AcuteCare Telemedicine Blog


The Personal Side of Acute Stroke Intervention

Mr. Rigby was found unresponsive, gazing to the right and unable to move his left side. Just moments ago, his nurse had seen the 91 year old awake in his hospital bed preparing himself for discharge from the hospital. Though the hospital lacked a neurologist, it had invested in telemedicine services. Immediate assessment of his acute neurological deficits would determine whether treatment with tissue plasminogen activator (tPA), a clot-busting medication, or even thrombectomy (direct mechanical extraction of the clot) was appropriate. If performed within a very short time window, tPA or thrombectomy would open arteries and prevent progressive death of brain cells. However, it could also lead to hemorrhage, bleeding into the brain that could be devastating and even life-threatening. Thus, the teleneurologist was charged with not simply recognizing Mr. Rigby’s stroke symptoms, but also those factors which make the risk greater than the benefit.

As the AcuteCare Telemedicine physician on call, I was at the bedside within minutes via remote presence technology. The evidence; left hemiparesis, left visual field loss and inability to speak, made it clear; Mr. Rigby had sustained a large right hemisphere stroke. A large artery, the MCA, was blocked by clot. His nurse knew the exact time of symptom onset. Without treatment he may have survived, but it was likely he would not walk or talk. He met every inclusion criteria for tPA. Unfortunately, Mr. Rigby was not a good candidate. He had undergone a surgical procedure just the day before, his anticoagulation had been restarted that day and his platelets were very low. At the age of 91 years with these risk factors, the likelihood of serious hemorrhage was too great. As I informed the family members that had filled the hospital hallways, a look of desperation filled their eyes. His daughter stated, “This man is worth-saving.” Remembering my Hippocratic Oath, my immediate response in this case was, “I am certain he’s worth saving, but nobody is worth harming.”

Then I remembered this “case” was her father. I asked her to tell me more about Mr. Rigby. A picture of a family patriarch emerged. He was still vigorous, taking walks daily. He was driving. Indeed, he still routinely played 9 holes of golf. But what she told me next illustrated the shortcoming of using population-based inclusion and exclusion criteria as the sole determinant of risk-benefit for an individual. Mr. Rigby was the caretaker of his 89 year old disabled and blind wife. Without the ability to walk and speak not only Mr. Rigby would suffer. I made an immediate call to the Marcus Stroke Center at Grady Memorial Hospital in Atlanta. The Marcus Center stroke physician agreed the criteria for invasive intervention suggested a high risk, but Mr. Rigby would be given a chance because the potential for benefit was irrefutable. Within a few hours the clot was extracted. Mr. Rigby had an opened artery with full reperfusion. His symptoms improved with only residual left arm weakness. Though speaking slowly, his good humor was immediately apparent. A family had their patriarch back.



Looking Backwards to See Ahead – Part 2: Accountability & Relationships

This is another in a series of blogs chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at 2011’s Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on ACT’s approach to accountability and relationships.

Accountability refers to the promise of optimal healthcare outcomes while maintaining an expected return on investment. Patient and physician satisfaction are cornerstones of accountability, but to depend solely on these measures has become passé. Administrators want measurable financial and clinical outcomes, and to obtain and retain clients, will expect supporting data for all assertions.

One must constantly seek meaningful measures of the services promised; encounter surveys gather data on every patient interaction, regardless of outcome. This data measures service utilization (e.g. stroke vs non-stroke, tPA vs. non-tPA, etc.) and efficiency (e.g. response time, “door to needle” time, etc). Constant focus on patient outcome requires frequent Mordibity & Mortality conferences. This leads to continuing education, reduced miscommunication and shared responsibility. Finally, financial impact (more specifically than simply “satisfaction”) can be obtained with quarterly or annual reviews of year-to-date ICD-10 referenced charges or admissions. However, emotionally powerful patient anecdotes must complement the sterile numbers. It is this human component that provides the raison d’etre, separating telemedicine from any number of telecommunication ventures.

Accountability also extends to the development and maintainance of relationships with ACT’s clients. A client considering telestroke invests significant time and capital and must undergo a fundamental paradigm shift regarding what constitutes optimal patient care. To facilitate this endeavor, a telemedicine service needs to become as integrated as possible into the culture of its remote partners. One cannot afford to simply be the latest technological gimmick, but rather must provide an approachable solution.

Frequent contact is paramount and must not be limited to patient encounters. Not all interaction can take place in the cloud; physical meetings allow remote presence technology to become an alternate mode of communication between colleagues, rather than a proxy for an actual relationship. Communication is the foundation of every meaningful relationship. Listening to the client will uncover their goals and challenges.  The telemedicine service will integrate more fully with a remote partner, helping the client on their terms. This may result in vertical integration with mutually beneficial services including electrophysiology studies, clinical trials, medical directorships, etc.

Horizontal integration may include multiple disciplines such as telestroke, teleICU or telepsychiatry. Ultimately, integration into a client’s business model and culture is crucial for long-term sustainability. ACT assures clients are not simply invested in telemedicine services, but in their relationship with ACT.