STROKE IN THE WILDS
TELEMEDICINE TO THE RESCUE
When the entire Medical College of Georgia (MCG) stroke faculty was away at a conference in Hilton Head, SC, last year, the on-call neurologist was paged just as they were all getting ready to sit down for dinner. The 58-year-old man with a left hemiparesis who had just rolled into McDuffie Regional Hospital in Thomson, GA, benefited from a neurology consultation from two MCG stroke experts – who examined him from the resort's business center 200 miles away.
“He received tissue plasminogen activator (tPA) in 112 minutes, and improved from 17 National Stroke Scale (NIHSS) points to 11 by the following day,” said David C. Hess, MD, who recalled the information from his database. And the neurologists re-joined their colleagues well before dessert.
Dr. Hess, MCG Professor and Neurology Chair, used a telestroke system called REACH (Remote Evaluation of Acute Ischemic Stroke), which provides emergency coverage to nine small hospitals (10 to 75 beds) in rural Georgia. When the stroke specialists on call receive a field alert from the MCG central hub, all they need is a broadband connection. A real-time video interface sent over the Internet lets the physician interview and examine the patient, attain an NIHSS score, review the CT scan, and speak with the local emergency room (ER) staff.
As described in the April 4 issue of Neurology Today (page 6), public expectation about the wonders of tPA is rapidly rising and hospital administrators are pushing neurologists to participate in their efforts to qualify as certified stroke centers. But the practical dilemma for neurologists serving non-urban areas hinges on transit time. Should they delay treatment until they can evaluate each candidate in person, while risking the three-hour window of opportunity, or do they approve an ER doctor's decision and hope that the patient was not misdiagnosed? As several pilot centers are finding, stroke coverage appears to be ideally suited for telemedicine: It reallocates resources to areas underserved by neurologists, solves the critical time frame problem, and may even address growing medical liability risks.
CARE IN THE REMOTE AREAS OF WYOMING
As one of only eight neurologists in full-time practice in the entire state of Wyoming, Allen L. Gee, MD, PhD, believes that telestroke programs hold the potential to improve the delivery of neurological care to residents in the rural west. When Dr. Gee leaves home in Cody, WY, population 9,000, to go to work at outreach clinics, he travels up to 90 miles each way.
“Acute stroke care in Wyoming is severely challenged by geography,” said Dr. Gee, describing the Bighorn basin in the northwest part of the state as isolated by several mountain ranges. He noted that the landscape restricts both the timeliness of the patient's arrival in the ER as well as accessibility to a neurologist.
In Wyoming, with the exception of Casper and Cheyenne, he explained, ER physicians typically consult with a neurologist from a tertiary center and, if appropriate, tPA is delivered to the patient. These patients and those who require immediate or additional evaluation are then stabilized and transported to one of the centers.
In fact, the cart-laden REACH system and similar systems are currently being considered by several state departments of health to provide so-called “frontier” stroke care – the entire apparatus including the audio-video camera set up, computer workstation, and software, is of relatively low cost. “In Alaska and Montana, for example, the population is so sparse that it would be otherwise impossible for tPA to be given,” explained Dr. Hess.
OUTREACH TO THE EXURBS
Even neurologists in more populated states are struggling with the tight time window. Suzanne Brown, DO, is one of three neurologists in the only neurology group that covers emergency room calls at Putnam Hospital, a 164-bed acute care hospital surrounded by windy roads separated by reservoirs in upstate New York. It takes her 45 minutes to get there from home – in good weather and without traffic. But since the hospital has begun the process of becoming a certified stroke center, she is worried that she will not be able to get to the ER within the three-hour time limit.
“The ER doctors want a neurologist to examine the patient before any tPA is given because they are apprehensive about potential lawsuits,” explained Dr. Brown, who is concerned about the liability risks for withholding tPA. “On the other hand,” she added, “I may be rushing in at 3 am, trying to avoid deer on the one-lane unlit roads, and it may well turn out that laboratories or subsequent history ultimately exclude the patient as a candidate.”
A SOLUTION TO MALPRACTICE RISKS
As the medical malpractice climate grows more ominous, telemedicine may actually provide a solution: because everything is taped, it is self-documenting and comprehensive.
“I feel good about that,” said Dr. Hess, who believes that it will make it harder for litigators to suggest that care was poorly provided. “The problem with making the call over the phone is that scans are often wrong,” said Dr. Hess, “you just can't rely on second-hand information.” Telestroke care may also prove to give better outcomes. “Symptom onset to door is typically 30 to 35 minutes at local hospitals, which are actually less busy than urban centers,” said Dr. Hess.
He pointed out that unlike in those busier ERs, patients receive the staff's full attention, rarely get lost, and the CT scanner is not tied up. Because of the expedited door-to-needle time, results are often better too, an impression backed up by studies showing that if onset to treatment time is 90 minutes or less, the odds ratio for a favorable outcome is substantially higher (Lancet 2004;363:768–774).
While telestroke systems may be able to deliver the expertise, there is a need to develop quality indicators to compare them to alternative models of care. This is exactly what stroke specialist Cheryl Jaigobin, MD, and her colleagues have done at the University of Toronto telemedicine program. Their telehealth network in Ontario provides stroke consultation to nine referring sites, via videoconferencing link. After five years of experience, they have developed telestroke quality-of-care indicators to provide a framework for these programs.
In a poster at this year's AAN meeting in San Diego, they presented outcome information such as length of stay and Rankin scores at discharge (P01.045: Canadian Stroke Quality of Care Study: Identification and Selection of Telestroke Quality of Care Indicators, available online at www.am.aan.com).
Dr. Jaigobin said, “I am currently working on other outcome information, including hemorrhage, mortality, and stroke-related complications.” She also hopes to add new referring and consulting sites, expand data collection to all referring sites, and to attain funding of a Web-based data collection format for telestroke.