Telemedicine helps rural EDs access critical neurology expertise for stroke patients

Approach helps physicians determine whether patients are good candidates for clot-busting therapy

With a national shortage of neurologists, it is impossible for all hospital EDs to have neurology specialty expertise on site whenever patients with symptoms of stroke present for care. This is a particular problem for hospitals in rural communities, many of which do not have any neurologists on staff. However, a small but growing number of these facilities are getting around this dilemma by partnering with larger centers of excellence in stroke care that have the expertise on staff to guide decision-making for these patients through virtual consultations at any time of the day or night.

For example, the Carondelet Neurological Institute in Tucson, AZ, is now providing this kind of expertise to three rural hospitals in southern Arizona through its TeleStroke Program, and experts anticipate that it will be providing neurological consultations to additional hospitals in the future.

"We have time windows sometimes under three hours in which to acutely treat a stroke patient, and that doesn't give you much time to transfer an acute stroke patient to a hospital that has neurology and the right kind of imaging," explains L. Roderick Anderson, MD, medical director of the Carondelet Neurological Institute's Stroke Program. "So it makes sense for rural hospitals to do the initial evaluation and then discuss the case with a specialist, and now the TeleStroke Program gives us the ability to even evaluate and examine the patient live. This has been shown in studies to improve patient care."

The approach links patients in rural areas with the kind of specialty expertise that is generally only available at larger facilities. "We know that roughly 300 strokes occur per 100,000 people, so a lot of rural hospitals aren't going to see that many strokes in a given year," says Anderson. "We see stroke patients on an almost daily basis, whereas the ED physicians in small towns may only see them once a month. We can guide management of these patients so that decisions can be made quickly."

Anderson emphasizes that implementing this type of approach requires much more than an Internet connection between two sites. "We have to make sure that there is education with both the ED physicians and ED nursing staff so that they are aware of our protocol, they are aware of the exam we are going to do, and they understand what we are dealing with," he says. "What we are doing is mirroring what our guidelines are from the American Stroke Association, but what we often find is that hospitals are doing things a little differently for any number of reasons, so it is important that everybody gets on the same page, and I think that is actually good for patient care."

Experts on both ends of this arrangement agree that while the education process needs to be ongoing, there are dividends in terms of more knowledgeable staff, and vigilance in connecting patients who exhibit symptoms of stroke to care quickly.

Develop step-by-step instructions

Sierra Vista Regional Health Center (SVRHC) in Sierra Vista, AZ, has been participating in the TeleStroke Program with Carondelet for about six months, explains Kimberly Riggs, RN, BSN, MSN, the ED director at Sierra Vista Regional Health Center. She explains that one of the key preliminary steps in establishing the relationship involved making sure that neurologists at Carondelet could access SVRHC's picture archiving and communications (PAC) system.

"We wanted their physicians to be able to tap into our system so they could see our CT [computed tomography] scans for our stroke patients, so IS [information systems] personnel from the two sites had to work together," she says. The hospital also needed to purchase a computer-on-wheels that has high resolution and is equipped with a camera so that neurologists at Carondelet could view patients during consultations, adds Riggs. "We had to purchase that equipment and ensure that we had the right software," she says.

While IS professionals worked out the technical details, Riggs worked with Carondelet to formulate an education plan to get staff ready for participation in the TeleStroke Program. "All of my staff, including nurses and technicians, went to an educational session that Carondelet hosted," says Riggs, explaining that the session focused primarily on what stroke is and how to complete the National Institutes of Health Stroke Scale (NIHSS).

The NIHSS is an abbreviated neurological exam that helps neurologists assess the severity level of a stroke, explains Anderson. "It is a very easy exam to do, very reliable and reproducible, and in doing that, we can determine whether a patient is perhaps a good candidate for receiving a clot-busting drug, tPA [tissue plasminogen activator], to treat their acute stroke."

While tPA works very well in some cases, it comes with certain risks; people can bleed to death, explains Riggs, and people don't always fall into specified or easy to delineate risk categories. This is why it is helpful to have a neurologist available to consult with on these cases, she says.

Carondelet helped Riggs develop a stroke packet, detailing step-by-step instructions on what staff should do to get patients exhibiting symptoms of stroke into a room and diagnosed quickly. Then Riggs conducted several trial runs in which she would wheel the TeleStroke computer into a room, plug it in, make a quick connection to Carondelet's network, and make sure that people on both ends could see each other.

