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A 10 year adventure in stroke telemedicine

A stroke telemedicine partnership has been a transformative force in England for a decade – and is now an example to others seeking better outcomes, as NR Times reports.

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The East of England Stroke Telemedicine Partnership has been delivering consultant expertise to the bedside of stroke patients for a decade. NR Times reports on its learnings and successes at a time when healthcare teams across the world are looking for guidance in telemedicine.

The Covid-19 pandemic has raised the profile of telemedicine in the NHS; but the idea of using technology for the remote triage, treatment and support of patients is far from new.

The East of England Stroke Telemedicine Stakeholder Partnership has been delivering a successful thrombolysis service for patients with acute ischaemic stroke for a decade.

Video conferencing technology supplied by Visionable has enabled the consultants on its rota to interact with hospital base teams and patients.

Lynda Sibson, the partnership’s telemedicine manager, says: “A cart is taken to the patient’s bedside, so the stroke consultant can talk to the stroke nurse and to the patient, and see their CT scan, and decide whether to thrombolyse [administer ‘clot busting’ drugs].

“Many projects that are called telemedicine give a clinician a data feed or access to the scan; but that is not telemedicine. Being able to see the patient really matters.”

Covering an area of 7,500 square miles and 5.6 million people

The partnership works with seven hospitals that serve a largely rural area. It was set up in 2010 after a review found the region was struggling to meet national target times for delivering thrombolysis to patients with acute ischaemic stroke (AIS).

Thrombolysis drugs, which dissolve the blood clots that form in the arteries feeding the brain, need to be given quickly, but only to the right patients. This decision is taken carefully by specialist stroke consultant, after going through detailed clinical information.

So, patients need to be assessed before treatment. In the East of England, long travel times meant it was not possible to transfer patients who arrived at their local hospital to another hospital on a hub-and-spoke model.

Yet a shortage of stroke physicians made it impractical to offer a 24-hour consultant service at every hospital. So, a decision was made to use digital technology to support a rota of skilled stroke consultants, who could provide expert advice remotely.

Visionable technology brings specialist advice to the bedside

Now, when an AIS patient arrives out of hours, a cart is taken to their bedside by the base team, which sets up a video link to the consultant on call. By its tenth anniversary, the service had assessed 4,185 patients, of which 1,788 or 42.7 per cent have been thrombolysed.

Just 478 or 20 per cent of the patients who were not thrombolysed missed the critical 4.5 hour timeframe and, while door to needle time varies across the seven hospitals, the service has been able to achieve a DTN of just 46 minutes.

Clinical lead Raj Shekhar, who is also a consultant at The Queen Elizabeth Hospital Kings Lynn, says: “We are using video telemedicine to provide safe care in a good, clinically well-governed environment. We have always had telephone support for our junior colleagues, but this is very different.

“We have very clear video streaming. That is the particular benefit of this system; we can assess as if we were assessing at the bedside.

“We can talk through the computer to the patient, talk them through the assessment, explain what is happening, make sure there is informed decision making, and that they are kept in the loop.

“Or, we can talk to their next of kin or the clinical team. We can get confirmation of our assessment and see treatment being given. We also have software to create a report. Everything is written up and can be printed from the system, so there is a note for the patient record, and data for audit.

“Thanks to the ongoing training and education that we do with base clinical nursing and junior medical staff, each consultation is just 15 to 17 minutes long; so it is a very fast paced environment.

“However, we have been doing this for ten years now with no clinical or governance concerns, and that makes us very confident with this way of providing safe care in a timely fashion.”

Lessons learned

The partnership has learned lessons that NHS services new to remote working and teleconsultation may wish to consider.

Both Sibson and Shekhar say good admin and IT support is essential, to make sure that the rota is kept up to date, new consultants are ‘buddied’ with experienced colleagues, base teams have a single number to call when they need it, and there are no network or log-in issues.

They also stress the need to train junior doctors in how to spot stroke and when to refer to the service. This can be a challenge as they move through short rotations during their training.

