Parts of this chapter have been adapted with permission from the evaluation protocol (Version 1.3).1
Context and rationale for this evaluation
Optimising access to organised stroke care in the NHS in England
Stroke is a major cause of death and disability in the UK and internationally.2 Evidence from urban settings suggests that ‘system optimisation’ of stroke services, whereby they are centralised into a small number of hyper-acute stroke units (HASUs), is linked with better care delivery and outcomes.3–6
HASUs (which in future will be termed acute stroke centres, or comprehensive stroke centres if they deliver mechanical thrombectomy) offer rapid access to stroke specialist assessment and treatment, including intravenously administered ‘clot-busting’ therapies, if appropriate.
Such centralised services rely on effective collaboration between multiple stakeholders, including hospital stroke services and ambulance services, to ensure the appropriate conveyance of patients to a HASU.7–9
In recent years, the NHS in England has sought to improve patient access to organised stroke care in several ways. The NHS Long Term Plan reinforces the role of networked stroke systems at a regional level to improve care delivery and clinical outcomes.10 Integrated Stroke Delivery Networks (ISDNs) are made up of multiple health agencies, including ambulance trusts, and aim to ensure that NHS stroke services comply with 7-day quality standards for stroke care and National Clinical Guidelines for Stroke. In addition, there is support to scale up technologies that improve the quality of stroke services, such as the potential use of artificial intelligence to interpret computerised tomography (CT) and magnetic resonance imaging (MRI) scans and the implementation of telehealth.10
Minimising unnecessary conveyance to specialist stroke units using telemedicine
Because of the limited specificity of screening tools for stroke [e.g. the Facial drooping, Arm weakness, Speech difficulties and Time (FAST) tool, or variations, which is used by most ambulance clinicians and has been heavily promoted in the national press], acute stroke services commonly manage large numbers of patients who, although suspected to be having a stroke (e.g. because they are ‘FAST positive’), turn out to have non-stroke conditions (so-called ‘mimics’).11 Remote specialist stroke assessment via telemedicine has been found to support accurate triage of patients12 and has the potential to identify patients who do not need urgent treatment in a specialist unit. However, to date, the piloting and implementation of such technologies has been limited in England. Reported obstacles to adoption include technical issues (e.g. reliable video-call signal quality) and cultural barriers (e.g. ambulance clinicians’ concern regarding the benefits of potentially increasing on-scene time to seek specialist secondary care stroke expertise).
International evidence for ‘telestroke’ and mobile stroke units
Elsewhere, there has been movement towards the uptake of telemedicine in stroke care, particularly in the USA and Germany (see Chapter 3).16 There is emerging evidence about telemedicine’s safety and cost-effectiveness,13,14 indicating that the uptake of telemedicine in stroke care can provide neurological expertise in real time effectively and within the tight time window necessary for hyper-acute stroke treatment.12
However, from clinicians’ perspectives, there may be issues with the usability of new telestroke systems or mobile facilities that rely on visual cues. Reviews of the evidence on implementing telestroke describe several obstacles to and enablers of adoption. Major barriers include unfamiliarity with the technology and how it conflicts with cultural norms; technical issues with audio-visual quality; lack of staff confidence in systems; lack of information technology (IT) support; and poor communication between clinicians.15,16 Reviews also note the potential impact of prehospital video triage on decision-making, for example through the addition of stroke specialist expertise.15
A recent scoping review16 describes a small but growing evidence base on how remote technologies may support ambulance clinicians in triaging potential stroke patients, including the use of prehospital biomarkers and imaging and mobile telemedicine. The review16 reports no UK-based research on ambulance telemedicine systems to support remote assessment by stroke clinicians. However, the international research reported indicates that such systems are viewed positively by staff and can result in reduced time to care interventions, and that prehospital remote diagnosis can be as accurate as hospital-based diagnosis.16 The review also noted relatively few data to suggest that such systems result in more appropriate conveyance of patients, or about their impact on outcomes such as patient safety.16
Understanding implementation of digital innovations in health-care systems
There is increasing interest in how innovative digital technologies come to be adopted by and used in health-care systems and may shape clinical practices and workflows. For example, recent World Health Organization guidance17 suggests that digital health should be understood in terms of an ongoing process of development, whereby digital interventions evolve from early piloting and prototyping to digital maturity, requiring ‘real-time’ monitoring of both technical functionality and stability in addition to health outcomes.
NHS service context for the pilot services
As outlined above, there are many areas (including implementation, impact and experience) where knowledge is limited in relation to prehospital digital triage services.
In this evaluation, we studied two pilot schemes that introduced prehospital video triage for suspected stroke patients in North Central (NC) London and East Kent. These pilots were introduced in response to the COVID-19 pandemic. Below, we provide contextual information on these two areas and summarise briefly the local responses to COVID-19.
