Conférence Télémédicine et Télésanté en Europe

FIEEC / ASIP Santé

Paris, 21.10.2011

Dr. Peter Müller-BarnaDepartment of Neurology

Klinikum Harlaching

Städtisches Klinikum München GmbH

Telemedical Project for Integrative Stroke Care in Bavaria, Germany

Overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

Overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

Burden of Stroke

Strokes in Germany:

• 260.000 strokes every year

• #3 for death: 40% of the stroke patients die within 1 year

• #1 for disability: 1 million patients with long-term disability caused by stroke

Kolominsky-Rabas, Stroke 1998

→ Stroke is a public health challenge of prime importance

Changes in Age Distribution

2000 2050

→ Stroke is a public health challenge of prime importance

with increasing relevance !!!

What to do?

Stroke unit care• reduces death or dependency

(OR 0.82; 95% CI 0.73 to 0.92; P = 0.001)

NNT = 5

i.v.-Thrombolysisincreases favourable outcome• OTT 0-90 min NNT 4,5

(OR 2,55; 95% CI 1,44 to 4,52; P = 0.001)

• OTT 90-180 min NNT 9(OR 1,64; 95% CI 1,12 to 2,40; P = 0.012)

• OTT 180-270min NNT 14(OR 1,34; 95% CI 1,06 to 1,68; P = 0.014)

Lees et al., Lancet 2010Cochrane Database of Systematic Reviews 2009

Time is BrainIn acute stroke 1.9 million neurons die every minute!

Only a minority of all stroke patients in Europe receive stroke unit care Leys, Stroke 2007

Stroke Units in Bavaria, Germany, in 2002

4Stroke Unit

Stroke Center

Network-Hospital

The need in 2002 was

to improve stroke care

in the underserved

areas of Bavaria.

Overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

Exchange of Experience Teleconsultations

Training –

center-based and onsite

Standardtreatment protocols

Key features of the TEMPiS-Network

Implementation of Stroke

wards in each hospital

Quality Management

1. Stroke Wards

Implementation of Stroke Wards

in each network hospital:

• stroke wards with

3-6 monitored beds and

~ 15 additional beds

• well defined stroke team consisting of:

doctors, nurses, physiotherapists, ergotherapists,

speech & swallowing therapists and social workers

• (on site) ward round of a neurologist from Monday

to Friday

• continuous medical training

• concept of early rehabilitation

2. Standard treatment protocols - SOPs

Our TEMPiS-SOPs form our common basis of

managing stroke:

• TEMPiS-SOPs were developed and are updated

yearly in a cooperative effort

• with statements for doctors,

nurses and therapists

• we obligate and control network

hospitals to follow the SOPs

Stroke classes Training days for

speech & swallowing therapists

3. Centre based Training

LaryngoscopyStroke Update Sonography

3. Onsite training

Regular ward rounds

in each network hospital

Bedside training for nurses

Bedside training for therapists

4. Exchange of Experience

www.tempis.de

Newsletter

Ward rounds & Meetings

5. Quality Management

Visitation of all network hospitals by the project manager at least 3 times per year

Evaluation of teleconsultations

benchmarking of the rate of thrombolysis, the door-to-needle-time, etc.

obligatory participation in the German stroke register database

documentation and analysis of critical incidences

DSL

Academic Stroke Center

6. Teleconsultation - Network Hospital

6. Stationary workstation – Stroke Center

6. Teleconsultation – mobile solution

works with fast UMTS = HSDPA (High Speed Downlink Packet Access)

6. Teleconsultations

Obligatory indication for a teleconsultation:

• onset of symptoms within 4.5 hours

• intracranial hemorrhage

• impaired consciousness

• progressive stroke

• brainstem symptoms

• NIH-SS 12

• stroke patients aged < 60 years

A voluntary teleconsultation is possible whenever requested !