Also they underline the need for good clinical champions, a role fulfilled in the East of England by the lead stroke nurse at each hospital; and to make sure that everybody involved is comfortable with their role and the technology.

Moving onto the wards; and into ambulances

The partnership is exploring new ideas for how it could extend its support for stroke services. Starting in early 2021 with Queen Elizabeth Hospital Kings Lynn, it is in the process of establishing a ‘virtual ward round’ for patients who have had a stroke but are at low risk and not suitable for thrombolysis.

The government has set a target for patients in this situation to be reviewed by a consultant within 14 hours and seen by a consultant within 24 hours of admission, and the virtual ward round should help local hospitals to deliver this.

The telemedicine carts used to deliver the thrombolysis service in emergency departments are too big to use easily on wards and present infection control challenges, so the service is experimenting with iPads and iPhones that enable clinicians to access Visionable’s platform through a browser.

Meanwhile, the partnership has been working with the East of England Ambulance Service NHS Trust on a project to assess whether people with stroke symptoms are suffering from a stroke or a ‘stroke mimic’ such as a migraine or a transient ischaemic attack (TIA).

TIAs are caused by a temporary disruption in the blood supply to the brain, and don’t require the same treatment, although they may be a ‘warning sign’ for stroke in the future.

A study established that around 40per cent of the patients in the East of England being taken into hospital with stroke symptoms were experiencing a stroke mimic.

So, the partnership set up a trial to give ambulance teams an iPad with the Visionable app loaded on it that they could use to call a consultant for advice.

Although the study was a small one, all but one of the patients involved – who had a chest infection – was able to stay safe at home and then attend a TIA clinic if appropriate.

Sibson says: “The project went really well. The ambulance service thought it was a great idea and patients loved it. One of the things that it demonstrated is that telemedicine is not second-rate care, but another pathway into care that can be better for everybody involved.

“If stroke mimic patients are taken into hospital, then they can often spend hours in A&E, only to be sent home and then told to come back to a clinic for treatment. If they avoid doing that, it’s a better outcome for everybody.”

Setting a new standard for care

These initiatives have been given new urgency with the pandemic, which has highlighted the need to keep clinical staff and patients safe at home whenever possible, while still delivering timely care. But the East of England Telemedicine Stroke Partnership now has a lot of experience to draw on.

“Many telemedicine projects are run across a single trust, and that is relatively easy because you can use the hospital’s own systems and scans,” Shekhar says. “We are doing this across a big region and across hospitals that are using different systems.

“Also, we can see the patient and that is critical. The team around the patient is being led by the consultant, just as it would be if they were at the patient’s bedside.

“It is bringing expertise to the patient. And this is the norm now; this is the standard of care set for all our participating hospitals.”

Facts and outcomes:

The East of England Stroke Telemedicine Partnership is supporting seven hospitals: Ipswich, James Paget, Lister, Peterborough City, Queen Elizabeth Hospital Kings Lynn, Watford General, and West Suffolk. It’s virtually hosted by Addenbrooke’s hospital.

It provides a consultant-led telemedicine service to assess stroke patients for thrombolysis 5pm to 8am Monday to Friday, plus weekends and bank holidays.

Since the service was set up in 2010, it has assessed 4,185 patients. Of these, 1,788 or 42.7 per cent were thrombolysed; and of those that weren’t, just 478 or 20 per cent missed the 4.5 hour timeframe (439 or 18 per cent saw their symptoms resolve, and 405 or 17 per cent were experiencing a stroke mimic).

Despite door to needle and onset to needle times varying across the seven hospitals, this service has been able to achieve a median DTN of 46 minutes across all the hospitals in recent months .

A health economic review conducted by the University of East Anglia has shown that the service saves money by delivering better outcomes for patients.

Because patients who receive rapid, appropriate thrombolysis have shorter stays in hospital and are less likely to need further treatment, and the service delivers this more reliably than ‘usual care’, it estimated that it saves the NHS around £470,000 a year.

MND

£1m dedicated to MND research through 7 in 7 Challenge

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A £1million fund has been created to lead new research into potential treatments for Motor Neurone Disease (MND) through the efforts of an iconic challenge by Kevin Sinfeld. 