The NC London pilot took place in the North Central sector of London, covering a population of 1.2 million people.18 The area is served by a single HASU, hosted by University College London Hospitals NHS Foundation Trust (UCLH) and the London Ambulance Service NHS Trust (LAS). This sector is part of the wider London ‘hub-and-spoke’ acute stroke service model, implemented in 2010, whereby all suspected stroke patients are eligible for initial treatment in a HASU (hub) and, if required, ongoing acute care in stroke units (SUs), which act as ‘spokes’, offering specialist acute rehabilitation services nearer home.8 In response to the pandemic, the UCLH
HASU was relocated from the main UCLH hospital site [where it had been co-located with an emergency department (ED)] to the nearby National Hospital for Neurology and Neurosurgery (NHNN), a dedicated neurological and neurosurgical hospital (which did not have an ED).
The East Kent pilot covered the area served by East Kent Hospitals University NHS Foundation Trust (EKHUFT) and the South East Coast Ambulance Service NHS Trust (SECAmb). EKHUFT serves a population of just under 700,000 people. Pre pandemic, this area was served by two stroke units, at the William Harvey Hospital and Queen Elizabeth the Queen Mother Hospital (QEQM). However, in response to the pandemic, hyper-acute stroke services were moved from these sites to a single routinely-admitting service at Kent and Canterbury Hospital (Canterbury, UK). As with the revised model in UCLH, this reorganisation moved the HASUs away from co-location with the trust’s ED and to a new location that did not have immediate ED support.
Pre-hospital video triage services implemented in North Central London and East Kent
In 2020, NHS services in NC London and East Kent introduced prehospital video triage services in response to the developing COVID-19 pandemic. These were ‘on-scene’ digitally supported systems that let ambulance clinicians contact acute stroke clinicians for remote clinical assessment using digital communication platforms [i.e. FaceTime (Apple Inc. Cupertino, CA, USA)] using communications devices [i.e. smartphones and iPads (Apple Inc.)]. The aim of the video assessments was to establish whether or not a patient was suitable for conveyance to a HASU or if they should be on a different care pathway, thus minimising unnecessary conveyance or delays. The anticipated benefits of this system were to:
provides an overview of the key events in the development and early implementation of prehospital video triage in NC London and East Kent.
Timeline: implementing prehospital video triage in NC London and East Kent
The evaluation of these services represented an important opportunity to build an understanding of the acceptability and safety of prehospital video triage for suspected stroke patients. Key examples of potential learning were establishing the acceptability of the services to their users (i.e. ambulance and stroke clinicians); factors influencing usability (e.g. signal quality and environment); the impact of the service on patient destination, travel times and the delivery of clinical interventions; and factors influencing the implementation of these services (e.g. governance and training).
In 2020 and 2021, the authors engaged with ambulance and stroke services across the UK, establishing that, at the time, no equivalent prehospital video triage services were active. Since our evaluation commenced in July 2020, two other areas of Kent have launched their own prehospital video triage services and a number of other areas of the NHS in England have indicated that they are interested in potentially implementing a service of this kind.
Overview of the project
This service evaluation was conducted through the Rapid Service Evaluation Team (RSET) programme. RSET, funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) programme, is a 5-year research programme that aims to rapidly evaluate health and care service innovations to produce timely findings of national relevance and immediate use to decision-makers. The topic of this evaluation was identified through discussions between RSET staff and leaders of the local pilots. A proposal to evaluate an earlier East Kent pilot of prehospital video triage was explored by RSET in 2018/19, but initial scoping indicated that it was at insufficient scale for study. Further discussions commenced in spring 2020 with clinical representatives of stroke and ambulance services who were leading the NC London and East Kent pilots. Working with these clinical leaders, RSET staff developed an evaluation protocol which underwent local review by RSET colleagues outside the core team, review by a panel of two patient experts and independent peer review by Professor Henry Potts [University College London (UCL)] and Professor Helen Snooks (Swansea University). The final version of the revised protocol (v1.3) was approved by the NIHR
HSDR programme in August 2021.
Our protocol underwent a number of revisions over the course of the service evaluation. The key revision in terms of evaluation design was the addition in March 2021 of a staff survey conducted with ambulance clinicians. The other revisions related to extending the evaluation timeline. Although the project was initially scheduled to conclude on 31 March 2021, it was extended to 30 June 2021 to permit the completion of qualitative data collection (which had been severely disrupted by the winter wave of the COVID-19 pandemic); it was then extended to 30 September to permit write-up and the incorporation of clinician and patient feedback in report drafts.
