Server Business Broadband provision for Consultants Training provided (face-to-face & online) Hosted at Addenbrookes Hospital Project Manager appointed April 2011 IT support from SHA There are two levels to the service. Level 1 - �6000 which provides hardware/software and also the relevant IT and management support. These hospitals use the equipment to run an internal rota system Level 2 - �20,000 provides the above, but also access to the regional rota allowing these hospitals access to a Stroke Consultant OOH for advice, management and decision making support in the administration of thrombolysis The funding also provides the all the items listed here. This includes training & support, additional business broadband installation for the Consultants' homes that require it � access to appropriate broadband is patchy across the EoE. The server is hosted on the N3 network, ensuring the appropriate level of security. The service is hosted by Addenbrookes.There are two levels to the service. Level 1 - �6000 which provides hardware/software and also the relevant IT and management support. These hospitals use the equipment to run an internal rota system Level 2 - �20,000 provides the above, but also access to the regional rota allowing these hospitals access to a Stroke Consultant OOH for advice, management and decision making support in the administration of thrombolysis The funding also provides the all the items listed here. This includes training & support, additional business broadband installation for the Consultants' homes that require it � access to appropriate broadband is patchy across the EoE. The server is hosted on the N3 network, ensuring the appropriate level of security. The service is hosted by Addenbrookes.

6. Organisation of work Week days: 17:00 hrs � 08:00 hrs Weekend: Fri 17:00 � Mon 08:00hrs 10 Stroke Consultants (Buddy system) CUHFT (Drs Warburton & Barry), PCH (Dr Owusu), NNUH (Drs Metcalfe, Gange), Southend (Dr Guyler), Ipswich (Drs Phillips & Ngeh), QEHKL (Dr Shekar) & Watford (Dr Collas) We currently have a rota of 10 Stroke Consultants (some seen here) with plans to expand this number, who provide out of hours & weekend support for provision of expert advice on stroke thrombolysis via videoconferencing The hours are 17:00 � 08:00 during the week and 17:00 Fri � 08:00 Mon and BH QUIPP Stroke Consultant - laptop access to patient & CT images 230 cases. We currently have a rota of 10 Stroke Consultants (some seen here) with plans to expand this number, who provide out of hours & weekend support for provision of expert advice on stroke thrombolysis via videoconferencing The hours are 17:00 � 08:00 during the week and 17:00 Fri � 08:00 Mon and BH QUIPP Stroke Consultant - laptop access to patient & CT images 230 cases.

7. The participating hospitals in the stroke telemedicine service are spread across the region as you can see here from the map. They are spread relatively evenly across the region � reducing ambulance times to A&E and therefore stroke to needle for stroke patients. The participating hospitals in the stroke telemedicine service are spread across the region as you can see here from the map. They are spread relatively evenly across the region � reducing ambulance times to A&E and therefore stroke to needle for stroke patients.

8. Where we are now! 360 telemedicine cases to date 7 hospitals currently access regional rota at Level 2 (shorty to be 8) Videoconferencing software upgraded to Visimeet (developed by IOCOM) Retrospective Audit underway (Nov 10 � Nov 11) Changes to the regional rota New Stroke Consultants to join regional rota from participating hospitals Two Stroke Consultants leaving regional rota (Dr Paul Cotter � Jan 2012 & Dr Gange - May 2012).

9. Overview of key outcomes to date Average length of teleconsultation = 23 mins Telephone consultation only - 25.6% of calls (n= 85) Consultant pre-alerted - 11.3% of all calls (n=38) From May 2011 (change to Audit Form) Time from ED arrival to CT scan: = 15 � 125 mins (n=55)* Time from ED arrival to teleconsultation: = 2 - 240 mins (n=51)* NIHSS range: = 0 � 28 (n=49)* ED door to needle time (thrombolysis treatment):= 30 -270 mins (n=24)* * Where documented

10. Regional Collaboration A Stakeholder Partnership was formed as a method of governance and management of the service. This means that effectively all these organisations �own� the stroke telemedicine service and meet on a � basis to discuss the implementation of ongoing delivery of the service. IOCOM is the software company that we have been working very closely with to develop the software so that is was suitable for clinical practice We also work in close collaboration with the 3 stroke and cardiac networks in the region. This has been really important in ensuring communication, effective governance and quality assurance of service delivery.A Stakeholder Partnership was formed as a method of governance and management of the service. This means that effectively all these organisations �own� the stroke telemedicine service and meet on a � basis to discuss the implementation of ongoing delivery of the service. IOCOM is the software company that we have been working very closely with to develop the software so that is was suitable for clinical practice We also work in close collaboration with the 3 stroke and cardiac networks in the region. This has been really important in ensuring communication, effective governance and quality assurance of service delivery.

11. Slide showing the nurse using the telemedicine cart in A&ESlide showing the nurse using the telemedicine cart in A&E

12. The Stroke Consultant can view the CT scan � have a high resolution screen laptop. The scan is not of diagnostic quality, but is clinically acceptable to provide a scan, by capturing the desktop image, for the Consultant to make a decision on care.The Stroke Consultant can view the CT scan � have a high resolution screen laptop. The scan is not of diagnostic quality, but is clinically acceptable to provide a scan, by capturing the desktop image, for the Consultant to make a decision on care.

