The aim of this systematic review and meta-analysis was to evaluate the safety and efficacy of IV thrombolysis (IVT) with tissue plasminogen activator (tPA) delivered through telestroke networks in patients with acute ischemic stroke.
We conducted a systematic review and meta-analysis according of prospective randomized controlled and nonrandomized studies comparing telemedicine-guided IVT to IVT administered at stroke centers and were published from the earliest date available until April 1, 2015.
- Outcomes of interest were symptomatic intracerebral hemorrhage,
- mortality, and functional independence (modified Rankin Scale scores 0-1) at 3 months.
- 1,863 patients fulfilled our eligibility criteria.
- Among these, thrombolysis was largely restricted to the 3-hour time window.
- Symptomatic intracerebral hemorrhage rates were similar between patients subjected to telemedicine-guided IVT and those receiving tPA at stroke centers
- There was no difference in mortality or in functional independence at 3 months between telemedicine-guided and stroke center thrombolysis.
Our findings indicate that IV tPA delivery through telestroke networks is safe and effective in the 3-hour time window. Lack of prospective trials, however, emphasizes the need to further substantiate these findings in the 3- to 4.5-hour time window.
© 2016 American Academy of Neurology.
Telehealth growth accelerates as challenges in workflow, interstate licensing and reimbursement continue to be addressed . Dr. Naomi Watts of Biogen Idec says “patients clamoring for physician access”.
Dr. Roy Schoenberg, CEO of AmWell says telehealth is providing the right way of getting in front of a physician.”The value of seeing a patient – visual is key” says Schoenberg.
Jason Sibley of Flare Cap Parnters believes telehealth’s business is to build a system that meets the needs of specific group of patients. One group that comes to mind is the large number of patients with chronic diseases such as Diabetes, Heart Failure, and Hypertension.
John Moore, MD, PhD of Twine Health noted that patients want to have “a low friction channel to access physicians particularly when they are experiencing an emotional need”.
This has been a preview of what’s to come at HIMSS at the end of February and is reported by Brian Dolan of Mobihalth News.
One story which never made the mainstream press is the humanitarian gesture of a group of ICU Telemedicine specialists providing civilian ICU care in war-torn Syria. Reported in the February issue of the Annals of American Thoracic Surgery, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The program utilized inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Launched in 2012 and within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. What would normally take numerous committee meetings including budgetary constraints was done on an all volunteer basis at a much lower than expected cost.
The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.
The critical care community and the world will be waiting to see data from this extraordinary and courageous endeavor. Congratulations to Drs. Moughrabieh and Weinert from the University of Minnesota Medical School, Minneapolis, Minnesota.
Researchers from Boston Childrens/Harvard reported:
- Higher confidence in clinical care with telemedicine compared to telephone.
- They also reported that the videoconferencing was high-quality, easy to use, and did not increase their telecommunication costs.
- The telemedicine encounters supported clinical decision-making, especially in patients with active clinical problems or when the patient was acutely ill.
- The telemedicine encounters prevented the need for 23 clinic visits, three emergency room visits, and probably one hospital admission.
Although the study was small, videoconferencing appears useful in the management of medically fragile patients on home ventilator support, producing high levels of family confidence in clinical management and value to clinicians in their decision-making.
A group of pediatric intensivists at the duPont Hospital for Children in Wilmington Delaware published the results of evaluating telephone versus telemedicine evaluation of pediatric patients with moderate to severe critical illness being transported between hospitals. Findings were as follows based upon the opinions of the medical command center physicians:
- Connection and audio quality were equivalent and there were no dropped calls.
- Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055).
- The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport.
- The iPad system offers a significant savings when compared with conventional telemedicine.
This was a prospective randomized study of a total of 50 patients divided between call only versus video conferencing. An iPad tablet was the technology used which the authors conclude is much more cost effective than other technologies.
