STROKE IS THE fifth leading cause of death and the leading preventable cause of disability in the US. According to the American Stroke Association, 1 in every 20 deaths is attributed to stroke, and approximately 800,000 people suffer a stroke annually. Of these, 75% of individuals are experiencing stroke for the first time and 87% of strokes are ischemic in nature.1 These data reinforce the urgency of improving care delivery to patients with stroke.
Expanding across healthcare specialties, telehealth is increasingly used in the evaluation and care of patients with acute conditions. Telestroke programs, a branch of telehealth focused on stroke, can bring stroke care to patients in rural areas who would otherwise not benefit from an expert consultation with a neurologist. These programs also offer significant benefits in settings with more resources and expert personnel. This article examines how a telestroke program introduced in the ED of an urban hospital reduced door-to-needle times and improved patient care.
Wilmington Hospital is part of the Christiana Care Health System (CCHS) in Delaware. Located in a city of more than 70,000 people, the Wilmington Hospital ED (WED) sees approximately 63,000 patient visits each year and is certified by The Joint Commission as a primary stroke center (see Stroke certifications). Also affiliated with CCHS, Christiana Hospital is a Level I trauma center that is certified as a comprehensive stroke center. Wilmington Hospital relies on Christiana Hospital as a partner in acute stroke care.
The WED nursing staff recognized a need to improve door-to-needle times in the facility. Door-to-needle times refers to the time from a patient's initial presentation to the administration of the fibrinolytic agent tissue plasminogen activator (tPA). Expedited door-to-needle times help preserve brain function, minimizing the risk of disability and potentially reducing healthcare costs.2
The American Stroke Association's door-to-needle time goal is less than 60 minutes.1 A team of emergency physicians, ED nurses, neurologists, and stroke program coordinators met regarding strategies to improve these times in the facility in early 2015. Prior experience with telehealth led the team to investigate the potential of this technology for acute stroke management.
To improve stroke care delivery and permit real-time consultations with neuroscience experts, video conferencing was initiated for stroke alerts at the WED in August 2015. A system was devised based on advances in telehealth technology and aimed to decrease door-to-needle times for this patient population, improving overall care delivery.
The telestroke program connected WED physicians, nurses, and stroke program coordinators with neurologists based at Christiana Hospital. The WED staff utilized a computer tablet with a camera mounted on a movable pole for the best visual access. Nurses wheeled the device to patients for a digital consultation with an on-call neurologist. Using the visual and audio feed, these neurologists were available for the full patient exam. Notably, they did not give orders; instead, they advised the ED physicians on the best routes of patient care. The pole-mounted telehealth device also accompanied patients during computed tomography (CT) scans, so the neurologist could view images with the WED staff. Additionally, the interface was compliant with privacy provisions in the Health Insurance Portability and Accountability Act.
Before the system went live, the team conducted a review of the literature and had many meetings to determine the best algorithm to care for patients presenting with acute stroke symptoms (see Examining the evidence). It covered walk-in patients and prehospital stroke alerts from emergency medical services (EMS). According to the algorithm, caregivers or ED nurses and physicians may request a stroke alert if patients present with the following signs and symptoms, including but not limited to:
- speech difficulties
- weakness or numbness on one side of the body
- facial droop
- pronator drift.
A stroke alert should be activated within 6 hours of the onset of stroke signs and beyond 6 hours for severe signs such as complete unilateral paralysis or an inablility to speak. Stroke alerts are upgraded to codes following the decision to administer tPA after the CT scan has ruled out possible hemorrhage.
Once the workflow was agreed upon, education ensued for WED physicians, paramedics, nurses, clerical, and radiology staff as part of the roll out. This education included how to obtain an accurate patient weight, when venous access should be obtained, and how to document interventions consistently.
Results and lessons learned
In September 2015, just 2 weeks after the telestroke program go-live, the facility saw a door-to-needle time of 29 minutes, well under the American Stroke Association's 60-minute guideline.1 Before this patient, the fastest time had been 60 minutes and the median time was approximately 84 minutes.
In June 2016, a door-to-needle time of 14 minutes was realized. Between August 2015 and May 2018, the median door-to-needle time was 38 minutes for patients who had experienced a stroke and met the criteria for tPA. At the WED, the door-to-needle goal is now 45 minutes or less.
