Présentation du système de téléconsultation neurologique et de téléradiologie chez des patients atteints d’accident vasculaire cérébral, mis en place par le réseau interhospitalier TEMPiS (Telemedical Project for Integrative Stroke Care) Docteur MÜLLER-BARNA, Klinikum Harlaching de Munich - TEMPiS

1. Telemedical Project for Integrative Stroke Care
in Bavaria, Germany
Conférence Télémédicine et Télésanté en Europe
FIEEC / ASIP Santé
Paris, 21.10.2011
Dr. Peter Müller-Barna
Department of Neurology
Klinikum Harlaching
Städtisches Klinikum München GmbH

2. Overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

3. Overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

4. 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

5. Changes in Age Distribution
2000  2050
→ Stroke is a public health challenge of prime importance
with increasing relevance !!!

6. What to do?
Stroke unit care i.v.-Thrombolysis
• reduces death or dependency increases favourable outcome
(OR 0.82; 95% CI 0.73 to 0.92; P = 0.001)
• OTT 0-90 min NNT 4,5
NNT = 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)
Time is Brain
In 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
Cochrane Database of Systematic Reviews 2009 Lees et al., Lancet 2010

7. Stroke Units in Bavaria, Germany, in 2002
The need in 2002 was
to improve stroke care
in the underserved
areas of Bavaria.
Stroke Unit
4
Stroke Center
Network-Hospital

8. Overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

9. Key features of the TEMPiS-Network
Implementation of Stroke Standard Training –
wards in each hospital treatment protocols center-based and onsite
Exchange of Experience Quality Management Teleconsultations

10. 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

11. 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

12. 3. Centre based Training
Stroke classes Training days for
speech & swallowing therapists
Stroke Update Sonography Laryngoscopy

13. 3. Onsite training
Bedside training for nurses
Regular ward rounds
in each network hospital
Bedside training for therapists

14. 4. Exchange of Experience
Ward rounds & Meetings
Newsletter
www.tempis.de

15. 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

16. 6. Teleconsultation - Network Hospital
DSL
Academic Stroke Center

17. 6. Stationary workstation – Stroke Center

18. 6. Teleconsultation – mobile solution
works with fast UMTS
= HSDPA (High Speed Downlink Packet Access)

19. 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 !

20. Main capabilities of the TEMPiS-Network
Implementation of Stroke Standardized Training –
wards in each hospital treatment protocols center-based and onsite
Exchange of Experience Quality Management Teleconsultations
TEMPiS is based on personal relationship,
know-how transfer, quality management
and telemedicine
► TEMPiS is a regional network with limited size

21. Overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

22. number of teleconsultations per year
3.560
3.216 3.187
3.062
3.000 2.859 2.837
2.688
2.000 1.924
1.000
0
2003 2004 2005 2006 2007 2008 2009 2010
Source : TEMPiS-database of teleconsultations

23. admission to CT-scan: less than 60 minutes
100% 2009 2010 96%
94%
93%
92%
91% 91%
90% 87% 88% 88% 88%
87%
85% 85%
81%
80%
80%
76%
70% 67%
60%
Bad Tölz
Traunst.
TEMPiS
BAQ
Dachau
Ebersb.
Rosenh.
Eggenf.
Mühldorf
Pasing
Burgl`feld
Freising
Straubing
Landshut
Cham
Kelheim
Zwiesel
Source: BAQ

24. 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)

25. tele-stroke units vs. conventional stroke units
Todesfälle
mortality TEMPiS-Kooperationskliniken (15)
Pneumonierate BAQ gesamt (80 Kliniken)
rate of pneumonia
door toto needletime
Door needle time
Frühzeitige Thrombolyse
early thrombolysis
Antikoagulation bei in AF
anticoagulation VHFli
antiplatelet drugsbei discharge
TAH at Entlassung
TAH innerhalb 48h
antiplatelet drugs at 48h
carotid Gefäßdiagnostik
duplex or CTA
Bildgebung
CT scan
Logopädie
early speech therapy
Screening nach for dysphagia
screening Schluckstörung
Mobilisierung
early mobilisation
Physiotherpie / Ergotherapie
early physiotherapy
Information Patient und Angehörige
information for patient/relatives
0% 20% 40% 60% 80% 100%
Source: BAQ; analysis for 2010

26. Overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

27. TEMPiS outcome trial
• Prospectively obtained data of 3122 stroke patients
• Comparing
Outcome of patients treated in network hospitals
to
Outcome of patients treated in control hospitals
• poor Outcome
dead or
institutional care or
at home with severe disability
Lancet Neurol 2006; 5: 742–48

28. Poor Outcome after 3 Months
43,0% 53,4%
-10,4%**
At home with
14,3% 21%
severe disability
12,5% Institutional 14,2%
Care
16,2% Dead 18,1%
TEMPiS Control hospitals
Lancet Neurol 2006; 5: 742–48

29. overview
• the need for stroke networks
• TEMPiS: key features
• TEMPiS: quality data
• TEMPiS: outcome analysis
• Summary

30. Take home ...
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.
Telestroke is part of routine stroke care in Bavaria.

31. Acknowledgement
We thank
► all participating stroke neurologists in the stroke centres
► all TEMPiS hospitals:
Asklepios Stadtklinik Bad Tölz Kreiskrankenhaus Kelheim
Kreisklinik Bad Reichenhall Kreisklinik Mühldorf
Asklepios Klinik Burglengenfeld Klinik München-Pasing
Kreisklinik Cham Klinikum Rosenheim
Klinikum Dachau Klinikum St. Elisabeth Straubing
Kreisklinik Ebersberg Klinikum Traunstein
Kreisklinik Eggenfelden Krankenhaus Zwiesel
Klinikum Freising

32. Thank you for your attention!
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 2259
E-Mail: peter.mueller-barna@klinikum-muenchen.de
www.tempis.de