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 Thought Leaders

Critical care 24/7

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   By Christina Thielst, FACHE, October 2011

Quick access brings better outcomes.

Christina
Thielst,
FACHE

In healthcare today, we face a changing landscape of national health policy, increasing demand and physician shortages. Providers want efficient and effective solutions to the challenges they face and are increasingly turning to remote-presence specialist care with telemedicine technologies. A recent HealthLeaders Media survey of technology leaders found that 46 percent of respondents already have some telemedicine in place and 24 percent have plans for implementation in one to two years, with another 17 percent in three to five years.

Remote physician presence using telemedicine technologies leverages the availability of limited resources and ensures that care is available when and where it is needed. Two high-volume (approximately 800,000 each per year) conditions with great risk for disability, high costs and/or mortality are sepsis and stroke. In these critical care situations, timing really is everything.

Hospitalized individuals with sepsis need early diagnosis and aggressive treatment to reduce the risk of poor outcomes. Fluids and antibiotics during the first couple of hours are important, but in the case of MRSA, the selection of the correct narrow spectrum antibiotic at the beginning is vital. According to Dr. Herb Rogove, president and CEO of C3O Medical Group, studies have shown that the sooner an antibiotic is given the better the chances for survival. The clock begins with the diagnosis, and each hour of delay is significant. The availability of a remote intensivist results in an expert being available at the bedside – someone who understands the value of rapid fluid resuscitation, focused diagnosis, antibiotic choice and the proper approach to patients who may present in shock.

In the case of stroke, time is brain. Emergency department physicians are too often frustrated because they believe more stroke patients should receive the clot-busting drug t-PA. However, there are only about 215 board-certified neurointensivists in the United States, thus leveraging of this limited resource is necessary. A remotely available neurologist can perform a neurological exam and watch a patient’s movement and response to a series of questions. If deemed an appropriate candidate, the local ER physician can administer the t-PA to the patient and then, together with the neurointensivist, they determine whether the patient can be managed locally, or if transfer for more specialized care is needed. A neurointensivist can also manage complications of stroke, such as hemorrhage, where minute-to-minute blood pressure management is essential to a good neurologic outcome.

One remote telemedicine physician program has demonstrated more rapid access to neurological care, better compliance with guidelines and improvement in national quality standards, according to Dr. Rogove. 

The team of three remote vascular neurologists, who are also board certified in neurocritical care, treated 129 patients over nine months. During this period, the response time for the off-site physicians was 21.8 minutes compared to more than 12 hours for local neurologists to physically arrive at the facility. The remote physicians attained a significant increase in compliance with Joint Commission metrics related to blood-clot prevention, clot-dissolving medications, cholesterol-lowering medications and stroke education. During the course of the following year, compliance by the local neurologist was significantly improved, attributable to the standard set by the telemedicine neurocritical-care physicians, as well as the fact that outcome data was shared between both groups. Once this hospital started its telemedicine program, it realized an increase in utilization of t-PA, as well as complex diagnoses and treatment for patients with neurological emergencies.

Identifying opinion leaders and change agents – who understand the value of the program to patient care and physician buy-in – and involving them in planning is important. According to Rogove, “In order for the implementation to be successful, buy-in also needs to occur at the highest executive level.” This often comes when the hospital is working toward, or maintaining, certification as a comprehensive stroke center. But it can also occur when the county EMS systems begin to divert patients to other hospitals, resulting in patient loss and decreasing revenues. In addition, recent public interest in transparency of quality metrics and performance and patient experience measures is also likely to capture the attention of hospital leaders.

Resistance to change and the fear of losing patients can exist among local neurologists. However, engaging them in the process from the beginning and maintaining effective communications soon helps them realize that the telemedicine program is a trusted partner for providing emergency care to their patients. In the case above, the local neurologists appreciated the remote physicians being available to see their patients in emergencies, when they couldn’t break away from their office practice or get to the hospital in time.


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