For patients who suffer a stroke, the amount of time between the first sign of symptoms and treatment makes a significant difference in the amount of brain damage and speed of recovery. That’s why the American Heart Association/American Stroke Association (AHA/ASA) recommends the use of telemedicine, or telestroke, to improve stroke care—especially in underserved areas.
Four years ago in Pennsylvania, Ray Reichwein, M.D., co-director of the Penn State Hershey Stroke Center, and a stoke neurologist himself, set out to create a telestroke program, as he wanted to improve the continuity of care and access to care in the region (Mount Nittany Medical Center in State College is the only hospital for 30 minutes in any direction). “We wanted patients be able to stay in their homes rather than drive long distances for care,” says Morgan Boyer, R.N., head of Penn State's telestroke program, called LionNet. “The whole stem of it, and where telestroke really comes from, is that emergency department providers aren’t as comfortable with stroke [care] like neurologists are, so they don’t treat it as much. If neurologists are involved more readily, it easily could lead to better patient outcomes,” says Boyer. But the issue is that there are simply not enough neurologists available on-site relative to the amount of people in the U.S.
As such, LionNet has evolved into a partnership between Penn State Hershey Medical Center (PSHMC) and regional hospitals to provide specialized stroke care to rural areas of Pennsylvania. Established in the summer of 2012, the LionNet network includes 15 partner site facilities, with a 16th in the works, within two hours of PSHMC, and averages between 75 and 80 telestroke consults per month.
Morgan Boyer, R.N.
Boyer explains how a normal telestroke consult occurs within the LionNet network: First, she says, with the initiation of a stroke alert at a community site, a computerized tomography (CT) scan is taken while the attending clinician assesses the patient for stroke symptoms. Or, on the inpatient side, if a hospitalist thinks a patient is having a stroke, he or she will call the LionNet number and get connected with a neurologist on call at Hershey. They will discuss the case together; the neurologist will ask what the clinician on the other side sees and what help is needed, and they will then go forward with the telemedicine consult, Boyer explains.
By then, the patient is in the room, vitals are collected, and the CT scans are back, at which point the non-contrast scan get pushed to telemedicine solutions vendor REACH Health, “so the consulting provider can then view the images in a timely fashion while they assess the patient in a real-time audio and video connection,” Boyer says. The provider then assesses the patient with help from a nurse—or whoever else is available to help—completes the exam, confers with the ED provider to go or not go with the clot-busting intravenous tissue plasminogen activator (known as IV tPA), and finally discuss if transferring the patient is needed.
A key point in this process is that if tPA is administered in the wrong conditions, the drug has the potential to cause a brain hemorrhage. To this end, Boyer notes that some community ED doctors do not have the level of comfort and neurological expertise to always make key treatment decisions. “Often times, the [ED provider] needs the neurology relationship to fall back on and expedite the transfer. So that has to happen one way or another, be it through telephone or telemedicine,” Boyer says. Officials at Hershey further note that the Penn State Hershey stroke team is able to help make the decision to administer tPA and are more likely to capture tPA candidates that may have otherwise gone untreated.
Speaking to the program’s results, Boyer says that all but three of Hershey’s partner sites have become primary stroke centers. “Some were in process of doing so before we became partners, and some were already, but well over half of the sites became primary stroke centers because of our relationship and guidance, so we have helped them achieve that designation,” she says.
Beyond that, Boyer notes how door-to-needle times have decreased by up to 20 minutes at some facilities, and by 28 percent since the inception of the program. The door-to-needle time goal set by AHA/ASA is 60 minutes, and Boyer says that the partner sites continue to get better at driving the process and getting their times down, first from 81 to 72 minutes, and now, “We are more consistently seeing times around 45 minutes now, which we are setting our benchmarks to. At the same time, we want our patients to be safe and stay in the [patient care] facility when appropriate. So our complication rate is less than 2 percent as well,” she says.
What’s more, within this program, officials note that 29 percent of ischemic stroke patients are treated with tPA (compared to nationwide average of 5 to 10 percent); tPA administration rates have increased by 500 percent at some facilities; and 75 percent of patients are now treated in their local community. All of these results point to the system working and the core goals that were laid out four years ago being achieved, Boyer notes.
As is the case with many telemedicine initiatives, there can be apprehension from both providers and patients who are unfamiliar with this new care delivery model. Boyer says, like with anything in the beginning, there has been mixed feedback when new provider sites join. But she adds that there is an accountability piece to the program that gets providers on board sooner rather than later. “We have report cards every month on neurologists’ performances where we are looking at specific data elements that are important to the quality of their documentation and the [telestroke] encounter,” Boyer says. “And there is a peer review process for them to be able to basically ‘peer review’ each other’s reports and documentations, and eventually this works into the shadowing of each other. So they are held accountable, they see how they’re doing, and if they’re falling behind.” Ultimately, they don’t want to be seen as the doctor who gets graded poorly on these report cards, Boyer says, additionally noting that the telestroke providers do get paid for each consult.
Meanwhile, the patients have taken strongly to the program, Boyer says. “There has been no hesitation so far on the part of patients—the young or the elderly—outside of the Amish community, who will actively not participate,” she says. Boyer adds that they had one patient who actually wanted to relive the telestroke consult experience and watch the video after receiving tPA. The LionNet program doesn’t record the consults, making the patient’s request moot, but Boyer says it struck her team that the patient was so engaged.
Moving forward, Boyer notes that future plans include outpatient follow-up for Hershey’s partner sites that don’t have neurology support, and also for patients that come to the medical center from a long distance and don’t necessarily want to come back for a follow-up. For them, it would be much easier to do the next visit in the comforts of their own primary care office and just have a telemedicine consult there, Boyer says. “We are trying to close the gap in the continuum of care by hitting the pre-hospital world and also with outpatient follow-ups. The idea is to get the whole picture of stroke care. Prevention is key and getting patients timely care is important, so these are the two main areas to focus on,” she says.