AcuteCare Telemedicine Blog


Telemedicine Increases tPA Use for Stroke Treatment

Presented at the annual American Academy of Neurology meeting in early May, a new study highlights the benefit of teleneurology care. The report indicates that a telemedicine program for patients with acute ischemic stroke increases the use of recombinant tissue plasminogen activator by as much as 13% in the year after the program’s implementation.

Stroke patients who receive the clot-busting drug tPA within 60 minutes of experiencing stroke symptoms have the best chance of avoiding brain damage or death. The administration of intravenous recombinant tissue-type plasminogen activator (tPA) and intra-arterial approaches, attempt to establish revascularization so that cells in the penumbra can be rescued before irreversible injury occurs, but restoring blood flow can mitigate the effects of ischemia only if performed quickly. “Most of the 13 hospitals in the study significantly increased their recombinant tissue plasminogen activator (tPA) use”, Dr. Jeffrey C. Wagner said at the annual meeting of the American Academy of Neurology.

The study population included patients aged 18 years and older who were admitted with a primary diagnosis of acute ischemic stroke. The hospitals represented a variety of patient demographics. About two-thirds were rural; approximately half were small, defined as fewer than 200 beds. The hospitals were located in the Northeastern, Southern, and Western portions of the United States.

Overall, tPA administration increased significantly, from 4.5% to 7.3% after a telemedicine program was introduced and the use of tPA in smaller hospitals increased from 1% to 7% after implementing a telemedicine program, compared with an increase from 5.4% to 7% in larger hospitals. Those results were similar when patients were stratified as inpatients or transferred patients.

The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS. Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.

“Reducing DTN time is a primary goal when treating patients via telemedicine”, says Keith A. Sanders, Founder and Director of the Stroke Center of Emory St. Joseph’s Hospital and AcuteCare Telemedicine (ACT) COO. “ACT has seen dramatic improvements in the tPA administration rate and DTN times at our hospitals. We collect, review and distribute DTN times and other quality measures to our hospital partners. This report reaffirms the importance in administering tPA and its impact on patient outcomes.”



Stroke Treatment Gets a Boost

Fifty years ago, the only advice medical textbooks gave physicians for someone suffering with a stroke was to put him to bed and keep him comfortable, hoping that with time, the brain would heal as best it could. For 30 years, promising techniques preceded disappointing trials. First, heparin was going to be the savior, and for most of the 70s and 80s, it almost served as a standard, but better studies eventually showed that the treatment was not just worthless, but in reality dangerous, causing more brain hemorrhages than no treatment at all. Later, drugs that were intended to clear out “free radicals” were going to save the ischemic penumbra, part of viable brain tissue around a central core of dead cells, but all studies showed that either the medication didn’t get to the target, didn’t work, or could even be toxic to the brain.

In the mid 90s, tissue plasminogen activator (TPA), long used for heart attack victims to break up the clots inside arteries of the heart, was shown to be effective in doing the same in arteries of the brain. For the first time, physicians had something to offer patients that actually made a difference. About a third of patients who received TPA had better three month outcomes than those that did not. This success rate was quite good, but patients with severe strokes still did not respond as well because, in most cases, thrombi in the large arteries were not effectively dissolved.

Only in the last few years have studies been done to consider the effectiveness of a thrombectomy, the process of physically pulling out a thrombus inside an artery in the brain or neck, The early devices available to physicians are fairly good at the task, but a substantial number of patients continue to suffer from residual blockages of the arteries following the procedure.

A report of clinical trials using two new types of thrombectomy devices, called Solitaire and Trevo Retriever, show both of these new devices as being up to five times more effective than their predecessors in opening up arteries. Advances this drastic are rare in medicine, but physicians should be optimistic about the potential for these instruments in improving outcomes. Provided that patients can have access to skilled practitioners in time, within eight hours or sooner, the treatment of stroke may be about to enter a dramatic new phase.

Stroke is the most serious disabling condition in adults, resulting in hundreds of thousands of permanent injuries and deaths every year. This decade may witness the greatest advances in the history of stroke treatment. There are still further trials to run, but with these exciting new prospects, the importance of stroke neurologists like the doctors of ACT being present in every emergency room, either in person or by remote presence, cannot be overstated.



ACT Partner Taylor Regional Hospital Embraces Technology for Better Care Standard

AcuteCare Telemedicine (ACT) partner Taylor Regional Hospital in Hawkinsville, GA is on the cutting edge of revolutionizing healthcare in underserved areas in rural parts of the Southeastern US.

Lacking the fiscal and logistical resources to implement the comprehensive services found at larger facilities in urban centers, Taylor Regional has openly embraced a wealth of new technologies to drastically improve the quality of care it offers patients within its surrounding communities.

