Georgia Regents University: Evolution of One of the Country s Longest-Running Telestroke Programs

Telemedicine Case Study Georgia Regents University: Evolution of One of the Country s Longest-Running Telestroke Programs Successes and Future Plans Each year, close to 800,000 people in the U.S. suffer from a stroke. It is the top cause of long-term disability and the fourth leading cause of death, killing 140,000 Americans annually. Stroke awareness and treatment options have grown significantly in the past decade as a response to these frightening statistics. To date, the GRU telestroke network has grown to 29 hospitals located across Georgia and has conducted more than 4,000 remote consultations. Administration rates for tpa have increased throughout the spoke sites, significantly improving positive outcomes for ischemic stroke patients. In fact, Dr. Hartmut Gross, a GRU neurologist, has conducted more than 600 remote consultations not only from GRU, but also from home and, in one case, from a computer store. Dr. Gross was paged by a rural hospital about a potential stroke victim. The doctor, with the help of the store manager, set up the two-way audio and video connection on a computer at the back of the store and was able to diagnose the patient with minimal delay. GRU s groundbreaking telestroke model is now replicated at other healthcare networks throughout the country. Due to GRU s vision, telestroke networks are becoming routine standards of care for stroke patients when every second counts. And the hospital has no plans to slow down, finding new ways to use telemedicine to overcome distance barriers and facilitate the continuity of care. GRU plans to explore telemedicine in the pre-hospital, rehab and homecare settings to ensure even faster treatments and reduce readmission rates. It is also taking steps to expand its neurology coverage with the spoke sites offering coverage for patients dealing with other nervous system issues. Today, the telestroke program extends into urban and suburban community hospitals - improving how these hospitals manage stroke patients and treatments. REACH Health technology powers many of the nation s largest, fastest growing and most successful telemedicine networks, helping health systems and accountable care organizations achieve measurable improvements in their clinical, operational and financial performance. 855.641.8911 www.reachhealth.com Cover photo provided by GRUcrule from Wikimedia Today, telestroke programs are part of the routine standard of care in many U.S. hospitals. By virtually connecting stroke specialists to patients, regardless of their locations, these hospitals have saved countless lives using time-sensitive treatments. But how did telestroke programs start? What is the history behind these life-saving initiatives? In this article, we will introduce you to Georgia Regents University (GRU), an Augusta, Ga.-based academic health center and research university. GRU s groundbreaking telestroke program, which started 11 years ago, has become a de facto model for telestroke programs at other hospital systems around the country. This article will take you through the program s evolution and show you how GRU has helped change the way stroke patients are treated today. Inside: How GRU leads the nation in stroke telemedicine Expanding coverage to subhubs and super spokes Telemedicine advancements to meet patient and hospital needs

Timeline of the Georgia Regents University Program 1996: Great Leap Forward for the Treatment of Stroke In 1996, the Food & Drug Administration (FDA) approved intravenous (IV) tpa for the treatment of ischemic strokes. IV tpa became the first, and remains the only pharmacologic therapy to reduce longterm disability in acute stroke. Yet despite FDA approval and the proven benefits of the medication, the vast majority of hospitals were treating no more than 2% of all ischemic stroke patients. Why wouldn t ED physicians embrace tpa a treatment that could significantly help a large percentage of stroke victims? For tpa to be the most impactful, national guidelines state that it should be administered within three hours of the onset of stroke symptoms or 60 minutes from a patient s arrival at a hospital. Given the time-sensitive nature of the medication and the general lack of access to stroke specialists to make real-time treatment decisions, the use of tpa was minimal for several years. 2003: GRU Launches Telestroke Program In 2002, a group of doctors at GRU (formerly known as the Medical College of Georgia) came together to rethink treatment options for stroke patients in the Augusta region. Despite having a world-class stroke team, GRU was treating less less than one patient per month with tpa. The reason for this was that many of their patients went to their rural, resource-strapped hospitals first and subsequently transferred to GRU. In fact, half of the stroke patients admitted to GRU were initially seen at an outside hospital causing a time gap that often negated the opportunity for and/or benefits of tpa. While GRU stroke specialists would sometimes conduct phone consultations with area hospitals to assess patients, they often had to make treatment decisions based on very little information. One GRU neurologist, Fenwick Nichols, MD, referred to this process as tpa by Russian roulette. GRU looked to telemedicine to solve this problem using an audiovisual connection and transmission of CT images to diagnose and, if appropriate, treat stroke patients with tpa faster at their local hospitals and subsequent transfer as needed ( drip and ship ). GRU kicked off a hub-and-spoke-based telestroke program in 2003. As the hub, GRU would connect to the rural hospital spokes and provide consultations with stroke specialists via video and audio to help treat ischemic stroke patients faster and more efficiently. The program started with eight hospitals in East Central Georgia. These facilities were small, some critical access hospitals, and all of them had significantly fewer than 100 beds and saw no more than 1,000 patients per month in their emergency department. How it Worked Trial and Error at the Start As one of the first telestroke programs of its kind, GRU didn t have many choices in terms of technologies or vendors on which to rely to help make its vision a reality. In the early 2000s, telemedicine was not the sophisticated industry that it is today, so GRU had to turn inward and create its own solutions. In the beginning, the spoke hospitals were equipped with makeshift carts, which consisted of an IV pole with a mounted laptop and camera. The carts had a one-way video connection with point, tilt and zoom camera controls, and two-way audio was provided via telephone. One GRU employee managed all of the support for the spoke hospitals and three GRU neurologists were on call 24 hours a day, seven days a week to take calls and assess stroke patients. The doctors could answer those calls and log on to see the patient, whether they were at the hospital, at home or anywhere with Internet access. While the initial system was simple, it provided GRU s stroke specialists with more information so that treatment decisions could be made in a timely fashion. Despite a limited staff and technology that could be faulty at times, the telestroke program flourished in its first few years with major improvements to clinical care. 2008: Program Notoriety and Spinoff In the years following the initial rollout, GRU began to receive a lot of attention for its program with other hospitals visiting GRU to learn how to replicate its telestroke system elsewhere. Additionally, larger community hospitals were asking to join GRU s network. Unlike the rural hospitals, these sites had partial stroke resources, but were looking to strengthen their neurology coverage and improve patient care. The expansion of the telestroke network resulted in the need for more sophisticated technology, workflows and organization. In order to stay ahead of this change, several doctors at GRU made the choice to spin off a company called REACH Health and dedicate time and energy to the creation of telemedicine technology to fit the needs of GRU s growing network.

