Essentia Health-Fargo didn’t necessarily have a specific problem that led them to implement tele-stroke technology. Rather, the implementation stemmed from the desire to be proactive in providing the best possible care.
A PROACTIVE MOVEMENT
“According to the AHA/ASA stroke care guidelines, implementation of tele-stroke is effective in assessing patients for IV thrombolytics and endovascular therapy,” said Chelsey Kuznia, RN, SCRN, stroke program manager at Essentia Health-Fargo, DNV Certified Comprehensive Stroke Center.
“This technology is intended to provide timely access to expert stroke physicians to create a care plan for patients with suspected or diagnosed stroke,” she explained. “Much of Essentia’s service area includes rural communities that may not have access to a stroke expert. Thanks to Tele-stroke, we can provide that access almost immediately, even in rural areas.”
PROPOSAL
Tele-stroke technology provided the opportunity for expert stroke care 24 hours a day, 7 days a week in Essentia’s service area, including rural areas. With a simple phone call, the healthcare provider can connect with the teleneurologist on site to discuss or conduct a video assessment of the patient to determine treatment options and further suggest needed or other recommendations.
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MEETING THE CHALLENGE
Tele-stroke technology is used to improve timely access to an expert stroke provider. It is available to both emergency department and inpatient staff for use during a stroke alert.
“The process starts with initiating a stroke alert,” Kuznia said. “If a patient is within the window for IV thrombolytics (less than 4.5 hours from last known well or LKW), a call is made to notify the teleneurologist that a consultation is necessary.
“Once the call or video connection is completed and recommendations are made, the on-site provider will place orders and continue patient care.”
Chelsey Kuznia, RN, SCRN, Essentia Health-Fargo
“Essentia uses a tiered stroke alert process: a level 1 or 2 stroke alert for a patient with LKW of 4.5-24 hours and a level 3 stroke alert for a patient with LKW of more than 24 hours or at whose symptoms have disappeared,” she says. explained. “Once the call is received, the teleneurologist discusses the patient’s case over the phone with the on-site healthcare provider.”
They decide whether a video assessment for conducting the NIHSS is necessary to determine the care plan. Video connections are primarily only established for patients who are candidates for IV thrombolytics, or patients with a level 1 stroke.
“Once the call or video connection is completed and recommendations are made, the healthcare provider will place orders on the spot and continue care for the patient,” Kuznia noted. “Then, depending on the capabilities of the facility, a consultation is placed for the local stroke team provider to see the patient, or a transfer of the patient to a higher level of care is initiated. The teleneurologist also documents the events that occurred during the conversation.”
RESULTS
Kuznia said it is difficult to quantify the hard results achieved because the impact of this technology is experienced across all core metrics of stroke care. Tele-stroke technology has had an impact on therapeutic treatment plans and staff confidence in providing stroke care.
“As we look more closely at the administration of an IV thrombolytic agent in the treatment of patients with acute cerebral infarction, there are ways in which tele-stroke technology could have an impact,” Kuznia explains. “The first is the consideration of an IV thrombolytic agent. Unfortunately, this is difficult to measure because it does not involve a time frame but involves discussion and assessment.
“The teleneurologist can perform the NIHSS via the video link and discuss the inclusion/exclusion criteria for IV thrombolytic administration with the patient and/or family, if available,” she continued. “A thrombolytic agent is often a medication decision that general emergency department or hospital providers prefer to discuss with an expert stroke physician before placing an order for administration.”
The second way in which tele-stroke technology could impact intravenous thrombolytic administration would be the “door-to-needle” time.
“This measurable metric is influenced by streamlined access to an expert stroke provider for advice,” Kuznia explains. “For example, in the 12 months prior to the implementation of tele-stroke technology, four out of five patients received a thrombolytic agent within 60 minutes of arrival. In the 12 months following implementation, 21 of 21 patients received a thrombolytic agent within 60 minutes of arrival. .”
Based on the data, one could also imply that the initiation of tele-stroke technology has increased confidence in the administration of IV thrombolytic agents, as evidenced by the increase in stroke cases receiving a thrombolytic agent , she added.
ADVICE FOR OTHERS
“For other healthcare providers considering tele-stroke technology, start talking to your frontline staff early and involve them in preparing to include this in your stroke code protocol,” Kuznia advised. “Consistent use, education and timely follow-up are essential for successful implementation of this technology.”
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