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Telemedicine Extends Stroke Expertise to Southeast Texas

Telemedicine Southeast Texas HospitalBefore Baptist Beaumont Hospital joined the Mischer Neuroscience Institute’s (MNI) Telemedicine Program in 2002, there were no acute care hospitals equipped to treat ischemic stroke between Houston, Texas, and Lake Charles, Louisiana. The two cities lie 132 miles apart in the southwest tip of the Stroke Belt, an area of the southeastern United States with an unusually high incidence of stroke and other forms of cardiovascular disease.

With only a handful of neurologists available to provide on-call coverage for a 75- to 100-mile service area, the hospital was ill equipped to provide care for the area’s older population. But thanks to telemedicine and its partnership with MNI, Baptist Beaumont Hospital has been accredited as a Primary Stroke Center since 2007 and has morphed into a powerhouse for the delivery of tPA.

“The average age of our stroke patients is 62, which is very young,” says Donna Biscamp, RN, CEN, an emergency department nurse who serves as the hospital’s ED stroke champion. “Because of our telemedicine program and the physicians affiliated with the Mischer Neuroscience Institute, we’ve been able to deliver tPA at high rates. As a result, many of our former patients who would otherwise be in nursing homes are walking, talking and living active lives.”

Biscamp, who began collecting data in 2007, is enthusiastic about the stroke program’s growth. “In 2007, 202 patients presented with stroke, and we were able to administer tPA to 12 patients, or 6 percent,” she says. “By 2012, our program had more than doubled in size. We saw 484 stroke patients, 55 of whom received tPA. Those numbers translate to lives and quality of life saved.”

Among those who have benefited is 66-year-old Orange, Texas, resident Johnny Wilson, who, while helping dress his grandchildren in March 2012, became dizzy and began vomiting. His wife Trudy Wilson caught him as he fell and eased him to the ground.

“When I saw Johnny’s mouth drawing to the right and his right arm going limp, I knew he was having a stroke,” she recalls. “I’d heard good things about Baptist Beaumont Hospital – a friend’s mother was treated for stroke there. An ambulance happened to be parked at the nursing home across the street from us, and I asked them to take Johnny to Baptist Beaumont. I followed in my car, and by the time I got to the emergency center, they’d done a CT scan and had Johnny in a room with computers and a lady on the screen. She was examining him remotely. It was amazing.”

Telemedicine Southeast Texas ScanThe physician on the screen was Nicole R. Gonzales, M.D., an assistant professor of neurology at McGovern Medical School, who was on call for telemedicine at MNI. From her laptop control screen, Dr. Gonzales logged on to Memorial Hermann-Texas Medical Center’s RP-7™ Remote Presence Robotic System, a teleconferencing technology that links the MNI Stroke Center to 13 outlying hospitals.

The system includes a robot that can be remotely maneuvered by the stroke team member on call. Equipped with two-way video capability, it allows physicians to consult with specialists, see patients and view monitors and other clinical data sources firsthand from remote locations.

When Dr. Gonzales activated her computer, the emergency staff in Beaumont directed their remote presence robot toward Wilson, allowing physician and patient to view each other on the screen and talk. Dr. Gonzales could see Wilson’s facial droop, and he demonstrated right-side weakness. Based on his CT results, the physical exam conducted by emergency physician Loc Nguyen, M.D., and her observations via computer, Dr. Gonzales determined that he would be a good candidate for tPA. When the tPA had no effect, Wilson was transported by Memorial Hermann Life Flight® to MNI, where a CT angiogram of the brain showed a basilar artery occlusion.

At MNI, Wilson was treated by neurointerventionalist Roc Chen, M.D., an assistant professor in the Vivian L. Smith Department of Neurosurgery at McGovern Medical School, who used an endovascular technique to open the artery. “We navigated a special catheter and device through the femoral artery in the groin to the aorta to the vertebral artery in the neck, which is the main trunk for the basilar artery,” Dr. Chen says. “We were able to remove the clot in time and completely open the artery and its occluded branches. Ultimately, he did quite well.”

Wilson was transferred to TIRR Memorial Hermann for inpatient rehabilitation at the end of March and discharged in late April. He continued his therapy at TIRR Memorial Hermann Outpatient Rehabilitation at Kirby Glen in southwest Houston.

“Telemedicine saved Johnny’s life,” Trudy Wilson says. “Everyone calls him the Miracle Man because of the size and nature of his stroke. The doctors and nurses who treated him knew exactly what was happening to him and what needed to be done. I think telemedicine is the best technology ever designed.”

