About five years ago, officials at Maryland-based Bon Secours Health System confronted the need to deliver faster treatment for stroke patients arriving at the system's hospitals, which stretch from New York to South Carolina.
It often took far too long for emergency department doctors to reach a neurologist, whether they were on staff or in community practice. Neurologists, often busy on others cases, took far too long to show up or return phone calls.
Because only a neurologist can provide a definitive stroke diagnosis and order intravenous administration of tissue plasminogen activator or tPA, which rapidly dissolves clots and saves lives and brain cells when given soon after the event, the delays were disastrous for many patients.
“Time is brain and brain cells,” said Dr. Juan Grau, an assistant professor of surgery at Columbia University College of Physicians and Surgeons in New York. “The early diagnosis is crucial.”
Bon Secours' door-to-needle time for tPA administration averaged an unacceptably high 71 minutes across the system. That was well above the maximum 60 minutes recommended by patient advocacy groups. Bon Secours' St. Francis Health System in Greenville, S.C., had a 91-minute door-to-needle performance in 2010.
Officials at first responded by asking staff neurologists to work extra hours. Few took up the offer fearing burnout in the gut-wrenching grind of the ER. “Very few like treating stroke patients,” said Tim Shephard, executive director of Bon Secours' neuroscience institute and vice president of its neuroscience service line.
Some of its hospitals tried to hire more neurologists, but they bumped into the nationwide shortage. The demand for the specialty continues to outpace the supply, according to the American Academy of Neurology. The current 11% shortage is expected to grow to 19% by 2025.
Bon Secours turned next to hiring temporary neurologists—the locum tenens solution. But it was simply too expensive, Shephard said.
Short on neurologists for analyzing stroke patients?
Analyze how long before stroke victims are seen by a neurologist.
If longer than 15 minutes, consider telemedicine, especially if community physicians or staff neurologists are either in short supply or evade the work.
Screen telemedicine vendors to ensure they have the necessary infrastructure and can deliver rapid support.
Recognize that telemedicine requires upfront investment in cameras, electronic data interchange and a strong WiFi Internet signal.
Train emergency department clinicians on appropriate video and telephone consultation techniques.
Starting in 2008, Bon Secours began experimenting with an alternative at its Richmond (Va.) Community Hospital. It contracted with a telemedicine firm, which guaranteed a 15-minute telephone response from its 24-hour-a-day, seven-day-a-week neurology staff.
The hospital installed a video camera so the firm's neurologists could monitor patients in its emergency room during the initial examination. The hospital electronically transferred data from the lab tests and ER to those doctors. The equipment even allowed the tele-neurologists to zoom in on the pupils of the stroke victims.
All the data and video is transmitted over a wireless Internet connection to the on-call neurologist. “It was like having a neurologist in your ED 24/7,” Shephard said. “It takes the time lag out.”
The training for emergency department staff was minimal—about 20 minutes to learn how to use the video teleconferencing equipment. The real issue was helping them overcome their discomfort with the process, Shephard said.
Performance improved significantly. Initial neurologist response times in Richmond fell to nine minutes from 44 minutes. Encouraged by the results, Bon Secours expanded the system throughout its eight Virginia facilities.
Door-to-needle time for brain-preserving tPA went from 71 minutes across the system in fiscal 2012 to 53 minutes in fiscal 2013. Nationwide, 3.5% of acute ischemic stroke patients are reached early enough to receive tPA. Bon Secours' rates now range from 6% to 15% across the hospitals in its system.
Bon Secours estimated the cost of a tele-neurology program is comparable to what it would cost to pay for on-call neurologists in the local community—if they could find them. “As far as direct costs are concerned, it's a wash,” Shephard said. “The benefit comes from access—you get the job done faster.”
It also helped Bon Secours gain primary stroke center certification from the Joint Commission. Its guidelines, adopted in 2003 and backed by the American Heart Association, require a hospital to have 24-hour neurology coverage in its emergency room. There are now 925 such certified stroke centers in the U.S.
Consultants estimate the rapidly growing telemedicine market is more than $10 billion a year.
“Now that the technology is becoming more pervasive and comfortable with the consumer, I think things will continue to expand,” said Daniel Ruppar, research director for Frost & Sullivan Connected Health Global. “Technologies that use video or other equipment (give) the consumer even more advantages.”
Follow Ashok Selvam on Twitter: @MH_aselvam
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