Exchange of Experience Teleconsultations

Training –

center-based and onsite

Standardizedtreatment protocols

Main capabilities of the TEMPiS-Network

Implementation of Stroke

wards in each hospital

Quality Management

TEMPiS is based on personal relationship,

know-how transfer, quality management

and telemedicine

► TEMPiS is a regional network with limited size

Overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

number of teleconsultations per year

Source : TEMPiS-database of teleconsultations

1.924

2.688

2.859 2.837

3.062

3.560

3.1873.216

0

1.000

2.000

3.000

2003 2004 2005 2006 2007 2008 2009 2010

admission to CT-scan: less than 60 minutes

Source: BAQ

67%

76%

81%

85% 85%

87% 88% 88% 88%

91% 91%92%

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96%

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90%

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2009 2010

TEMPiS

Teleconsultations

since 2003 more than 25.000 teleconsultations

currently ~ 360 per month

Thrombolysis with rt-PA

since 2003 about 2.300 thrombolysis

currently ~ 45 per month

~ 6.500 strokes per year in the 15 regional

network hospitals (extra 1.800 strokes in the stroke

centres Harlaching and Regensburg)

tele-stroke units vs. conventional stroke units

0% 20% 40% 60% 80% 100%

Information Patient und Angehörige

Physiotherpie / Ergotherapie

Mobilisierung

Screening nach Schluckstörung

Logopädie

Bildgebung

Gefäßdiagnostik

TAH innerhalb 48h

TAH bei Entlassung

Antikoagulation bei VHFli

Frühzeitige Thrombolyse

Door to needle time

Pneumonierate

Todesfälle TEMPiS-Kooperationskliniken (15)BAQ gesamt (80 Kliniken)

Source: BAQ; analysis for 2010

mortality

rate of pneumonia

door to needle time

early thrombolysis

anticoagulation in AF

antiplatelet drugs at discharge

antiplatelet drugs at 48h

carotid duplex or CTA

CT scan

early speech therapy

screening for dysphagia

early mobilisation

early physiotherapy

information for patient/relatives

Overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

TEMPiS outcome trial

• Prospectively obtained data of 3122 stroke patients

• ComparingOutcome of patients treated in network hospitals to

Outcome of patients treated in control hospitals

• poor Outcomedead or

institutional care or

at home with severe disability

Lancet Neurol 2006; 5: 742–48

Poor Outcome after 3 Months

TEMPiS Control hospitals

18,1%16,2% Dead

InstitutionalCare

12,5% 14,2%

At home withsevere disability14,3% 21%

-10,4%**

Lancet Neurol 2006; 5: 742–48

43,0% 53,4%

overview

• the need for stroke networks

• TEMPiS: key features

• TEMPiS: quality data

• TEMPiS: outcome analysis

• Summary

Take home ...

Telestroke is part of routine stroke care in Bavaria.

TEMPiS is a regional network based on personal relationship,

know-how transfer, quality management and telemedicine.

Stroke care within this kind of network improves the prognosis

of stroke patients.

Acknowledgement

We thank

► all participating stroke neurologists in the stroke centres

► all TEMPiS hospitals:

Asklepios Stadtklinik Bad TölzKreisklinik Bad Reichenhall Asklepios Klinik BurglengenfeldKreisklinik ChamKlinikum DachauKreisklinik EbersbergKreisklinik EggenfeldenKlinikum Freising

Kreiskrankenhaus Kelheim Kreisklinik MühldorfKlinik München-PasingKlinikum RosenheimKlinikum St. Elisabeth StraubingKlinikum TraunsteinKrankenhaus Zwiesel

Dr. Peter Müller-Barna

Consultant - Coordinator of TEMPiS

Department of Neurology and

Neurologic Intensive Care

Städtisches Klinikum München GmbH

Klinikum Harlaching Sanatoriumsplatz 2 - 81545 München

Tel. 089 6210 2259E-Mail: peter.mueller-barna@klinikum-muenchen.de

www.tempis.de

Thank you for your attention!