A Tele Stroke network in internal areas of Umbria
In Umbria, Central Italy, (900k inhabitants), about one-third of the population lives in rural or internal areas with reduced access to time dependent therapy for stroke care.
In USL Umbria 2 catchment area there are 4 hospitals for about 400k inhabitants. Only one of these, Foligno, has a fully equipped Emergency Department with a stroke pathway for thrombolysis.Among the other hospitals, the biggest one without a stroke center is Orvieto hospital (30k inhabitants, stroke hospitalization volume 100/year).
Figure 1 Map of Umbria with regional Stroke network centers and USL 2 hospitals. Red area indicate the county of Perugia; White area indicate the county of Terni.
The catchment area of USL Umbria 2 covers both counties and the municipality of Foligno and Spoleto-Valnerina of the Perugia county as well as all the Terni County. Terni Stroke Unit is in the city Hospital included in the regional network but not fully interfacing with USL 2 provider. Blue arrows indicate the intranet connections; Yellow arrows indicate connection to the mobile unit.
According to data available by the Italian neurology society, the ratio between stroke units and inhabitants in Umbria is adequate and equal to 112% (ideal ratio: one stroke unit per 200,000). Other Italian Regions, such as Campania, have a ratio of around 10%. But in Umbria the number of recorded thrombolysis treatments on all ischemic strokes, as observed by the European Register of the Karolinska Institute, is half the theoretical. As tought, only half of the ischemic stroke patients had access to the acute treatment. Other Italian Regions, such as Veneto, reached a more satisfactory result (almost the 80% of procedures) on potential annual cases.
For this reason, during the last years in Umbria, many initiatives have been undertaken to enlarge the accessibility to stroke care as well as to bridge the infrastructural gap.
Since 2014, in USL Umbria 2, stroke has been “coded” as an independent therapeutic diagnostic pathway and a reorganization of the Emergency Department pathway has been carried out. The ability to centralize acute stroke patients was guaranteed through facilitated delivery by spoke centers in Foligno ensuring the presence of 118 staff in each hospital. Also adopting the policy of “always free stroke beds” at the Hospital of Foligno. In addition a targeted training activity, supported by SIMEU, was addressed to emergency department staff operating in all hospitals.
In addition to these measures, from June 2016, a teleconsultation connection between Orvieto
Emergency Department and Foligno Neurology was introduced with a medical video-conference system (Meytec TM, Werneuchen; Germany) for patients real-time assessment (Fig. 2).
Additionally, during the earthquake emergency in central Italy, a Teleambulance in bundling mobile phone connection, was put beside the first aid station in the city of Cascia (Fig 3).
The stroke care pathway provides that emergency physicians of Orvieto activate the neurologist, or the on-call neurologist during night/holyday, in Foligno.
The neurologist, briefly discussing the case on the phone, agrees with a teleconsultation with:
– view of Orvieto TC images via the USL Umbria 2 PACS.
– patient tele-visit in the presence of medical and/or nursing staff in Orvieto Emergency Department.
After discussing the clinical case, interviewed if needed the patient, family members, emergency transport paramedics for other details, the neurologist provides a written report via fax to Orvieto. Doctor stamp and signature faxing is currently preferred, according to the risk management service, since it is more traditionally validated by a legal medical point of view.
Figure 2a.HD screen framing the emergency room of Orvieto hospital.
Figure 2b. Zoom to isocoria testing and fotomotor response.
Figure 3a. Teleambulance Interio,r wall-mounted microphones and ceiling-mounted camera.
Figure 3b. Arrival of the vehicle to Cascia on 30th November 2016 with the Major Mr. Emili and Meytec staff with Mr. S. Meyer.
Figure 3c.Set up at the hospital in Foligno.
- ECG devices
- Monitoring systems
- Point-of-care laboratory diagnostic systems
Portable ultrasound device
Stroke pathway development
From 2014 thrombolysis candidates centralization on Foligno hospital showed an increase of 30% (from 104 cases to 187 respectively PNE data) with an increase in the absolute number of thrombolysis. The volume of stroke hospitalization in smaller hospitals dropped by 10-15%. From June 2016 to January 2017 on average 0.5 to 1 cases per week were evaluated in teleconsultation.
In January 2017, the first i.v. thrombolysis was successfully performed in remote assistance, see below.
Woman, 68 year old. Remote pathological history positive for hypercholesterolemia, systemicarterial hypertension and concomitant hypertensive cardiomyopathy, hypothyroidism in hormone replacement therapy.
The patient suddenly presented, around 14 o’clock, weakness of the right upper limb and a speech disturbance. Once arrived in Orvieto Emergency Department a brain CT scan was performed, excluding bleedings or acute signs of infarction. The neurological teleconsultat was then activated and neurologic examination at about 15 pm highlighted: lower right facial palsy, right limbs hemiparesis (3/5 upper and 4/5 lower according to Medical Research Council score) speech was poor with anomie. The overall National Institute of Health Stroke Scale (NIHSS) score was 14. Blood pressure and heart rate were both normal.
Due to the time window, the clinical and neuroradiological findings and the normality of the laboratory examinations, i.v. fibrinolytic therapy with Alteplase, 0.9 mg/ kg with a 10% in bolus, remaining infused dose in 1 h, was administered.
The door to needle time was below 60 minutes. During the infusion, the patient presented a progressive improvement in clinical conditions and, at the time of the discharge, was fully independent in daily life. Secondary prevention with aspirin was undertaken.
- Corea F, Hubert G, Abilleira S. Letter by Corea et al Regarding Article, “Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association”. Stroke 2017 Jun;48(6):e139.
- F. Corea, A. Gamboni, P. Brustenghi, M. Bracaccia, P. Manzi and M. Zampolini a stroke network in internal areas of central Italy European Stroke Journal 2017, Vol. 2(IS) 98–476