Choosing ACT’s 24/7 teleneurology services was an elegant solution to a major deficiency facing the hospital. Taylor Regional has no neurologists on staff, and the nearest available specialists are located more than an hour away. Prior to the partnership with ACT, the hospital lacked the capability to effectively diagnose and treat stroke-causing clots, often having to transfer patients to a larger hospital, compromising crucial ‘door-to-needle’ time and reducing potential hospital revenues.

Through the adoption of beneficial programs such as the telemedicine services offered by ACT, the hospital has not only taken strides forward in treating patients internally, but has also enhanced communications with other facilities, connecting with other physicians for consultation and collaboration as well as streamlining transfer processes to ensure patients receive timely and expert care.

Most recently, the teleneurology services provided by ACT resulted in the administration of tissue plasminogen activator (tPA) in two separate cases of acute stroke at the facility in the month of August 2012. The two successful administrations of the clot-busting agent are a significant achievement, serving as a milestone for a teleneurology partnership that has now successfully extended this potentially-life saving service to residents of the counties surrounding Taylor Regional.

“We are very pleased with our partnership with ACT. The neurologists are extremely professional and eager for our telemedicine program to make a real difference in the care we are able to extend to our stroke patients,” commented Lynn Grant, Emergency Room and ICU Nurse Manager, Taylor Regional. “ACT is available 24/7, taking the time not just to be there for the patients, but for our physicians, nurses, and staff, answering questions and educating about the technology and techniques that are helping us save lives. Having this service is very rewarding.”

“Taylor Regional Hospital is on the cutting edge of emergency stroke care in rural Georgia. ACT has been particularly impressed with their clinical judgment, leadership and organization,” said Dr. James Kiely, Partner, ACT. “Their community is well served.”

For more information about ACT, visit www.acutecaretelemed.com.



Big Med Goes Back To School

In his most recent article in The New Yorker, contributor Dr. Atul Gawande demonstrates the value of quality-focused innovation in providing excellent service. Dr. Gawande nods to the Cheesecake Factory’s success in nimbly updating its large and varied menu as a potential model for healthcare innovation. Initially, he takes Big Med (as he calls organized American medicine) to task because, in his words, “good ideas still take an appallingly long time to trickle down,” but in the latter half of the article he provides examples of how the industry is getting things right.

Gawande’s own mother’s knee replacement surgery serves as his first example; by utilizing standardized protocols and equipment, his mother and her hospital achieved top results at a low cost. He then points to an innovative new way of managing patient data in real time that is serving to improve care: In Tele-ICU, nurses and doctors collect patient care data remotely from ICU patients and give direct feedback to the caregivers at the bedside. Using standardized treatment plans, Tele-ICU actually improves the quality of care while simultaneously lowering the costs associated with the sickest and traditionally most costly patients in the hospital.

As providers of teleneurology services, AcuteCare Telemedicine (ACT) wholeheartedly agrees with Dr. Gawande’s observations. Improving the quality of care in emergency neurology requires a standardized, quality-driven approach. Simply put, something done frequently becomes something done well. Traditionally, most neurologists who take ER calls don’t get much experience treating acute stroke patients, and neurology training focuses on diagnosing the problem rather than emphasizing treatment options and paradigms. The nuances of tPA inclusion and exclusion and the decisions about other stroke treatment options mandate that the neurologist treating stroke emergencies be familiar with the most up-to-date practices. Who would you rather have piloting your medical care: the team that flies sporadically, or the one that flies every day?

 



Acutecare Telemedicine CEO Featured Speaker For American Heart Association’s Stroke Webinar Series

Dr. Matthews Gwynn, CEO of AcuteCare Telemedicine (ACT), appeared as the featured speaker for a webinar series produced by the southeast affiliate of the American Heart Association. The presentation, entitled “Extending Stroke Care through Telemedicine,” was delivered to several hundred hospital administrators and medical staff throughout the southeast and other areas of the U.S.

Dr. Gwynn’s webinar presentation, hosted by Mary Robicheaux, Vice-President of Quality Improvement for the American Heart Association southeast affiliate, focused on the advancement of teleneurology in the treatment of acute stroke patients. Dr. Gwynn discussed the positive effects that teleneurology continues to have on advancing stroke treatment, such as the increased use of the clot-disolving medication tPA (tissue plasminogen activator), as well more advanced neuro-interventional procedures known as thrombectomies, performed by neuro-interventionalists at such world-class facilities like Grady Hospital’s Marcus Stroke and Neuroscience Center in Atlanta, GA.

“Advanced treatments for acute stroke cases are becoming more and more prevalent with the advent of greater technology and treatment procedures,” stated Dr. Gwynn.  “The medical community observed this within the cardiology field over the past couple of decades, and now we are starting to see similar advancements in stroke care via neurocritical care and interventional neuroradiology.

