EXECUTIVE SUMMARY

Typically, smaller hospitals without in-house neurologists use telestroke applications. Recently, Norwalk (CT) Hospital developed a program using a telemedicine hookup to connect with its own neurologists at home when a potential stroke patient presents to the ED during off-hours or on weekends. The idea is to ensure emergency physicians and patients receive the same timely access to expert consultations they would receive during normal business hours when neurologists are present in the hospital.

  • A big factor driving the telestroke initiative was the fact that heavy traffic congestion in the Norwalk region can delay travel to and from the hospital significantly, making it difficult for an on-call neurologist to get to the hospital quickly.
  • Neurologists are equipped with computer camera hookups in their homes so they can respond remotely to a stroke alert if they are on call.
  • The ED maintains the telestroke technology on movable carts that can be brought to the bedside quickly to facilitate consultations between the remote neurologist, the patient, and the emergency physician.
  • While the technology is used only during off-hours and on weekends, hospital leaders are considering leveraging the approach to connect patients who present to the ED with behavioral health concerns with needed psychiatric expertise.

For many years, smaller community hospitals have been contracting with larger medical centers to provide neurology expertise via telemedicine hookup when they see patients who present with suspected strokes. Called telestroke, it is an approach that can expedite needed care for a time-sensitive condition. The tool has been a literal life-saver, particularly for patients who live in outlying areas, far from the resources and expertise available in more urban settings.

However, are there other uses for telestroke technology that have not yet been explored? Clinicians at Norwalk Hospital in Norwalk, CT, a city about 50 miles from New York City, think the answer is yes. Recently, facility leaders implemented their own version of telestroke for those times when their in-house neurologists are not present in the hospital but can be reached at home through a telemedicine linkup.

One factor driving the initiative is the fact that traffic congestion in the region can make it difficult for an on-call neurologist to get to the hospital quickly when a stroke case presents during off hours, potentially depriving emergency clinicians and their patients from the neurologist’s expertise when determining whether the patient is a candidate for clot-busting drugs.

The telestroke solution that Norwalk Hospital has employed solves the problem without the need for contracting with a third party. Clinicians already are thinking about other ways they can leverage the technology to expedite care to emergency patients with other health concerns.

Customize a Solution

Benjamin Greenblatt, MD, chair of emergency medicine at Norwalk Hospital, is a big believer in leveraging telemedicine to advance and improve care. “It is not really an option anymore in terms of health systems having [telemedicine]. It is really about how you integrate it into your practice on an enterprise level and on a hospital and departmental level,” he explains.

Consequently, it was not a leap for Greenblatt to embrace the idea of using telemedicine technology to accelerate expert care to potential stroke patients. “Stroke is an extremely time-sensitive area of emergency medicine,” Greenblatt notes. “There are efforts around educating the population about recognizing stroke. That is a big aspect, but once patients get [to the ED], we want to treat them as quickly as possible.”

Norwalk Hospital is a level II trauma center that sees 50,000 patients in the ED every year, but it is also located in Fairfield County, CT, which includes a large population of older residents, Greenblatt notes. “We probably do 30 to 40 stroke alerts every month,” he says.

When such cases present, the goal is to treat appropriate patients with clot-busting tissue plasminogen activator (tPA) within 60 minutes of arrival in the ED. However, the drug is contraindicated in some patients, and it is not without risk; discerning which patients should receive the treatment is best accomplished in consultation with a neurologist.

Usually, there is a neurologist present and available at the hospital to handle these bedside consultations in the ED from 8 a.m. to 4 p.m., explains Michele Lecardo, RN, CCRN, CNL, SCRN, the hospital’s stroke program coordinator. However, managing potential stroke patients who present to the ED outside those hours has proven challenging. “A lot of our neurologists don’t live in Norwalk. They are not close to the hospital ... so in order to expedite their connection with the patient, telestroke seemed to be the answer to what we were looking for.”

When the idea first surfaced, clinicians thought about using Facetime or Skype to establish face-to-face connections between ED physicians, patients, and an on-call neurologist during off-hours and weekends when a neurologist is not present in the hospital. However, it became clear quickly that such connections would not comply with the Health Insurance Portability and Accountability Act (HIPAA) or other mandated regulations. “That is when we came up with the program we have now,” Lecardo says.

Facilitate Consultations

Under the new telestroke program, which went live in October 2018, all neurologists have installed computers with cameras in their homes. If a stroke alert signals, they can connect with a camera-equipped cart in the ED that can be moved to the bedside easily. “Once we turn [the equipment] on, the neurologist who logged in is there and ready to go,” Lecardo explains.

“Having our colleagues, the neurologists, at the bedside helping us to make decisions about sometimes complicated patients or patients who can’t give us a lot of information ... is really helpful to us,” Greenblatt observes. “It gives us a lot of confidence when managing these patients.”

In addition to providing an audiovisual connection between the remote neurologist and the patient and clinicians on site in the ED, the neurologist also can access to the patient’s electronic medical record and any imaging tests that are completed.

“We can talk to the patient, and we can interact with them sort of face to face,” observes Daryl Story, MD, a neurologist and director of the acute stroke team at Norwalk Hospital. “Obviously, I am not there to lay hands on the patient and feel their strengths ... but I can get a very good idea [of those elements] by asking either the nurse or the physician in the room to ask the patient to perform a particular maneuver.”