13. Visimeet Software developed inVisimeet Software developed in

15. The Stroke Telemedicine website, currently hosted by the SHA, has the rota and access to Stroke EoE Stroke Room and also a Standby Room � if there is a simultaneous call, which is happening The Stroke Telemedicine website, currently hosted by the SHA, has the rota and access to Stroke EoE Stroke Room and also a Standby Room � if there is a simultaneous call, which is happening

16. To give a practical example of the service, a clinical pathway is shown here. The patient presents to the A&E dept (Hyperacute Stroke Unit in some of the hospitals) with potential stroke symptoms. The patient is assessed in the usual way and a CT scan performed. The on call Stroke Consultant is contacted using the telemedicine cart in A&ETo give a practical example of the service, a clinical pathway is shown here. The patient presents to the A&E dept (Hyperacute Stroke Unit in some of the hospitals) with potential stroke symptoms. The patient is assessed in the usual way and a CT scan performed. The on call Stroke Consultant is contacted using the telemedicine cart in A&E

23.   We were fortunate enough to win the EHI Award last year as one as innovative project using telemedicine. I was not in post at this time, but as the recently appointed Project Manager, I have been given the task of updating you all with how we have developed this telemedicine project over the last 12 months. We were fortunate enough to win the EHI Award last year as one as innovative project using telemedicine. I was not in post at this time, but as the recently appointed Project Manager, I have been given the task of updating you all with how we have developed this telemedicine project over the last 12 months.

24. Key Messages Taking a project to a managed service Using technology to support a clinical need Improved OOH availability of thrombolysis for stroke management Taking the expert to the patient Reduced diverts & repatriation of patients. The key messages for today are that: We have taken this from a project to a managed service across the EoE One of the reasons for this success is that there was an identified clinical lead �that could be effectively supported by technology. The technology was able to provide access to OOH stroke thrombolysis service across the region This essentially meant that the expert, the Stroke Consultant, was able to come to the patient using videoconferencing As a result, this has drastically reduced the number of patient diversions for treatment and their subsequent repatriation. The key messages for today are that: We have taken this from a project to a managed service across the EoE One of the reasons for this success is that there was an identified clinical lead �that could be effectively supported by technology. The technology was able to provide access to OOH stroke thrombolysis service across the region This essentially meant that the expert, the Stroke Consultant, was able to come to the patient using videoconferencing As a result, this has drastically reduced the number of patient diversions for treatment and their subsequent repatriation.

25. Outcomes More stroke patients thrombolysed during past 14 months - up to 8% Reduction in door to needle time regional adoption of updated protocol Minimises journey times fewer diverts Keeps patients closer to home Cost effective (potential saving �2.7m) On going care, transfers, rehabilitation Training/education of staff locally Rapid referral for those needing regional neurological intervention. The clinical outcomes so far: Considerably more patients have been thrombolysed within the timeframe There is a shorter stroke to needle time Fewer diversions 10% of 6000 pts = 600 x 15% (increase in independent stroke patients) = 90 pts x �30,000 (cost of care for dependent stroke survivor first year) = �2,700,000 Additional cost savings from multi site rota 230 cases. The clinical outcomes so far: Considerably more patients have been thrombolysed within the timeframe There is a shorter stroke to needle time Fewer diversions 10% of 6000 pts = 600 x 15% (increase in independent stroke patients) = 90 pts x �30,000 (cost of care for dependent stroke survivor first year) = �2,700,000 Additional cost savings from multi site rota 230 cases.

26. Overcoming technical challenges Engagement of local support Collaborate & liaising with Heads of IT & team members Wireless networks Some hospitals wireless, others wired Opening of ports in ED/Stroke Ward Consultant home IT set up Business Broadband required for some Consultants Poor sound Speakerphones to boost sound Five different PACS systems across EoE Software captures image of Desktop � ability to share a view of the CT scan Different logons required at each site Encouraged generic logons Regional server IOCOM have server on N3 network Opening firewalls Collaborating with local IT Teams to open firewalls

27. Clinical Governance The patient remains at all times under the care of the hospital in which they are treated On call Stroke Consultant remains accountable for advice they give Indemnity via employing hospital NHSLA All documentation of decision making filed in patients notes All documentation deleted from PC Consultation not recorded.

28. Lessons Learned VC software can meet the needs N3 & internet speed - business broadband Sound � use speakerphone Engagement of SHA team Widespread stakeholders must be involved Information is key � continuing information, key site lead. Keeping commissioner informed and engaged Project Management.

29. Patient Benefits Some of the patients that have benefitted from stroke telemeidicine Some of the patients that have benefitted from stroke telemeidicine

30. Future Developments Formal retrospective Audit Linking prisons to CUHFT for hepatology care Supporting pre-hospital care Outreach critical care support Paramedic primary care support Supporting other stroke services Improved management of primary to secondary care referrals Teaching & education. These are the proposed future developments These are the proposed future developments

31. Summary Service needs to be: Effective Efficient Acceptable Meets QIPP criteria Early clinical & IT engagement Good communication Address & plan for sustainability. The service meets the quality, innovation, productivity and prevention (QIPP) challenge as part of the EoE�s opportunity to prepare the NHS to defend and promote high quality care in a tighter economic climate. The service meets the quality, innovation, productivity and prevention (QIPP) challenge as part of the EoE�s opportunity to prepare the NHS to defend and promote high quality care in a tighter economic climate.

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