Assessment of the Stroke Patient Through Telemedicine

Executive Summary

Telestroke is one of the technology-driven medical services that is continually taking shape and gaining acceptance in many parts of the country. It involves the neurologist remotely evaluating stroke patients and recommending the appropriate diagnosis and treatment to the onsite healthcare practitioners. In this paper, a technology approach for teaching nurses how to assess stroke patients using the modified mNIHSS is discussed. The approach also includes video learning for the rural nurses, a support system to facilitate neurologist follow up and review of the assessments, and a mobile app that gives updates on the stroke management best practice. The project aims at improving efficiency in the provision of stroke services by reducing the time taken before the patients get evaluated and treated, and equipping the nurses with the latest guidelines on stroke assessment according to the mNIHSS.  The project will be implemented in the state of Florida and will take two years and three months. This project perfectly fits into the current healthcare environment since it is implemented within the existing facilities. By making use of the already available infrastructure and upgrading some of the existing equipment (rather than buying new ones), the costs will be significantly be brought down.

Introduction

Stroke is among the leading killers in the US. Its severity is experienced mainly by the rural communities. The disease results from blockage or bursting of blood capillaries in the brain thus interfering with the flow of blood and nutrients to the brain tissues. The result of this condition is the death of brain cells just within few minutes. Being a medical emergency, therefore, prompt treatment is critical to avoid further brain damage and other potential complications (Cumbler et al. 2012). Telemedicine is vital in enabling the nurses in rural areas to take timely actions to avoid fatalities. This paper looks into the use of telemedicine to teach nurses how to conduct stroke assessment using the modified NIHSS, with video learning for rural nurses and other healthcare providers in rural areas. The approach will also facilitate remote monitoring of the stroke assessment by the neurologist. Also, a mobile app with different updates on current stroke guidelines is proposed in this approach.

Significance

According to Meyer and Lynden (2009), many nurses are not well informed about the assessment of stroke using the modified NIHSS. The importance of this technology project proposal is that when the new telecommunication technologies are incorporated into the evaluation and treatment of stroke patients, efficiency is enhanced. Accurate and complete assessments will be possible since the nurses will conveniently access the stroke assessment and management guidelines from their devices. Also, appropriate medication is achieved through the use of the telecommunication infrastructure. The project proposal is also crucial in ensuring that nurses and especially the ones based in the rural areas get updated instantly and regularly on stroke management guidelines. The incorporation of this approach in our stroke assessment and treatment system will lower the rate of fatalities resulting from the disease.

Background

Stroke management in rural and regional areas varies significantly. According to the US Census Bureau, the term “rural” should be taken to mean an excluded locality. On the other hand, an urbanized area is a human settlement that is densely populated and that meets the minimum requirements of the number of people per unit area. Traveling time and costs, lack of economies of scale, and the lack of links to the other units are some of the factors that make stroke patients’ access to quality and prompt medication a challenge. In America, the 1996 National Health Interview Survey statistics showed that rural areas were 1.46 times more affected by stroke than urban areas (Ghandehari, 2013). Research also indicates that there is a difference in the pathology of stroke between rural and urban areas. In France for example, as McArthur et al. (2014) record, there was a significant difference between Avallon (rural) and Dijon (urban) regions regarding stroke pathology. The rural patients had higher rates of cerebral haemorrhage.

Service delivery is generally weaker in rural areas compared to the urban areas. According to Commiskey et al. (2017), only 39% of the 58 leading hospitals in Wyoming and Montana have 24-hour CT scanning capabilities. The scholars further observe that in Australia, though more than 90% of the rural facilities have full-time access to Computer Tomography (CT) scans the people had to averagely travel about 100km. In an investigation of the stroke service delivery in 22 rural healthcare facilities in Idaho, there were patient delays in 77.8% of them, transport delays in 66.7%, equipment delays in 22.2% and auxiliary services delays in 61.1%. tPA was available for stroke in only 55.6% of the hospitals (Wechsler et al., 2017). Additionally, no facility had a specialized stroke team.

Adhering to best-practice guidelines can reduce the risks of stroke by 80% (Baer et al., 2017). According to the authors, however, only 50% of health facilities in rural New South Wales, Australia, use the National Stroke Guidelines as required in the country. Another problem in the rural areas is the acute stroke management. The CAST and IST trials indicate that administering aspirin within 48 hours of a suspected ischemic stroke significantly decreases the risk of death and dependency. However, a study in two East Texas rural communities shows that heparin administration was common than aspirin at 9% and 5% respectively (Baer et al., 2017).

