Robot saves ED stroke patients, addresses subspecialist shortage

Neurologists in another facility speak through robot, guide care

When a patient presents at Frankfort (KY) Regional Medical Center with neurological symptoms, a "code neuro" is called. In addition to ED staff jumping into action, the lab, radiology, and additional nursing help are alerted.

"It tells the CAT scanner we will quickly do an EKG, start an IV, and that they have to clear the way so we can get the scan done and read by radiology within 15-20 minutes," says Mike Presley, MD, FACEP, medical director of the ED.

Meanwhile, the robot swings into action.

That's right, robot. Provided by University of Louisville Healthcare, NELSON (Neurological Evaluator for Lowering Stroke Outcomes Nationwide) stands about 5 feet 6 inches tall and glides across the floor on unseen wheels. He allows neurological specialists at Louisville to communicate via wireless broadband Internet with the Frankfurt ED staff. His "face" is a 21-inch computer screen, on which the head of the consulting neurologists appears and speaks to the ED staff.

But NELSON is more than just a rolling computer screen. His movements are controlled by the team in Louisville. So, for example, when the patient or family member has a question, he will turn his head. The distant physician will speak directly to the questioner.

What's more, NELSON has his own voice. Once treatment has been completed, for example, he is supposed to be plugged into an electrical outlet. If that fails to happen, NELSON's computer will detect that failure and a computer voice will say "Please plug me in."

Louisville makes NELSON and its staff available free of charge in exchange for Frankfurt deploying the program.

"We've gotten nothing but positive feedbacks from patients and clinical staff," reports Presley. "I was concerned that patients would get 'freaked out,' but the technology we're using actually blows people away."

Eliminating call problems

The decision to try the program grew out of the frustration of having stroke patients come into the ED and not being able to find the resources to take care of them in a timely manner, says chief nursing officer Sammie Mosier, RN, BSN, MA, CMSRN, NE-BC, who helped initiate communication with Louisville.

"We had a lack of neurology coverage, especially on a 24-hour basis, and we were even to the point where EMS services would not bring patients to us because they did not know if we had coverage, and with stroke patients you have a window of time in which they need immediate treatment," Mosier says.

In the past, notes Presley, these patients had to be transferred to another facility, which could have negatively impacted outcomes if the transfer took too long. "This allows us to keep more of the neuro patients at our facility," he explains. "We have hospitalists that can admit and care for patients from a general medical sense, but we need special care by neurologists."

Mosier adds, "It's definitely increased the intensity level and care we can provide for patients. Delay is bad for their care, and it's scary not to have the service you need. With this relationship the patient gets treatment immediately, and if they need surgery and we can't do it, they are put on a direct route to Louisville."

Mosier went to Louisville to observe the program in action. "We learned all the things they could offer patients, and they also had a track record," she says. "We would not be the first facility to use the program."

There are 11 other facilities in Kentucky that are using the program, including Louisville.

Among the key deciding factors, were the 24/7 availability of consultants and their expertise, she says. (There was little formal training of ED staff required. See the story below.) Now the ED physicians perform a quick assessment of new patients, and if they determine it could be a potential stroke, they initiate a call to Louisville and the robot is initiated, Mosier says.

"The on-call doc at the U of L activates the robot, brings it to the bedside, works with the nurse or doctor, and starts doing the neural assessment immediately," she says. "There's no way, even if we had coverage, that the patient could be seen any faster."

NELSON also wears a stethoscope around his "neck" for the physician to use at the request of the neurological consultant.

The examination is a complete one, says Presley, who explains that the assessment must be completed before a decision is made about whether to administer a thrombolytic. "Most of the neurologic exam is done by asking the patient to perform a certain task, such as holding both hands out with palms extended and then opening their eyes. The specialist can assess the patient's strength by having them hold their arms up for a period of time and their reflexes by how fast they move their arms."

In addition, says Presley, the neurologist can "zoom in" on the patient's eyes while the Frankfurt caregiver shines a light in the eyes, so they can see how the pupils react. "It's amazing how much they can do," he says.


For more information on using robots in the ED for stroke victims, contact:

  • Sammie Mosier, RN, SN, MA, Chief Nursing Officer, and Mike Presley, MD, FACEP, ED Medical Director, Frankfort (KY) Regional Medical Center. Phone: (502) 875-5240.

Robot requires little training

15-minute demo training provided

There was minimal training required to prepare the ED staff for the implementation of a robot-aided stroke care program at Frankfort (KY) Regional Medical Center, says Medical Director Mike Presley, MD, FACEP.

"The robot is very user friendly, says Presley.

The staff went through a 15-minute demo training at the request of Kerri Remmel, MD, PhD, stroke team leader for University of Louisville Healthcare, which provides the robot. "We linked with her, and she show us how it moves, how it can see the room, and how it can talk clearly with us, the patient, and the family," says Presley.

He notes that it is really the consulting neurologist in Louisville who speaks through the robot. "The only thing we need to remember is to plug it back up when it's done," Presley says.

One change was made in the program after it had been in place for a while, adds Presley, who notes that the robot is also being used by the intensive care unit (ICU).

"We found that they not only do a lot of ED consults, but they are also in the ICU, seeing people on the floor. So rather than training every doctor or nurse that might use, it we decided to train the house supervisors, and one is always in the house," Presley explains. "So if one of our hospitalists needs a consult from ICU, the house doctor can hook them up."