2009: Program Maturity and Growth While the GRU telestroke program was initially created to work with rural, resource-constrained hospitals, it began to change in 2009 with larger suburban and urban community hospitals asking to join the network. This evolution was likely driven by development of designated Primary Stroke Centers, increasing the focus on hospitals to provide tpa for all potential candidates. At the same time, there was still widespread discomfort among emergency department physicians around the administration of tpa without the help of neurologists. Hospital administrators were also concerned that if their facilities did not provide tpa, they would be bypassed by EMS for other providers. Additionally, many neurologists were backing away from in-hospital care, putting hospitals in a tough spot when on-site neurologists were needed more than ever. During the next few years, GRU added several of these larger hospitals, dubbed super spokes, to its network. These facilities were based across Georgia and many were Primary Stroke Centers that simply lacked around-the-clock stroke coverage and required that same acute coverage that rural hospitals sought. How it Worked Expansion in Motion Working closely with REACH Health, GRU modified its telestroke technology at this time. The system was designed to accommodate the way a physician would work at a patient s bedside. It now provided two-way video (audio was still via telephone) and more sophisticated clinical documentation and guided workflow capabilities, which facilitated and streamlined the consult and allowed physicians to capture their thoughts, treatments and advice, all in one system. While GRU still had no coordinator for the program, REACH Health provided all of the IT support, and the number of on-call neurologists increased from three to five. GRU required that the larger spoke hospitals fund their own carts and IT support and began charging them with on-call fees for physician coverage. Based on the interest we received from other hospitals and health systems, we knew we had created a prototype for a telestroke system that could be widely deployed. ~Jeffrey A. Switzer, DO

Super Spoke at Work St. Mary s A 200-bed, non-profit community hospital in Athens, Ga., St. Mary s was the first Primary Stroke Center certified by the Joint Commission in Georgia. Despite being a Primary Stroke Center, St. Mary s tpa usage was minimal, averaging three to four patients per year (about 3 percent of its ischemic stroke volume). In 2008, a private practice that was providing on-site neurology care disbanded and would no longer be able to provide coverage for the hospital. While it had two neurohospitalists to provide care during the day, St. Mary s did not have the resources to hire more neurologists to provide 24-hour coverage. As a solution, the hospital joined the GRU telestroke program to provide neurology coverage at night. In the years since partnering with GRU, St. Mary s tpa usage skyrocketed, with administration rates increasing by a more than 700 percent. 2014: Complex Relationships, Sophisticated Technology Today, GRU s telestroke program has grown tremendously in terms of spoke partner relationships, sophistication of technology and strengthened infrastructure. GRU Telestroke Network (2009-2012) Initially a hub-and-spoke network, GRU now refers to itself as a multi-hub-and-spoke network due to the more complex relationships within the program. While GRU is still the primary hub, it now has 29 subhub, spoke and super spoke locations across Georgia. Subhubs, like St. Mary s, have their own small, rural hospital networks, but they still rely on GRU for stroke guidance and coverage. Yet when a patient must be transferred, if appropriate, he/she is moved to the subhub rather than GRU. The next-generation telestroke technology, developed by REACH Health, now provides live two-way audio and video, combined with critical patient data, integrated access to CT scans, workflows and clinical documentation. GRU s stroke specialists have everything they need to complete an entire consult on one platform. The technology is also designed for rapid, easy deployment at spoke and subhub sites, as well as expansion into other service lines (cardiology, pediatrics, psychiatry, etc.) for cost-effective support of future telemedicine plans. Finally, GRU strengthened its internal infrastructure around the telestroke program by bringing on a full-time coordinator who is responsible for communicating and collaborating with spoke hospitals. GRU now also has at least six physicians taking calls and has set up a system where it charges both super spoke and subhub sites for 24-hour, seven-day-a-week physician coverage. GRU Telestroke Network (2013-2014) For similar telemedicine resources, please visit reachhealth.com/resources.