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'The missing link': New program improves treatment for stroke patients

Telestroke simulation
ICU Registered Nurse Lisa Nugent, foreground, talks with the "patient" during a simulation exercise at the Milwaukee VA Medical Center as part of training for the new TeleStroke program. The program connects staff with an off-site neurologist via an iPad (visible in the background).

Time is brain.

That’s the message when it comes to treating strokes, which occur when blood flow to the brain is blocked or reduced. The quicker a stroke patient gets vital treatment, the better the chances of preventing long-lasting disability or death.

But it takes specially trained doctors — neurologists — to assess stroke patients and prescribe the appropriate treatment. Because strokes happen without warning and at any time, there’s no guarantee a neurologist will be available when a stroke hits.

Previously, stroke patients who came to the Milwaukee VA Medical Center after hours or on the weekends had to be sent to another hospital for treatment, adding more time to the critical treatment window.

But not anymore.

The Milwaukee VA Medical Center is now part of the National TeleStroke Program, which provides the hospital 24/7 access to neurologists via technology we’re all familiar with — iPads.

The program has a virtual “hub” of VA stroke neurologists located around the country. They participate in a 24/7/365 call schedule to provide coverage to participating facilities. Milwaukee VA is one of about 60 VA facilities in the program.

When a patient is diagnosed with a stroke, the care team can immediately connect with a neurologist via FaceTime. The iPad is on a rolling stanchion and is wheeled into the patient’s room, where the neurologist can visually assess the patient and communicate directly with the care team.

“Having the rolling tele-doc gives us the missing link that we didn’t have prior to now,” said ICU Registered Nurse Lisa Nugent. “It’s better for the Veterans; we don’t have to send them to another hospital. They want to stay here; they like the care we give here. So now we’re able to offer that 24/7.”

Simulations sharpen skills

Part of the Milwaukee VA’s training for participation in the TeleStroke program took place recently when a pair of simulations were staged — one in the Emergency Department and one in the Intensive Care Unit.

In both scenarios, the patient presented stroke symptoms, including slurred or incomprehensible speech, facial drooping on one side and inability to move one arm.

The on-call doctor was contacted, and as the team administered care, the TeleStroke neurologist was called and joined virtually, helping to guide the team as the treatment progressed.

The patient was taken for a CT scan, and results from that and other tests were forwarded to the Telestroke neurologist, who then prescribed medication and next steps, which were administered by the care team.

Both simulations lasted about 45 minutes, from initial diagnosis to medication administration. According to the Centers for Disease Control and Prevention, stroke patients who receive treatment within three hours of symptom onset often have less disability than those who receive delayed care.

Nugent said the simulation was “very much how a real emergency happens. Everyone collaborated and worked together, and we got the medication in less than 45 minutes, which is the TeleStroke goal,” she said.

Dr. Ga K. Le, who was the on-call doctor for the ICU simulation, agreed.

“The simulation demonstrated a well-thought-out process to provide our Veterans with 24/7 neurology expertise,” she said. “I was very pleased with how competent our staff was with the process of caring for a code stroke Veteran.”

The technology allows the off-site neurologist to monitor the care team and converse with everyone in the room — including the patient and, in the case of the ED simulation, the family member who accompanied the patient to the hospital.

In addition, the neurologist was able to immediately access the results of the CT scan.

“For them to have access to the images within minutes is a huge difference for our hospital,” said Tricia Hughes, lead CT technician. “We can start the process rather just deciding if the patient needs to go to Froedtert. … It’s very possible they could continue their care here.”

Praise for the program

Both simulations were viewed virtually by program experts, and the care teams took part in debriefings afterward.

Facilitators praised the teams for their actions during the simulations, complimenting their teamwork and quick response. Nugent agreed.

“I feel like it was very successful and a good learning opportunity,” she said.

“I found that communicating with the iPad neurologist was pretty straightforward,” said Dr. Mark Kostic, chief of Emergency Medicine for the hospital. “I thought it went well.”

“As a rapid response doctor, we appreciate the neurologist support in making critical care decisions for our Veterans,” Le said. “We feel confident that our stroke team will optimize the care of stroke patients within our facility.” 

Each year, medical staff diagnose approximately 4,500 Veterans with an acute ischemic stroke. Stroke is the fifth leading cause of death in the United States and the leading cause of serious, long-term disability.

“The TeleStroke program will definitely improve patient care as it provides the needed 24/7 neurology support without delays associated with transfers,” Le said.  “It will allow us to deliver expert care when and where our Veterans need it without relying on other hospital facilities. It will also move our VA toward the standards of being a stroke center.”

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