Although the technology produces high-quality video that can enable the remote neurologist to zoom in on a patient’s eyes and closely examine his or her pupils, that kind of exam usually is not required in the case of acute stroke, Story notes. “Hard-to-detect subtleties are generally not what we are interested in [for] that context,” he says. “It is really more the disabling issues like being able to speak or having a very weak side of the body.”

Story notes that the telestroke technology makes it easy to see on the screen what neurologists are looking for in the typical case of a suspected stroke. “We can get a very good sense about how the patient is doing,” he offers.

Even though this is a novel use of telestroke technology, it is something the neurologists on staff at Norwalk Hospital have been talking about for several years, Story shares. “To be at home and need to rush to the hospital to see a stroke patient puts us under a lot of duress, especially if there is bad weather or traffic,” he says. “We welcomed the opportunity to be able to stay at home and do this.”

Watch the Clock

While the telestroke technology is available to the ED 24/7, it is used when suspected stroke patients arrive in the ED outside normal business hours. “The on-call neurologists take calls starting at 4 p.m. and through the weekends. If they are not at the hospital during that time ... they can opt to use telestroke instead [of driving into the hospital],” Lecardo explains.

Considering the region’s proximity to New York City, it is particularly prone to heavy traffic congestion that can slow travel to and from the hospital significantly. “This is a better use of the [neurologist’s] time. We may get a higher-quality consult as opposed to having a frazzled neurologist show up in the ED as the time is dwindling,” Greenblatt says.

Every minute counts during a stroke, Lecardo stresses. “Patients are eligible to get [tPA] up until four and a half hours after symptom onset. But if they get the medicine one hour after symptom onset ... all the studies have proven that we see a better outcome. The sooner a patient gets the medicine, the better,” she explains.

The ED strives to treat appropriate patients with tPA within 60 minutes of arrival in the ED, and the telestroke process helps clinicians meet and sometimes exceed that goal. For instance, Lecardo recalls one recent case involving a woman who presented with stroke during the off-hours. Her workup confirmed she was eligible to receive tPA. “The neurologist used telestroke, and we still gave her the drug within 44 minutes [of her arrival to the ED],” Lecardo reports.

Of course, the telestroke process is equally important in determining which patients should not receive tPA. “There are a lot of stroke mimics out there,” Greenblatt explains. For example, he recalls one recent case involving a 60-year-old woman who had apparently experienced a seizure and some partial paralysis that looked very much like a symptom of stroke. The neurologist consulting on the case via telestroke discerned that the symptoms were not because of a stroke and that tPA should not be administered.

“If I had seen that case [alone], there is a good chance I would have given the patient tPA,” he says. “I was really happy to have the neurologist looking at that patient in real time.” Greenblatt adds that activating the telestroke consultation is almost faster than when the neurologists are in the hospital and can respond to the bedside in person.

Test the Technology

Clinicians on both sides of the telestroke hookup report no problems using the technology. “It is a relatively easy system,” Greenblatt notes. “The actual monitor is stored. Nursing is responsible for keeping it safe behind lock and key within our storage facility [in the ED] so that no one gets in there and plays around with it. Then, when [telestroke] is activated, they bring it out.”

Further, very little education or training was required to implement the system. “We just needed to make sure everyone was comfortable that they were going to have conversations with the neurologist on the monitor instead of in person,” Greenblatt adds.

Story agrees, noting that all the neurologists engaged in a practice interaction from home with a mock patient to make sure their linkup worked and that they understood how to use the system. Otherwise, no further instruction has been required. Lecardo concurs with these sentiments, adding that once clinicians on both sides of the hookup tried the equipment and saw how clear the camera images were, they embraced the concept. “Emergency physicians would much rather be able to converse with [the neurologist] face to face or face to screen than over the phone,” she says.

One added factor that helped advocates of the telestroke approach at Norwalk Hospital win over colleagues was the fact that the hospital’s CEO is a neurologist who has a keen interest in this area, Greenblatt observes.

Consider Other Applications

For other EDs interested in leveraging telestroke like Norwalk Hospital, Lecardo recommends that leaders identify champions for implementation. She also advises colleagues to secure commitments from the appropriate IT employees early. “Research what equipment you are going to use,” she adds. “You have to purchase equipment, so this doesn’t come without cost, but the benefits to the patient outweigh the financial cost.”

Story notes that it is important to carefully consider how stroke is managed at a hospital and to establish broad acceptance of the concept by the emergency physicians as well as the neurologists. “This is still a low-volume idea,” he says. “The majority of strokes that we evaluate are when we are already here in the hospital when [telestroke] doesn’t apply.”

While the telestroke application is used during off-hours and weekends when neurologists are not present, there already are plans to further leverage the technology for other issues. “Psychiatry really lends itself to this type of technology ... and there is a tremendous need there. Psychiatric inpatient beds continue to dwindle, and the psychiatric demand continues to increase across the country,” explains Greenblatt, noting that many of these patients end up in the ED for prolonged periods. “We are in discussions with our psychiatry department to try to make [a telemedicine solution for behavioral health emergency patients] a reality. That would be, I think, a huge win for patients.”