Kevin, director of rugby at Leeds Rhinos, raised over £2million through his 7 in 7 Challenge, inspired by his former team-mate and close friend Rob Burrow. 

Rhinos legend Rob was diagnosed with MND in December 2019, and Kevin completed seven marathons in as many days to help boost badly-needed research into the condition. 

Now, with £500,000 of the money raised through the 7 in 7 Challenge ring fenced for research, that sum has been matched by medical research charity LifeArc. 

The move has created a £1million joint fund established by the MND Association and LifeArc, which will support research projects focused on developing new therapies or repurposing drugs already approved for use for other conditions.

“This is fantastic news and an amazing contribution from LifeArc,” says Kevin. 

“When we set out to complete the 7 in 7 Challenge we hoped to raise awareness and funds to support the MND community but it is so wonderful to see the inspiration it has given people and organisations, like LifeArc, so they too can support the need for more research.

“Our hope, like that of everyone affected by this brutal disease including Rob, is that this money will make a real difference and help find the breakthrough we all desperately want.”

Researchers are now able to apply for a share of the funding, with the criteria that they will be expected to conclude their project within three years and be target driving with set milestones and a credible delivery plan – including a clear route to reach MND patients.

Dr Brian Dickie, director of research development at the MND Association says: “We are so grateful to LifeArc for this generous contribution and are looking forward to working with them to identify projects which have a real chance of making a difference to our community in the coming years.”

Melanie Lee, LifeArc’s chief executive, emphasised that the focus of the new funding is on boosting research around potential treatment options based on the latest understanding of the disease.

“The ambition around stimulating the search for new treatments fits with LifeArc’s approach over the last 25 years to translate early science into health care treatments or diagnostics that can transform patients’ lives,” she says. 

“Our partnership with the MND Association is the latest in a series of strategic partnerships that maximise LifeArc’s expertise in translating strong discoveries from the lab into benefitting patients with conditions with few or no effective treatment options.”

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What causes a stroke?

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Ischemic and hemorrhagic are the two main types of stroke

Over 100,000 people in the UK suffer a stroke each year, with there currently being around 1.2 million survivors living in the country.

Many people note that despite how common strokes are they remain unaware of what the actual causes of a stroke are.

Depending on which of the two types develops, causes and outcomes can differ.

What both have in common is they restrict blood flow to the brain. This leads to a reduction in the brain’s oxygen levels, which can cause tissue damage.

Here, NR Times breaks down why a stroke may occur and what risk factors there are behind each different type.

What are the different types of stroke?

There are two main types of strokes: ischaemic and hemorrhagic.

Ischemic strokes make up nearly 90 percent of all cases and they materialise when an artery which provides blood and oxygen to the brain becomes blocked. 

A hemorrhagic stroke is much less common, but happens when an artery leading to the brain bursts and starts to leak blood around or in the brain.

Causes of an ischaemic stroke

The brain is only able to function properly when its arteries supply it with oxygen-rich blood, meaning any blockages can cause lasting damage.

With a lack of blood flow, the brain is unable to make enough energy to work. If this consists for more than a few minutes, brain cells will begin to die.

This is exactly what happens in an ischaemic stroke, but there are a range of reasons as to why these blockages develop.

One of the main causes is when the arteries around the head narrow, which makes it harder for the blood to pass through.

This can also lead to something called atherosclerosis, which is where substances in the blood (such as fat or cholesterol) stick to the sides of the arteries.

Blood can build up on these deposits, causing a further increase in pressure and a reduction to the brain’s oxygen supply.

There are a number of reasons for these blockages, with the most common ones being around a person’s lifestyle.

For example, smoking can increase the risk of a stroke by up to 50 percent.

This is because nicotine not only narrows the arteries, but it also makes the heart beat faster, causing an increase in blood pressure.

Excessive alcohol intake, obesity and high cholesterol levels are also all listed as major risk factors when it comes to ischaemic strokes.

Problems with the arteries around the heart can also lead to an ischaemic stroke.