Addressing small details also enabled WED healthcare professionals to decrease door-to-CT scan times. Before the implementation of the telestroke program, patients presenting as a potential stroke alert or code were placed into a treatment room for nurse assessment before their CT scan. Typically, other tasks may have been completed first, such as an ECG or venous access. Under the new protocol, however, triage nurses and ED physicians met patients in the ambulance bay, shaving minutes off the door-to-CT times.
From there, the nursing staff took the lead and devised other time-saving measures. For example, a stretcher dedicated to patients with stroke signs is available to facilitate rapid transfer from the EMS crew, with the new process posted nearby for easy reference. Similarly, a transport monitor is kept available.
The nursing staff also recommended mounting a basket to the telestroke device to hold I.V. supplies for circumstances in which I.V. contrast media is necessary for the CT scan. At first, it was considered impossible to start tPA in the CT department, before moving the patient back to the WED. With dedication to the process and clear roles established, however, this can now be accomplished when indicated. After the CT scan and a decision to administer tPA following a digital consultation with the neurologist, the ED physician may give the order for tPA while the patient is still in the CT department. If available, the pharmacist can help prepare the tPA, and it can be administered on the spot, saving precious minutes instead of waiting to transport the patient back to the ED.
Ongoing staff education is vital for the sustained success of telestroke programs. This includes a regular, dedicated review of metrics to investigate delays and continually improve performance. Front-line nursing staff willing to champion these stroke initiatives is also key. Telehealth complements the clinical stroke services offered in the WED, ensures coordinated care throughout a patient's stay, and allows for the best possible patient outcomes.
Approximately 7 million stroke survivors live in the US.3 Given the rising cost of healthcare, increased community outreach, patient education, and quality and delivery of stroke care is crucial. Based on findings in the literature supporting the use of telehealth and our own experience, telestroke programs are a fiscally responsible way to add value in healthcare by improving patient outcomes.
- Acute Stroke Ready Hospital Certifications are for hospitals or emergency centers with dedicated stroke-focused programs.
- Comprehensive Stroke Center Certifications are the most demanding certifications and are designed for hospitals with specific abilities to receive and treat the most complex stroke cases.
- Primary Stroke Center Certifications are designed for hospitals providing critical elements for long-term success in improving patient outcomes.
- Thrombectomy-Capable Stroke Center Certifications are designed for hospitals that provide endovascular procedures and postprocedural care.
Adapted with permission from The Joint Commission. Stroke certification: achieving excellence beyond accreditation. www.jointcommission.org/assets/1/6/TJC-Stroke-brochure-vfinal-low-rez1.PDF.
Examining the evidence
A 2018 study compared outcomes in patients receiving tPA with guidance from a telestroke program with those receiving an in-hospital neurology consultation. No difference was found in 7-day and 90-day mortality.6 Another study of military hospitals demonstrated that patients who had experienced stroke and were admitted to a primary care service had longer lengths of stay and poorer outcomes than those admitted to a neurology service, including higher inpatient mortality.7 These highlight the need for telehealth programs in hospitals without neurology services. If the neurologist is involved in care, patient outcomes improve.
American Stroke Association. Types of stroke. 2019. http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/Types-of-Stroke_UCM_308531_SubHomePage.jsp.
2. Whetten J, van der Goes DN, Tran H, Moffett M, Semper C, Yonas H. Cost-effectiveness of access to critical cerebral emergency support services (ACCESS): a neuro-emergent telemedicine consultation program. J Med Econ. 2018;21(4):398–405.
3. Schwamm LH, Chumbler N, Brown E, et al. Recommendations for the implementation of telehealth in cardiovascular and stroke care: a policy statement from the American Heart Association. Circulation. 2017;135(7):e24–e44.
The Joint Commission. Facts about Joint Commission stroke certification. 2019. http://www.jointcommission.org/facts_about_joint_commission_stroke_certification.
The Joint Commission. Stroke certification: achieving excellence beyond accreditation. http://www.jointcommission.org/assets/1/6/TJC-Stroke-brochure-vfinal-low-rez1.PDF.
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