When a resident or a visitor to a small town, farm or other rural areas suffer from a stroke, an initial assessment at the local emergency department for their stabilization is done. The early evaluation considers the time-dependent treatment with intravenous recombinant tissue-type plasminogen activator (rtPA). General medical care is essential for stroke patients. However such care is suboptimal in the rural health facilities. Apart from insufficient experience in managing acute stroke, most of the nurses in rural hospitals are not well trained in using thertPA. According to Lee et al. (2017), these reservations are however expected since the rtPA trial was carried out using neurology specialists in big metropolitan academic institutions. The table below summarizes the challenges that affect the rural hospitals in treating stroke patients.

Problems Possible solutions
Poor general and specialized care Targeted stroke awareness and joining a “hub-and-spoke” system
Local healthcare practitioners’ reservations aboutrtPA Targeted educational programs, tertiary assistance through a “drip-and-ship” arrangement, and telestroke
Fear of reduced income by forwarding stroke patients to hospitals with specialized stroke units Educational campaign on ethics, legal risks and legislative measures
Applicability of stroke trials to rural hospitals Perform parallel rural trials, performtelestroke research and use tertiary flight crews as investigator.

The disparity between stroke assessment in rural and urban areas is mainly because of the impracticability of hiring a full-time neurologist in the non-metropolitan health facilities (Harrison, 2013). To counter these challenges, several solutions have been developed. One of these solutions is the Mobile stroke units. The units are usually fully equipped ambulances with onboard or remote stroke services. The mobile hospitals comprise CT scanners. They are critical in reducing the time between the striking of the neurological attack and the treatment.

Other approaches aimed at reducing the distance related obstacle include educational campaigns and toolkits for Emergency Medical Care Providers. The education programs and the kits enable the health practitioners to diagnose and offer medication promptly. Additionally, in the US, the “drip and ship” has been adopted as a solution to the poor rural stroke assessment and treatment Ebinger et al., (2014). In this method, the victims are administered rtPA in a local emergency facility and then taken to a stroke Centre for further and more specialized treatment.

Telemedicine has also been implemented to some extent in some cases as a corrective approach. Research has shown that incorporating telemedicine in stroke services can increase the rate of rtPA use by 2.2%-5.1% (Hosseininezhad and Sohrabnejad, 2017). There exist many technologies that are useful in the transmission of the relevant information between centers. Speed, reliability, and quality are the requirements for any communication infrastructure.

Rationale

This approach is very relevant since it uses video learning.  According to Wechsler et al. (2017), the use of short video clips enhances efficient processing and memory recall. It enables the learner to master a concept within a short time compared to a written narration about a procedure or a precaution. Most of the learners learn best with visual training. They are more attracted to illustrations than trying to visualize after reading a text. The visual and auditory nature of the video appeals to the learner and allows them to process the information in a way that is natural to them. Other advantages of video training include the fact that it accommodates learners who learn best through audios and can be made once and reused for a long time after. Concerning the use of the mobile app, according to research over 95% of the US population uses a mobile phone (Demaerschalk, 2017). The study further reveals that 77% of these devices are the smartphones. Using a mobile app can, therefore, be a handy way of reaching out to the nurses and other medical professionals.

Goals

The purpose of this project is to promote early identification and treatment of strokes especially among the people living in the rural areas. The plan also aims at equipping the nurses, regardless of where they work from, easily accessible tools for use before, during or after the stroke assessment.

Objectives

  1. To enhance prompt treatment of stroke patients
  2. To enhance neurologist follow up and review the stroke assessment by the nurse
  3. To increase knowledge of stroke signs and symptoms and modified NIHSS among nurses
  4. To demonstrate competency among nurses with the utilization of the mNIHSS
  5. To improve compliance and utilization of mNIHSS within hospital EHR
  6. To establish long-term sustainability and continuing education regarding stroke assessment and use of the mNIHSS for stroke evaluation for current nurses and new hires.