Irregular heartbeats, heart attacks and other irregularities around this area can again limit the blood’s oxygen levels.

Causes of a hemorrhagic stroke

Hemorrhagic strokes are most common in people ages 45 to 70, but they affect a lot more younger people than an ischaemic stroke.

These are caused after the arteries around the brain burst and cause bleeding.

Depending on where the artery is can affect the outcome of the hemorrhagic stroke.

If the bleeding occurs within the brain, blood shooting out at high pressure can kill some cells.

Bleeding on the surface increases the pressure in the protective layer between the brain and the skull, potentially causing more cell loss.

This bleeding is normally caused by chronically high blood pressure. In many cases, the increased pressure can cause the arteries to expand and weaken, meaning a split in them is more likely to take place.

A rarer cause of hemorrhagic stroke is where the blood vessels around the brain are connected abnormally, causing further stress on the brain. These are congenital (present at birth) but the reason for their occurrence is currently unknown.

Again, the best way to reduce the risk of an hemorrhagic stroke is to make healthy lifestyle choices.

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NHS pilots video service for epilepsy diagnoses

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A new clinical video service which supports epilepsy diagnoses and management in the era of coronavirus and beyond has been launched in the UK.

vCreate Neuro allows registered patients and carers to share smartphone-recorded videos of potential seizures or unknown movements with their clinical team via a secure, NHS-trusted system.

The data and footage act as a visual aid to assist clinical teams with rapid precision diagnostics, creating a digitised clinical pathway that minimises the need for face-to-face clinic appointments and invasive tests.

The system is currently being piloted across Scotland and, following its initial success, across England including Great Ormond Street Hospital, Evelina London and Sheffield Children’s Hospital.

The system is available to families who are concerned that they, their child or loved one may be experiencing seizures or unexplained episodes including epilepsy.

Since May 2020, more than 2,000 families have shared over 5,000 videos with their clinical teams across the platform.

Dean MacLeod was referred to the service when her seven-year-old daughter, Olivia, began having unknown movements in May 2020.

Dean uploaded videos of Olivia during these episodes as Olivia’s seizures grew more frequent.

The videos were reviewed by Paediatric Neurology professionals at the Royal Hospital for Children, Glasgow, and, supported with telephone appointments, Olivia was diagnosed with a form of epilepsy and quickly started on treatment.

Speaking about her experience, Dean said: “I’ve found vCreate to be invaluable in Olivia’s journey since she started having seizures last summer.

“We live in a remote location on the Isle of Lewis, Scotland, and we have a very limited paediatric service on the Island. The service has made it easy to access the specialist clinical knowledge needed by sending recordings of various seizure events to the Paediatric Neurology team at Glasgow.

“Since the diagnosis, I have kept in regular contact with the clinical team through the platform, sending videos and typically receiving advice from a Consultant within 24 hours which is fantastic. Between the vCreate service and telephone discussions, our family have not needed to have face-to-face consultations which has been hugely beneficial during the pandemic.”

Professor. Sameer Zuberi, consultant paediatric neurologist at the Royal Hospital for Children, Glasgow, said: “vCreate Neuro has transformed how we use carer-recorded video in our service. We are diagnosing epilepsy more rapidly, preventing misdiagnosis and saving unnecessary investigations. Families feel in more control and better connected to the service.

During the Covid-19 pandemic, many people experiencing seizures and seizure-like episodes, including children, have been unable to see a clinician.

Create Neuro aims to help by empowering patients to use asynchronous video technology for self-management, reducing the need for physical appointments. 

Founder Ben Moore said: “We’re passionate about family-forward care, and worked closely with clinical teams, patients and carers to develop the vCreate Neuro service.

“The system aims to improve patient care, reduce the number of clinic investigations – and resulting costs to the NHS – and digitise the patient pathway. We want families to be in control of their healthcare journey and have a direct link to their clinical team despite the pandemic restrictions.”

The vCreate platform has been independently assessed and approved by Information Governance teams in over 100 UK NHS Trusts.

 Within the platform, a clinical database is available as a learning resource for clinicians to study seizure types, events, and other symptoms.

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