In a continued effort to expand teleneurology in the southeast, Dr. Gwynn and the other neurologists of ACT serve as critical evaluators at partner hospitals of stroke cases that may require advanced interventions such as those discussed in the webinar.

For more information about AcuteCare Telemedicine, visit www.acutecaretelemed.com.



A Timely Solution

In the few minutes it takes to read this post, two or more people will have suffered a stroke in the United States. In the Southeast, in what has become known as the ‘Stroke Belt,’ the rate of frequency is at its highest. The need to attack stroke from both a preventative as well as a curative perspective is critical if a  decrease in the incidence and the morbidity/mortality of stroke is to occur.

Over the course of the past few decades, several initiatives to lower the incidence of stroke throughout the nation and particularly in the Stroke Belt have been developed and implemented. Increased education, improved  blood pressure and glucose control,  advised dietary changes etc, have led to a decrease in incidences. What remains concerning, however, is the lack of acute stroke care treatment in many rural areas in states such as Georgia and Alabama. This deficiency is primarily due to excessive travel time necessary to gain access to physicians. Several rural counties in Alabama are altogether without hospitals. “Lack of access to health care is a reported problem in some areas of the state. Some counties have no physician in the entire county. It is difficult for poor rural areas to attract doctors

According to a report in 2010, 44 of 67 counties (in Alabama) did not have a single neurologist. “Some stroke victims have to travel across three counties to access a neurologist for care.” Stroke is the third leading cause of death in Alabama, with nearly 3000 Alabamians dying from stroke each year.

In 2010, only 2 hospitals in the entire state were certified by Joint Commission as Primary Stroke Centers. That number has since doubled, but still remains insufficient, as an overwhelming percentage of the population remains underserved. Although with preventitive measures and education in place, the incidence of stroke should continue to decrease, there will theoretically be no significant change in stroke related morbidity and mortality without timely and appropriate healthcare.

Unfortunately, poor quality health care is deeply and chronically rooted in the infrastructure, or lack thereof, of many of these rural communities. More than 30% of Alabama’s population is situated in these areas lacking equivalent government representation. Fundamental changes in, or the development of new infrastructures within these communities are requisite to create permanent changes in healthcare delivery.

Although not a solution to all of the health care concerns facing states like Alabama, telemedicine does offer an avenue by which cost effective, high quality care can be delivered to residents of rural communities. As pointed out earlier, there is a specific need for neurologic care, given the significant paucity in this area of the country. The implementation of teleneurology programs in these areas would lead to timely neurological consultations and care that would otherwise not be available. Where time equals brain cells in the case an acute stroke, expeditious treatment via teleneurology can literally be life saving. Teleneurology would help to improve not only quality of health in rural communities, but also quality of life. When a healthcare facility earns primary stroke certification (an initiative for which teleneurology programs can offer assistance), it typically sees a growth in ER volume and admissions, subsequently increasing revenue. Jobs can be created as a result of this growth, which in turn can help jumpstart  local economies.

Telemedicine alone will not solve all of the health care issues in rural Alabama and other similar regions in the stroke belt. However, these solutions can immediately fill a desperately missed need. Remember the two people in the United States who will have had a stroke in the time it took to read this article. The question is, will a neurologist have been able to reach them?

 



Telestroke: Not Just About tPA

Acute stroke evaluation remains among the most frequently cited benefits of modern telemedicine technology. Known as ‘telestroke,’ the technology allows a neurologist at a remote site to reliably gather data by interviewing patients and family, performing physical examinations and reviewing brain imaging, directly impacting the course of a patient’s care. A recent article from Europe highlights that telestroke offers other benefits, tangible and intangible.

Stroke care in general at a hospital improves in several ways when telestroke consultations become available. Having a system in place to rapidly evaluate and treat stroke patients leads to faster and more accurate treatment of patients who need other brain treatments, such as clot extraction and neurosurgical intervention. Patients with stroke mimics can also be more rapidly treated. Telestroke leads to fewer unnecessary patient transfers, saving valuable time and money.

In stroke, care delayed is care denied. Getting stroke patients the immediate care they need at a local hospital rather than transferring them out leads to better outcomes and happier patients.

As hospital stroke volume increases, the staff gains experience and expertise in treating stroke cases. Stroke order sets provide a checklist to ensure that quality measures are being followed, and with increased experience comes increased use of such standards, which have been shown to improve stroke care. Even obstacles to physician staffing are addressed with telestroke experts on call. Doctors, as much as patients, prefer hospitals providing state of the art care.

In the hospitals we serve, the value of telestroke coverage resonates from the board room to the triage room. This is a technology whose time has come.