Acute stroke timing measures such as door-to-call time and door-to-decision time have not improved with the development of the telestroke network in northern NSW.

A comparison of metrics between phase 1 (Jan 2017 – Oct 2018) and phase 2 (Nov 2018 – July 2019) of the network expansion suggested the main limiting factors may be workforce shortages and high staff turnover.

The study, published in Frontiers in Neurology, found 73% of the 827 patients assessed with multimodal computed tomography (mCT) had ischemic stroke or TIA.

Overall, the median door-to-call time was 36 min, the median door-to-image was 50 min, and the median door-to-decision was 82 min.

“There was no significant difference between phases for these metrics. Phase 1 had a median door-to-call of 39 min compared to 35 min in phase 2 (p = 0.18), median door-to-image was 49 min in phase 1 and 54 min in phase 2 (p = 0.36) and median door-to-decision was 81.5 min in phase 1 and 83 min in phase 2 (p = 0.31),” the study said.

In the subgroup of patients who received reperfusion therapy, there was a significant decrease in the rate of thrombolysis in phase 2 compared to phase 1 (76.5 vs. 53.7%, p = 0.01) but an increase in use of EVT (45.6 vs. 65.9%, p = 0.04).

There was a non-significant trend to slighter shorter door-to-call, door-to-image and door-to-decision times in this sub-group in phase 2 compared to phase 1.

In the thrombolysed subgroup, door-to-needle time was also slightly shorter in phase 2 than phase 1 but did not reach statistical significance.

“We noted no significant improvements in process of care metrics over a period of 2.5 years,” the study said.

The researchers, including senior investigator Professor Christopher Levi from Hunter New England Health, said rural hospitals suffer from workforce shortages and a high turnover across all career stages.

“Therefore, clinical experience does not concentrate within a specific team but disseminates.”

“Aiming to improve acute stroke workflows and times to reperfusion, a trial across the network with a focus in multifaceted education and support for workflow re-design (the TACTICS trial), is now underway.”

The study noted that while the telestroke network is currently limited to the provision of acute reperfusion therapy, it may also have a future role in supporting rural hospitals with general acute stroke care.

Clarification: This study was an academically driven pilot study which predates and informed but is separate to the NSW Telestroke Service (hosted by the Prince of Wales Hospital and currently operating in 10 hospitals across all non-metropolitan local health districts).