Once Riggs was satisfied that the technology was working properly, she set up a training schedule consisting of unannounced visits to the ED at different times of the day, including all the different shifts.

"I loaded a mannequin up in a wheelchair, wheeled it into the lobby, and told the front desk that the patient was having a stroke; treat him like a real person," explains Riggs. "We did this not only with the ED staff, but also lab and radiology. We expected them to respond as well ... just so we could tighten up loose ends that we had, and everybody could get a better idea of how things were going to go when we had a potential stroke come in."

Emphasize importance of time-to-treatment

While going through all of these preparations is necessary to getting all the technical issues resolved, the process has also made ED personnel more cognizant of the importance of time-to-treatment in stroke cases. "From the moment a patient gets here to when we administer lytics, we have 60 minutes; that's it," says Riggs, noting that there is not much margin for error when you consider that during this period IVs need to be placed, lab samples taken, a head CT done, results returned, and a decision made. "I think it has made the staff realize that just like with chest pain, this is extremely time-sensitive. But it has also made them realize that they are able to do it. We took this process and tightened it up."

Now, whenever a patient comes in who may be suffering from stroke, the ED will issue a "code brain attack" that immediately triggers all the steps that need to take place, explains Riggs, noting there are standard order sets in place that dictate what tests need to be completed, and there are special labels that go on the lab tubes so that they can easily be identified as they are spinning in a centrifuge. "The way we practice is if there is even the slightest thought that a person may be suffering from a stroke, you are going to call a code brain attack," she says. "The physician may then come in and say it is something else, but we are going to move on it until a physician tells us something otherwise."

As a result, the process is triggered as often as every week at SVRHC. And the physicians in the ED appreciate having the ability to consult with a neurologist on any case at any time, as there is 24/7 coverage. "If someone is having a cerebral infarction, our only option in a rural facility is to get them to Tucson as quickly as possible so that they can receive [appropriate specialty care], but we can administer the tPA here if the neurologist wants us to do that," says Riggs. "It is a safety-net for our physicians so that they are not making that decision on their own."

Over time, these regular consultations with neurologists have a tendency to improve overall stroke care as well, says Anderson. "We are providing education and knowledge that help ED physicians and nursing staff manage the acute stroke patient better," he says. "What we have seen in the EDs that we have worked with is more efficient workups and more of a readiness and an ability to treat strokes acutely and aggressively."

One of the concerns Anderson hears from hospitals that are interested in the TeleStroke Program is they are worried that the consultations with Carondelet neurologists will actually increase time-to-treatment, but he has not found that to be the case. "We have monitors in our offices and in the hospital, and we also have portable computer laptops that allow us to access [the hospitals] wirelessly if we are either at home or somewhere en route," says Anderson. "That really enhances our ability to respond [to hospitals in the TeleStroke Program] right away."

In the case of SVRHC, the approach has actually shortened time-to-treatment, says Riggs. "We go over all of our statistics and we have time parameters ... and on every single stroke case we have done this with, the [time-to-treatment] has been under 60 minutes," she says. "I am not confident that we were meeting that threshold before. We weren't moving as quickly, we weren't triggering lab and radiology the way we are now."

Plan for ongoing support, education

Hospital administrators that are interested in establishing a telemedicine link with a larger academic health center that can offer expert guidance on stroke care should first discuss the option with all ED providers because they have to be on board for the approach to be effective, says Riggs. "If you've got a physician group that is not willing to participate, that makes it very difficult, so talk with your providers and make sure they understand the importance of the time frames involved, and what the current standards of care are," she says.

Once you have the appropriate buy-in from providers, take the time to visit a hospital that is already using this type of approach and ask questions, advises Riggs. That is how she geared up for the program at SVRHC.

Anderson emphasizes that while upfront education is critical to an effective program launch, the education process needs to be ongoing because people and guidelines tend to change. "If you have very few stroke patients coming into a rural hospital, after a while, people can sometimes forget the protocols and what needs to be done," he says. "You need physicians and nursing staff on both ends, you need stroke coordinators who can help with education, and you need technical support. All of these things go into making a program run smoothly."

Sources

  • L. Roderick Anderson, MD, Medical Director, Stroke Program, Carondelet Neurological Institute, Tucson, AZ. Phone: (520) 881-8400.
  • Kimberly Riggs, RN, BSN, MSN, ED Director, Sierra Vista Regional Health Center, Sierra Vista, AZ. E-mail: kimberly.riggs@svrhc.org.