This fear is understandable. Many individuals naturally resist change; similarly, hospitals are hesitant to retrain personnel on a new protocol when the existing protocol works well enough.
This sort of reasoning focuses on the immediate changes sometimes required by telestroke. But in my experience, this perspective may be shortsighted because it: 1) presumes that existing processes for stroke triage and/or treatment provide the best possible outcomes and 2) ignores the ways in which any modifications necessitated by telestroke can actually improve stroke-related workflow.
Before delving into specific workflow changes, it’s best to set some parameters for the discussion. In my view, the appropriate way to consider potential stroke workflow changes involves asking these three questions:
- What is the current process for evaluating and treating suspected stroke patients?
- What aspects of the process need to change based upon the technology selected?
- How can the critical steps be accomplished while balancing the many benefits of telestroke with the desire to minimize the change in workflow?
The answers to these questions will vary across hospitals, but they provide a useful framework for any hospital considering telestroke. Any new technology inherently involves some degree of change, but potential workflow disruption can be minimized with the right technology and well-coordinated training and implementation. Based on my experience teaching doctors and nurses how to optimize telestroke workflow, I recommend the following best practices.
Understand Where You’ll Fit Within a Telestroke Network
The basic hub-and-spoke model still applies to many telestroke networks: the hub provides neurology coverage to spoke hospitals who treat the patients, if possible, but transfer patients to the hub if treatment options are limited at the spoke. Some mature telestroke networks, such as Georgia Regents University in Augusta, Ga., include hospitals dubbed subhubs and super spokes, which do not fit neatly into the traditional hub/spoke dichotomy.
Because telestroke workflow ultimately depends most heavily on the treatment options available at the point of patient care, individual hospitals must understand what role is best for them and how they will fit into the telestroke network. A comprehensive stroke center may see telestroke as opportunity to become a hub, caring for more patients and generating additional revenue. This will, without a doubt, alter stroke workflow. Patient mix at the hub hospital may change: patients who can be treated in the spoke hospitals will no longer be transferred to the hub; as only those patients requiring higher acuity intervention will be transferred. This will increase the focus on admitting transfer patients and rapid preparation for interventional procedures such as endovascular clot retrieval.
Another change for a hub hospital, specifically for the consulting neurologists, is the potential impact on staff scheduling and on-call coverage. Neurologists will now be responsible for treating stroke patients within their facility as well as performing remote consults, potentially at the same time. This may require a change in coverage based on the number of spokes in the network, accounting for both efficient coverage and physician satisfaction.
On the other hand, a small rural hospital could be interested in becoming a spoke as it would allow them to receive and treat stroke patients, better serving their community. This would mean implementing an entirely new workflow process for their ED staff and additional training for nurses on the NIH Stroke Scale and administering tPA.
Select the Right Technology for Your Hospital/Network
Some hospitals and health systems seek to bolt A/V capabilities onto existing EHR systems. Others wish to develop the technology in-house, adhering to precise and proprietary standards. Some hospitals select vendors who invest heavily in developing hardware, while others prefer a software-based approach. Some hospitals are content to have neurologists look at a patient’s CT scan and consult with the ED staff over the phone.
There are a variety of advantages and disadvantages to each approach that may be more or less prominent depending on how they are utilized by hospitals. Instead of singling out a specific approach, I’ll discuss the characteristics of well-designed and poorly designed approaches to telestroke.
From the standpoint of minimizing workflow disruption, the best possible telestroke solution is one that imitates an in-person assessment, utilizing only the tests and clinical information neurologists need to evaluate stroke patients and recommend treatment options. Of these telestroke solutions, the elite tend to be those with stroke-specific capabilities such as the NIH Stroke Scale integrated and tPA dose calculator, which can scale to provide support for other specialty-specific capabilities.
Telestroke solutions with the following attributes tend to complicate workflow:
- Approaches without stroke-specific workflow: A telestroke solution should give the clinicians everything they need at their fingertips, without the distraction of extraneous information. It is inadvisable to clutter the stroke examination/encounter documentation with irrelevant data fields or questions. Similarly, it is unwise to select a solution that doesn’t include stroke-specific tests like the NIH Stroke Scale. The ability to view CTs easily and make treatment recommendations is key.
- Approaches that require new technology-related skills: If a hospital is already experiencing pushback to telestroke from personnel, one can imagine how this resistance intensifies with the requirement of completely new skills or a complicated interface. For example: remotely piloting a robot has nothing to do with a stroke exam, and asking a neurologist to do so prior to beginning the actual exam virtually guarantees a longer response time.
- Approaches that require multiple systems/databases: Workflow issues may arise when a consulting neurologist must rely on multiple systems or databases to perform a consult. Because time is so precious in stroke care, the neurologist needs the fewest steps possible to be able to perform the consult and needs all the relevant information (clinical images, patient data and A/V connection) in one place and preferably with one login. This keeps the neurologist’s focus on the patient. Having all this information available from one login also has an added patient safety benefit: the neurologist cannot accidentally review the CT scan of one patient while remotely evaluating a different patient.
Pamela Hoback is the Director of Clinical Services for REACH Health, an enterprise telemedicine software company with more than a decade of experience.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.