In the just released issue of Telemedicine and e-Health, Doan and Merrell’s editorial addresses robotics in telemedicine. The editors write “Telemedicine, telehealth, and robotics are a few innovative approaches to alleviating the stress on an overburdened system. While technology continues its march forward, often unabated, the culture of medicine has not changed as rapidly. There are many individuals and health systems across the United States and the world that are reticent to change. Perhaps it is a lack of understanding or a fear of change or even a level of trust in the technology. Clearly a robot in a nursing facility that is driven by a remotely located physician who is in contact with the on-site nursing staff can add tremendous value. Robots have added value both in clinical settings and in the educational setting.”
The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents.
MATERIAL AND METHODS:
- We performed a prospective cohort study over 3.5 years.
- Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls.
- Consenting patients at intervention facilities could access telemedicine for acute illness care.
- Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses.
- The primary outcome was the rate of ED use.
- We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group;
- 1,058 subjects served as controls.
- Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home.
- Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction).
- Primary care use and mortality were not significantly different.
High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.
COMMENT: A very nice introductory cohort study on a very pertinent topic. Hopefully to follow will be a prospective randomized study looking at both outcomes and financial data. Additionally, for those seen through telemedicine, following the ED admission course would be important.
At ATA 2015 (American Telemedicine Association), held in Los Angeles, a milestone was achieved as over 5,000 attendees from around the world stormed the LA Convention Center. The content of the symposium keeps getting better, ranging from lightening rounds to superb plenary sessions. What particularly struck me was that the keynote speakers, both physicians in different areas of medicine both understood and support telemedicine as an integral part of healthcare delivery. Dr. Sanjay Gupta, chief CNN medical correspondent, had previously done a story on telemedicine featuring Yulun Wang, CEO of InTouch Health. Dr. Patrick Soon-Shiong, an entrepreneur and brilliant visionary, has already embarked upon ways to treat cancer utilizing mobile health. The exhibit hall allowed one to roam a roomy exhibit hall to see new and established medical product and software companies display and explain their technology. Based upon the opinion of those in attendance, the ATA is striving toward increasing the content experience. Looking optimistically to another high level meeting in Minnesota for ATA 2016.
Martin Luther King, Jr. Community Hospital has chosen C3O Telemedicine to provide acute teleneurology coverage. Dr. Herb Rogove, CEO of C3O, says “we are extremely delighted to have been chosen as MLK Jr. Community Hospitals telemedicine service provider”. MLK has built their hospital with the 21st century in mind as they are a true telemedicine facility according to Rogove.
The key strengths of C3O are:
- Rapid response times
- A virtual who’s who of teleneurologists from leading medical centers
- Proven achievement of quality metrics and excellent outcomes
Located in the Second District of the Los Angeles County, the brand new Martin Luther King, Jr. Community Hospital (MLKCH) is a priority project for local authorities. It is expected to serve 1.2 million residents from all over South Los Angeles and to create more than 900 jobs in the area.
MobileSmith is the provider for mobile apps.
“Our strategy is to get into mobile extremely quickly, without overly burdening our IT staff or infrastructure,” said Sajid Ahmed, Chief Information and Innovation Officer at MLKCH. “With its powerful capabilities and easy learning curve, the MobileSmith Platform is the ideal solution for us. We are looking forward to launching many great apps.”
Yaghi S1, Harik SI2, Hinduja A2, Bianchi N2, Johnson DM2, Keyrouz SG2.
- 1Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR firstname.lastname@example.org.
- 2Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial.
- Retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012.
- We compared the outcome of patients who were transferred to a “hub” with those who remained at the “spoke” hospital where thrombolysis took place.
- We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher’s exact test, two-tailed, and significance was considered at p < 0.05.
- Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy.
- The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS).
- However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026).
Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.
Many tele-stroke programs are based upon the hub-spoke model. Often in rural hospitals without ICU’s the obvious course is to start tPA then transfer to a hub center. The question then comes up, for these less severe patients, do we still need to transfer them after tPA is given. In depth data on complications in this cohort needs to be reviewed. Outcomes as far as survival look very good.