Recommendations on telestroke in Europe

Abstract

Lack of stroke specialists determines that many European rural areas remain underserved. Use of telemedicine in stroke care has shown to be safe, increase use of evidence-based therapy and enable coverage of large areas of low population density. The aim of this article is to summarise the following recommendations of the Telestroke Committee of the European Stroke Organisation on the setup of telestroke networks in Europe: Hospitals participating in telestroke networks should be chosen according to criteria that include population density, transportation distance, geographic specifics and in-hospital infrastructure and professional resources. Three hospital categories are identified to be part of a hub-and-spoke network: (1) the Telemedicine Stroke Centre (an European Stroke Organisation stroke centre or equivalent with specific infrastructure and setup for network and telemedicine support), (2) the telemedicine-assisted stroke Unit (equivalent to an European Stroke Organisation stroke unit but without 24 h onsite stroke expertise) and (3) the telemedicine-assisted stroke ready hospital (only covering hyperacute treatment in the emergency department and transferring all patients for further treatment).

Keywords: Telemedicine; network; remote area; stroke; stroke care system; telestroke.

Figure 1.

Minimum size of an area to be covered by a single stroke unit. Size is inversely related to population density (population/km²) and stroke incidence (number of strokes/100.000/year).

Figure 2.

Fictional development of a telestroke network in an example European mountainous area with three provinces of low population density and no current specific stroke care. Area size and population density in green, blue and purple provinces are 1748 km² and 65/km², 2884 km² and 25/km², 904 km² and 64/km², respectively. Stroke incidence is 270/100.000 in all three provinces. (a) There are two existing regional hospitals (cross with circle) and four small provincial hospitals. TSC would be located remotely from these provinces. (b) Applying the formula to account for rule No. 1 (size of region for one stroke unit), allows setup of two telemedicine assisted stroke units (TSU). One for green province, one for blue and purple province together (minimum area in green province 1140 km², in blue province 2963 km², in purple province 1157 km²). (c) Applying rule No. 2 (travel distance < 45 min) of these two TSU shows an inadequate coverage of only half of the provincial area (grey). (d) Set up of further three TSRH allows for timely coverage of three quarters of the area. No adequate coverage can be obtained in South of green province, as there are no health care facilities in this very mountainous landscape.TSC: Telemedicine Stroke Centre, TSU: Telemedicine assisted Stroke Unit, TSRH: Telemedicine assisted Stroke Ready Hospital.