Rural hospitals and underserved clinics simply don’t have neurologists on staff that can help stroke patients as they come into the emergency room. The uneven geographic distribution of neurologists is highlighted in an extreme misdistribution – there are 11.02 neurologists for every 100,000 people in Washington, DC, compared to only 1.78 neurologists per 100,000 people in Wyoming. Furthermore, neurology is currently seeing an acute overall shortage that is expected to hit 19% by 2025, and as America’s population ages, neurological disorders like stroke become more frequent.
Consider the following statistics:
• Every 40 seconds, someone in the United States suffers a stroke
• Strokes are the 5th leading cause of death in the United States
• Strokes are the No. 1 cause of adult disability in the United States
Since time is brain, how do we ensure that rural patients and the growing number of elderly in these communities are not disadvantaged by their distance from major health facilities? How do systems minimize the geographic penalty felt by rural stroke victims? Effective use of tPA (the only FDA approved drug to directly treat stroke) requires quick delivery after the stroke. Yet, as one journal noted:
[P]atients who have a stroke in a community served by a hospital with 50 beds or less, the frequency of receiving tissue plasminogen activator (tPA) treatment is 12% what it would be in a community with a 200-bed hospital.
Clearly, we need to find ways to mitigate the time it takes for individuals in rural and underserved communities to receive treatment. Tools that can effectively get neurologists to see the patient more quickly are essential.
A Very Brief History of Teleneurology
Telemedicine has been around for decades. Massachusetts General Hospital had an early form of telemedicine available in in the late 1960s. But the first detailed description of the potential use of telemedicine in acute stroke via video teleconferencing was only in 1999. Seventeen years later, there are many for-profit companies and hospitals with telestroke and teleneurology programs.
Indeed, the field has grown since its early days as the technology to enable interaction between doctors and patients has improved. What was needed in the early days that couldn’t be provided until the past several years was a reliable transmission rate of data to support high resolution imaging.
Today, there are multiple models of providing teleneurology:
• Do it yourself: technology is purchased by a hospital or company with consults by local neurologist
• Hub – Spoke: Consults provided by hub facility physicians to spoke clinics
• Independent: Consults are provided by independent telephysicians.
Regardless of the method of delivery, the point that remains most important is that the care is provided in a timely fashion. Patients must be seen within the critical tPA window to reduce the likelihood of significant brain damage.
Providing effective teleneurology for stroke today
Neurology Advisor notes “Stroke is 100% the number one application of teleneurology, not just to get tPA into a patient earlier but also to triage patients who do not respond to tPA and to get hemorrhagic stroke patients to a higher level of stroke care…. Several studies have shown that telestroke care improves tPA use and outcomes in ischemic stroke in rural areas and community hospitals.”
We have worked with several hospitals in rural areas that receive teleneurology services from a neurohospitalist. Our primary contact has been with the independent neurohospitalist groups that provide services to rural hospitals that are not connected to a hub. In the scenario we work with, doctors at the neurohospitalist group are contacted by the rural hospital when a patient comes to the hospital and is in need of neurological care.
Implementation of a time-sensitive and efficient workflow for telestroke services is the basis for a successful clinical operation for evaluating and managing suspected acute stroke patients using remote expertise. But this workflow is made difficult by the need for teleneurology to be provided 24/7.
Telestroke guidelines recommend ensuring a 24/7 operation, without any downtime. Providing this level of critical, immediate and on-going alerting proved difficult for the rural hospitals we work with. Use of traditional paging technology amplified this difficulty as rural hospitals were never sure if the doctor received the alert.
The need for critical alerting technology
Teleneurology is a field that feels the pager’s limits wholeheartedly. Given the importance of immediate access to neurologists in the case of stroke, nothing should stand in the way of reaching skilled care as quickly as possible. We have traditionally seen teleneurologists use pagers to receive alerts from rural clinics using their service. However, these physicians found that pagers often led to a delay in patient care.
When rural clinics paged neurologists on call, the physician did not always receive the alert. Furthermore, when the physician received the alert, they were not always able to assist the clinic as they were helping another patient. There was no way to automatically escalate the alerts when a physician was occupied. Clearly these limitations are notacceptable. Teleneurology serving rural areas needs a better alerting option.
A much better option is available. What wefind is that neurologists who have access to an immediate critical alerting service, are able to provide care to patients more quickly. The technology that is most useful to neurologists is one that:
• Provides robust alerts that are not blocked by normal physical infrastructures
• Escalated alerts so that if one physician was not available another physician on call can respond to the emergency
• Provided reporting so doctors can measure their time until response
• Ensured HIPAA compliance
• Is smartphone based to ensure a seamless workflow
By providing technology that has these components, physicians are able to cut down their response time by 90%. When time is brain and every second counts, this level of immediacy is necessary.
Conclusion
The results we found were heartening, as they meant that not only were lives saved, but the quality of the life lived would vastly improve. Ideally, we would love to see our experiences with immediate alerting in teleneurology mirrored in other fields that could help rural communities. We see fields such as cardiology and radiology as other fields that could potentially benefit from this introduction.
Clearly, telemedicine has the potential to transform how medicine is practiced in many disciplines. Critical alerting should not and need not be an impediment to its success.
Read more about this topic in Telemedicine in Action.
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