A national first: dedicated stroke telehealth cuts time to treatment for rural patient

Caption: Kim Cooper and Garry Tierney on a caravan holiday 18 days after Garry’s serious stroke

Garry Tierney, 70, a retired finance manager, knew he had high blood pressure and a bit of a cholesterol problem but described himself as being “in pretty good health”.

But recently, Garry experienced a severe stroke while driving near Nowra in NSW. Fortunately, he was able to stop the car in the middle of the road before confusion descended. His partner, Kim Cooper watched Garry’s eye droop and the other side of his face fall.

NSW Ambulance received a triple zero (000) call and paramedics were quickly on the scene.  These paramedics were participating in a clinical study taking place in South Western Sydney Local Health District in collaboration with NSW Ambulance.  This study is part of a series of clinical trials led by the Australian Stroke Alliance and partner Titan Neuroscience looking at new paramedic-led models of care. Paramedics had recently been trained to use a new prehospital telestroke tool, introduced in December 2022 with approximately 1,000 paramedics participating.

Paramedics told Kim that Garry was experiencing a significant stroke. “I had a bit of a cry when the realisation sank in that I might be losing him,” Kim said.

Within moments, Garry’s medical status was flowing from the paramedics’ Zeus app to the on-call neurologist, Professor Mark Parsons, who was at home in Sydney, exercising.

Traditional care wouldn’t involve the neurologist until the ambulance delivered the patient to an emergency department.

The prehospital telestroke data provided by the paramedics gave Mark crucial information. It was enough for him to direct the crew to bypass two closer hospitals – Bowral and Campbelltown – and to head straight to a specialist stroke centre where endovascular clot removal could be done 24/7.

It was a big decision to make.

Normally, a 160km drive from Nowra to Liverpool would take two hours. And with stroke, every single minute counts.

As Prof Parsons explains: “Garry’s severe stroke indicated he might be a contender for endovascular clot retrieval. For 50 per cent of these types of strokes, a patient is likely to be left with disability or die if their stroke score is at 10. Garry’s was 14.”

Neurology advanced trainee, Dr Lucinda Tran was primed, having spoken to Prof Parsons and seen the telestroke data flowing through as the stroke-smart ambulance travelled. Both doctors tracked the ambulance’s progress to the hospital using the Zeus telehealth platform.

When the ambulance arrived, Garry was rushed straight to CT for a perfusion scan. Unexpectedly, Garry had a small vessel occlusion, deep in his brain. Because the vein was less than one millimetre in diameter, endovascular clot retrieval was not possible. Lucinda and Prof Parsons discussed the scan, via the telehealth app, and decided to give intravenous clot dissolving medication.

From the moment Garry arrived at Liverpool Hospital to the time he was treated with the clot-busting medication 31 minutes had passed.

“At the time, I’m pretty sure this was a record for Liverpool*,” Prof Parsons said.

Within minutes of receiving thrombolysis, Garry regained use of his arm and leg. “He spoke clearly and his silly humour was back,” said Kim.

“We were all so elated. The staff and everyone cheered. It was absolutely amazing,” said Garry.

Prof Parsons adds: “I would be very surprised if many rural patients have ever been treated for their stroke within 90 minutes of onset with thrombolysis.”

Without prehospital telestroke communications allowing doctors and paramedics to work together, hospital-to-hospital transfers slow down a patient’s pathway to treatment by hours.

“There are significant delays when a patient goes to a primary stroke centre that doesn’t have endovascular clot retrieval. The median time for a patient arriving at Liverpool for endovascular clot retrieval, after a hospital transfer, is 90 minutes. That’s a long time,” says Prof Parsons.

“We have about one large vessel occlusion patient bypass and come straight to Liverpool each week, thanks to the paramedics using the telehealth app, and we know that the time saved to clot retrieval is a minimum of one hour, probably closer to two hours.”

Ultimately, this is leading to better outcomes for patients.

“We hoped this would happen. We’re getting earlier thrombolysis times as well. We’ve also been able to randomise patients into clinical trials because they arrive so quickly – particularly TASTE and ETERNAL and STOP-AUST trials.

“I’ve been working with paramedics for many years and they really appreciate the direct interaction with the hospital generated by the stroke-capable ambulances. And we are very big on feeding back the outcomes of the patients.”

He believes the teleconferencing tool is great for building confidence and rapport. “I got a call the other day from a new paramedic team that we had just trained. A young paramedic came on to the telecon and she was a bit nervous. I was able to tell her that her telestroke report was great and it told me everything I needed to know.”

The app is also faster than a standard doctor-to-doctor telestroke consultation in an emergency department. “A standard telestroke consultation will take an hour. These consultations take two minutes.”

The pilot continues in both New South Wales and Victoria with plans for other states and territories. To participate, please contact us at austrokealliance.org.au

*Since Gary’s record-breaking door-to-needle time of 31 minutes, the team has achieved a 24-minute record, thanks to improved communication and protocols, driven by the Australian Stroke Alliance’s telestroke platform.