Project Description

The primary target of this project is the nurses who serve in the rural healthcare centers. The state of Florida will implement the plan. By 2017, there were over 210 hospitals in Florida and about 155 rural clinics according to the National Center for Health Statistics (2017). All of the 67 Florida counties are partly or wholly identified as primary care Health Professional Shortage Areas (HPSAs). By design, there will be at least one neurologist for every county. All the nurses attending to stroke patients will work in consultation and under the supervision of the specialist. The nurses will do the stroke assessment in special stroke units with a specialized camera fixed to monitor each bed. The camera will be interphased with a computer. By connecting the computer at the local hospital to the county’s stroke unit’s computer through the internet, the neurologist will be able to see the assessment done by the nurse. Appropriate software will have to be developed to support the connectivity between the two centers. The Florida Department of Health in cooperation with other relevant organizations will develop the video content in line with theAmerica Stroke Association guidelines on stroke assessment. The video learning will help nurses accurately assess stroke patients according to the modified NIHSS. The health department will also be entrusted with developing a mobile application that will keep the users (nurses being the primary target) updated of the stroke guidelines. The video learning and the provisions of the mNIHSS may be incorporated in the app.

Market/ financial analysis

By 2017 there were 5564 registered hospitals in America. Of these facilities, 1829 serve in rural areas(Ebinger et al., 2014). As mentioned earlier, to bridge the gap between the rural and urban hospitals, mobile stroke centers have been invented. This approach is however very costly. There is extra personnel involved such as security. There are also additional costs of fuelling the ambulance and the alternative source of power for the equipment, which may be a generator. Other unnecessary expenditures include the costs of insuring the vehicle. The drip and ship approach also incurs some costs of fuel and insurance which are recurrent. But once the technology project is implemented and initial costs met, only the internet and the maintenance costs will be paid. Additionally, unlike the other approaches resorted to by some of the health care providers, this project does not directly depend on the physical infrastructure such as the roads.

Budget

The estimated budget for the project is as summarized below.

Ref Project expenditure Rate per unit per month ($) Number of units Number of months Total
1 Software expenditure
1.1 Application software development 50,000 50,000
1.2 Software modifications 10,000 10,000
1.3 Additional security applications 10,000 10,000
  Subtotal       70,000
2 Hardware costs
2.1 Servers (new or upgraded 2,500 67 167,500
2.2 PC’s new or upgraded 1,000 155 155,500
2.3 Additional processing services 5,000 5000
2.4 Dedicated Cameras 500 155 77,500
  Subtotal              250,500
3 Labor
3.1 Salary for 6 IT experts and 4 video content developers mobile app upgraders 70,000 10 24 16,800,000
3.2 Temporary labor (evaluation) 50,000 5 4 1,000,000
  Subtotal       17,800,000
4 Other expenses
4.1 Seminars and training 100,000 100,000
4.2 Fully equipped ambulance 40.000 40,000
  Subtotal       140,000
  Grand Total       18,260,500

Evaluation/ measurement plan for the implementation of the technology project

The evaluation will be done by the Florida Department of Health (FDOH) in collaboration with the 67 County Health Departments (CHDs) and the Stroke Association of Florida. The purpose of the evaluation is to identify the various obstacles at the different stages of implementation, make the necessary corrections and generally improve the effectiveness of the project. The process will seek to get information about the acceptance of the plan among the healthcare practitioners and the patients. Nineteen months after the launching of the project, the implementers will decide whether to continue with the project, the necessary improvements and whether they would recommend the system to the federal government and other states. During the evaluation, the questions will be based on both the process and the results. About the process, the patients will be asked whether it takes time and whether they think the procedure is confidential. The healthcare practitioners will be asked whether the process is tedious and easy to use. About the results, the patients will be required to say whether there is a general improvement of the procedures of assessment as conducted by the nurses. The health practitioners on the other hand will say whether technology reduced the rate of stroke mortalities. This evaluation will make use of questionnaires.The results of the evaluation will be taken to be positive is they meet 60%.

A contingency plan (alternative assumptions and strategies)

The telemedicine project largely depends on the internet connectivity and the availability of reliable electricity supply. However, in some of the interior regions, interruption of the internet networks, and the electricity distribution is a common phenomenon especially when a natural calamity strikes. This situation consequently calls for alternative methods of handling emergency cases. Each of the local hospitals will be required to have a referral plan with the nearest metropolitan hospital with a stroke service center. They will also need to have a fully equipped and readily available ambulance for the emergency cases.

Timeline

The total duration of this technology project will be two years and three months, i.e., from October 1st, 2018 to December 31st, 2020. During the first three months, the video content and the mobile app will be developed. By February 2019, all the resources will have been acquired including the support software, required expertise and machines. By the end of April 2019, all the necessary infrastructure will have been laid out including individual component installations and software loading. Training for the project managers and the nurses will take place in May. The technology project will be launched be the starting of the second half of the year.  The first evaluation exercise will start immediately after five months and take two months. The second evaluation will take place after the elapsing of 8 months after the initial assessment.

