Professor Ken Butcher, Medical Director of the NSW Telestroke Service, reflects on how a popular concept has become a world-leading, life-saving service to rural and regional NSW.
Stroke is the third most common cause of death and the leading cause of adult disability in Australia. It was once thought to be untreatable; however, developments over the last two decades have transformed our approach to acute stroke.
The most common type of stroke occurs when a blood clot blocks an artery. We can now remove the clot using thrombolysis, where the clot is broken down using a specific medicine, and/or endovascular clot retrieval (ECR), where the clot is removed using suction. However, these therapies can only be given after careful patient selection criteria have been met.
The complexity of acute stroke management has resulted in sub-specialties within neurology, interventional neuroradiology and other areas. Systems of care are evolving in urban areas to direct patients with a suspected stroke to centres with these sub-specialty services; however, this approach is not feasible in rural and remote areas in NSW. This is a clinical problem that lends itself particularly well to a telehealth solution.
Adopting a telehealth solution
Telestroke is not a new concept and has been part of my career in Australia and Canada for more than a decade. In principle, the concept is straightforward – bring sub-specialist stroke care to rural and remote hospital settings using telehealth technology.
A functioning telestroke service requires:
- brain imaging to be performed at the primary (referring) hospital
- a technology platform that allows rapid viewing and interpretation of the brain images immediately after they are acquired
- some form of audio-video communication link between the specialist, referring physicians and patient (I have used everything from a telephone to dedicated medical communication equipment in the past).
Most telestroke services around the world, including ours in NSW, have grown organically through small physician-initiated pilot projects.
While these projects are critical to demonstrating the ‘proof of concept’, in most cases they are not sustainable due to the increasing workload and lack of infrastructure support.
The individuals who have dedicated their time to this service are too numerous to name, but each of you has my gratitude and admiration.
The NSW Telestroke Service
Establishing a statewide NSW Telestroke service was an election commitment of the NSW Government in March 2019. The $21.7 million service is jointly funded by the NSW and Commonwealth Governments.
The service offers people living in regional and rural areas increased access to life-saving stroke diagnosis and treatment. This is done by connecting local doctors to specialist stroke physicians, via video consultation in the emergency department.
Over the last year, the service has grown from two to eight sites, with another 15 coming online by June 2022.
In my view, there are some key commitments to the NSW Telestroke Service, including those by the Agency for Clinical Innovation (ACI), that have made this a world-leading service.
Stewardship and governance leadership
The visioning of this service was developed within the Ministry of Health and the Agency for Clinical Innovation. It was recognised early on that this needed to be a dedicated clinical service and that specialist stroke physicians needed to be focused on the task, rather than doing this ‘on the side’ while looking after patients in their own hospitals.
In NSW, there is a small but dedicated group of stroke specialists, many who are working with the Telestroke Service. This group was consulted before the establishment of the service and after the service started operation. The commitment of this group has been refreshing. In addition, the Ministry of Health recognised this service was outside the scope of current local health districts services and established the appropriate level of infrastructure support, based at the Prince of Wales Hospital.
Infrastructure support
One of the service’s core principles is that primary referral sites must meet a minimum standard for performing imaging and brain scans, including offering full multi-modal computed tomographic (CT) scans. This decision has ensured that the correct diagnosis can be made rapidly and accurately, allowing the correct patients to be treated using telestroke technology.
I have been impressed by the efforts of the eHealth NSW team, who have very quickly become experts in CT scanning and image transfer. eHealth has also built a patient communications platform, by leveraging existing infrastructure such as workstations on wheels and Skype. This pragmatic decision allowed us to rapidly deploy a scalable telestroke solution that can be updated easily and frequently.
Training and support
The efforts of the ACI staff in this area cannot be over-stated. In most telehealth scenarios, specialist physicians encounter primary care staff who have little familiarity with the service provided – its goals, capabilities or procedures. For the NSW Telestroke Service, the ACI have provided exemplary training and capacity building to primary stroke site medical, nursing, allied health, technical and administrative staff. The level of support ACI has provided is unparalleled, including multiple on-site visits, simulations, support for data collection, and liaison with the Ministry of Health and local site.
Local support
None of this would be possible without the enthusiasm and commitment of staff at the primary referring sites. The initiative demonstrated by staff in overcoming all manner of barriers has been incredible to watch.
The NSW Telestroke Service has been one of the most gratifying projects I have been involved with in my career. The leadership at all levels, from the Minister of Health to frontline staff in rural emergency departments, must be commended. The individuals who have dedicated their time to this service are too numerous to name, but each of you has my gratitude and admiration.
Did you know?
- The NSW Telestroke Service is built on a foundation of pilot work. ACI Stroke Network clinicians worked with Hunter New England and Mid North Coast Local Health Districts in 2017-18 to pilot a telestroke program.
- ACI partnered with eHealth NSW and the Ministry of Health to structure a state-based approach to scaling the service.
- Implementation is a collaboration between the Prince of Wales Hospital, eHealth NSW, the Agency for Clinical Innovation and the Ministry of Health.
- The service is managed by the Prince of Wales Hospital, based on the ACI Stroke Network Telestroke model of care developed by the Telestroke and Reperfusion Working Group, in collaboration with proof-of-concept sites.
- The first telestroke sites to go-live were in Port Macquarie and Coffs Harbour in March 2020. The service most recently went live at Grafton Base Hospital, with Griffith close to follow.
- At local sites, many areas across the hospital come together with the Telestroke specialist to provide treatment. “This teamwork and the NSW Telestroke Service allows us to provide treatment locally that wouldn’t otherwise be possible,” says Donna Jay, Stroke Clinical Nurse Consultant in Illawarra Shoalhaven Local Health District.
- In April 2021, Telestroke celebrated treating more than 600 patients.
Read more about the NSW Telestroke Service.
About Professor Ken Butcher
Professor Ken Butcher is the Medical Director of the NSW Telestroke Service at Prince of Wales Hospital. He is also the Director of Clinical Neurosciences at the Prince of Wales Clinical School at the University of New South Wales and is supported by a NSW Health Senior Cardiovascular Scientist award. He is a clinician scientist who has dedicated his career to improving treatment and outcomes in stroke patients. Prior to relocating to Sydney, he was a tenured Professor at the University of Alberta and held a Canada Research Chair in cerebrovascular disease. He has held continuous salary and grant-in-aid funding related to stroke research since 2006 and has more than 180 peer reviewed publications.