Telemedicine Southeast Texas Wu

Baptist Beaumont Hospital and Memorial Hermann Southwest Hospital were early adopters of telemedicine. Eleven other hospitals in Southeast Texas are now live with the technology: Memorial City Medical Center, Memorial Hermann Greater Heights Hospital, Huntsville Memorial Hospital, Bellville General Hospital, Matagorda Regional Medical Center, Baptist Orange Hospital, the Medical Center of Southeast Texas in Port Arthur, Citizens Medical Center in Victoria, St. Joseph Hospital-Downtown in Houston, DeTar Healthcare System in Victoria and Tomball Regional Medical Center in Tomball.

At Citizens Medical Center in Victoria, stroke center coordinator Katrin McDonough, RN, ACLS, TNCC, EMT-B, reports, “With only sporadic neurology coverage, we were hardly administering any tPA before joining the telemedicine network in December 2012.” In less than a year, the hospital has become one of the network’s busiest sites for stroke treatment after Baptist Beaumont Hospital.

“Emergency physicians are delighted to have neurology coverage through telemedicine,” McDonough says. “As a result, our tPA administration rate is now 17 percent. The relationship with MNI is a good resource for us all the way around. They’re available when we have questions about a particular patient and are a great resource for physicians in general.”

McDonough and her team also work with the Victoria Fire Department to improve their stroke recognition and care and are working to raise community awareness about stroke. “We need to raise awareness of the signs and symptoms of stroke and the importance of seeking immediate medical care when stroke is suspected,” she says.

The MNI Telemedicine Program began at McGovern Medical School more than a decade ago with a grant from the United States Department of Defense, and has morphed into its present form thanks to a gift from the Alexander Foundation. “Our ultimate goal is to build a collaborative network of hospitals working together to deliver comprehensive neurological and neurosurgical care in the Southeast Texas region,” says Tzu-Ching (Teddy) Wu, M.D., medical director of the program. “As the Texas Medical Center hub, MNI provides 24/7 stroke consultations, as well as consults for other conditions, for our network hospitals. The program allows us to treat as many patients as possible at our partner hospitals, avoiding unnecessary patient transfers.” MNI’s stroke team provided more than 1,000 telemedicine consults in the last year.

In addition to access to physicians who are experts at neuroscience care for telemedicine consultation, benefits to hospitals in the telemedicine network include higher-quality care and decreased treatment delays as patients receive prompt diagnosis with a treatment plan based on the best available protocols. “More patients and families receive treatment where they live, in their community, rather than having to drive long distances to Houston,” Dr. Wu says. “Patients who require a higher level of care have a guaranteed transfer process that gives them access to the most advanced treatments and the best tertiary-care neuroscience partner in the region.”

Dr. Wu sees excitement among emergency department physicians and nurses as they collaborate with MNI on treatment protocols and plans, continue their education about stroke and expand their knowledge of evidencebased neurological care. “We work closely with the emergency department director and stroke coordinator at each hospital in the network to ensure that we’re delivering the highest quality acute neurological care,” he says. “Having specialists and subspecialists to rely on helps build confidence in their practice environment. We also work with the local EMS providers to help extend access throughout the community.”

Dr. Wu believes telemedicine is part of an emerging trend in health care to bring doctors to their patients. “Telemedicine has taught us that you don’t need a major medical center to provide good stroke care,” he says. “What you do need is community awareness, knowledgeable emergency physicians, an expert neurologist and a strong telemedicine program. MNI can now offer patients in outlying communities the opportunity to participate in clinical trials that would otherwise be unavailable to them, which helps the entire medical community by expanding knowledge.”

The stroke team at Baptist Beaumont Hospital recently used telemedicine to enroll a stroke patient in the CLOTBUST Hands-free Trial under way at the Mischer Neuroscience Institute. The trial is pioneering the use of a hands-free, operator-independent device to deliver external ultrasound to enhance the effects of tPA – a device that potentially could be used in any community hospital. A study led by Andrew Barreto, M.D., assistant professor of neurology at UTHealth Medical School, recently showed the safety of using the device in patients treated with tPA, and the MNI stroke team is now participating in a large international trial to test the efficacy of the combined approach in patients with acute stroke.

“In the future, we hope to move beyond stroke to offer multiple services from MNI’s telemedicine center,” Dr. Wu says. “We think the possibilities are limitless.”