Conclusion

Implementing the project will improve the stroke services in the rural areas. The system will enhance sharing of the few neurologists while ensuring there are no delays in service. The video learning will also result in improvement in the general performance of the nurses. This project ensures productive integration of telecommunication technologies in stroke assessment and general management. If adopted nationwide, the system will require that the private healthcare providers, the federal and the state governments work together to ensure efficient administration of the project.

References

Baer, H., El-Sherif, Y., Pearlman, L., Peana, A., Kusheleva, N., Folan, B. …& Capitano, J.            (2017). 157 How to Effectively Integrate Telestroke by Utilizing Mock In Situ           Telestroke Training in the Emergency Department. Annals of Emergency Medicine,           70(4), S63.

Breuer, L., & Schwab, S. (2017). Telemedicine in stroke care. MedizinischeKlinik,             Intensivmedizin und Notfallmedizin, 112(8), 687-694.

Commiskey, P., Afshinnik, A., Cothren, E., Gropen, T., Iwuchukwu, I., Jennings, B., …& Zweifler, R. M. (2017). Description of a novel telemedicine-enabled comprehensive             system of care: drip and ship plus drip and keep within a system of stroke care            delivery. Journal of telemedicine and telecare, 23(3), 428-436.

Cumbler E., Zaemisch R., Graves A., Brega K., and Jones W. (2012). Improving stroke alert         response time: applying quality improvement methodology to the inpatient neurologic       emergency. J Hosp Med. 7(2):137–141. [PubMed]

Demaerschalk, B. M. (2017). Remote evaluation of the patient with acute stroke.  CONTINUUM: Lifelong Learning in Neurology, 23(1, Cerebrovascular Disease),       259-267.

Ebinger, M., Winter, B., Wendt, M., Weber, J. E., Waldschmidt, C., Rozanski, M., and     Villringer, K. (2014). Effect of the use of ambulance-based thrombolysis on time to         thrombolysis in acute ischemic stroke: a randomized clinical trial. Jama. 311(16),        1622-1631.

Ghandehari, K. (2013). Challenging comparison of stroke scales. Journal of Research in    Medical Sciences : The Official Journal of Isfahan University of Medical  Sciences,             18(10), 906–910.

Harrison, J. K., McArthur, K. S., & Quinn, T. J. (2013). Assessment scales in stroke:          clinimetric and clinical considerations. Clinical Interventions in Aging, 8, 201–211.             https://doi.org/10.2147/CIA.S32405

Hosseininezhad, M., &Sohrabnejad, R. (2017). Stroke mimics in patients with clinical signs          of stroke. Caspian Journal of Internal Medicine, 8(3), 213–216.             https://doi.org/10.22088/cjim.8.3.213

Lee, V. H., Cutting, S., Song, S. Y., Cherian, L., Diebolt, E., Bock, J., &Conners, J. J.      (2017). Participation in a tele-stroke program improves the timeliness of intravenous   thrombolysis delivery. Telemedicine and e-Health, 23(1), 60-62.

Meyer,B.C., &Lynden,M.P.(2009). The Modified National Institutes of Health Stroke Scale:        its Time has Come. International Journal of Stroke, 4(4), 267–273.          https://doi.org/10.1111/j.1747-4949.2009.00294.x

McArthur, K., Fan, Y., Pei, Z., & Quinn, T. (2014). Optimizing outcome assessment to     improve the quality and efficiency of stroke trials. Expert review of   pharmacoeconomics& outcomes research, 14(1), 101-111.

National Center for Health Statistics (the US. (2017). Data Sources. In Health, the United            States, 2016: With Chartbook on Long-term Trends in Health. National Center for       Health Statistics (US).

Siegler, J. E., & Martin-Schild, S. (2015). Daily National Institutes of Health Stroke Scale            examinations at stroke centers: why not do they? International Journal of Stroke,     10(2), 140-142.

Wechsler, L. R., Demaerschalk, B. M., Schwamm, L. H., Adeoye, O. M., Audebert, H. J.,            Fanale, C. V., … & Rosamond, W. D. (2017). American heart association stroke            council; council on epidemiology and prevention; council on quality of care and             outcomes research. Telemedicine quality and outcomes in stroke: a scientific                         statement for healthcare professionals from the American heart association/American         stroke association. Stroke, 48(1), e3-25.

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