SAVES Transforming Arkansas Stroke Care on Arkansas Medical News Inc.

SAVES Transforming Arkansas Stroke Care

By: JENNIFER BOULDEN

Terri Imus, RN. Outrach Nurse UAMS CDH works with the Arkansas SAVES telestroke equipment during a recent training for staff at Helena Regional Medical Center.

Rural Hospitals Get High-Tech Expertise

Technology, training and timing are all coalescing around a new program for stroke care in the state. Although Arkansas is currently ranked 48th in the nation in stroke mortality, the state may soon make significant headway on improving that ranking. A unique telestroke program is bringing board-certified stroke expertise to rural hospitals throughout Arkansas and enhancing the state's overall stroke education in the process.

Started Nov. 1 by a one-year, $6.1 million Arkansas Department of Human Services Medicaid contract, the Arkansas SAVES (Stroke Assistance Through Virtual Emergency Support) program provides rural hospitals with a high-tech, video communications system so that when stroke patients come through the ER, they can quickly and expediently receive appropriate care and a real-time consult from one of the state's three board-certified vascular neurologists. The three neurologists are SAVES medical director Salah Keyrouz, MD, and James Schmidley, MD, both of UAMS, and Margaret Tremwel, MD, a neurologist at Sparks Regional Health System in Fort Smith.

In treating stroke, timing is everything, said Keyrouz. For qualifying ischemic stroke cases that can benefit from the clot-busting drug t-PA, timing is even more critical. The evaluations by SAVES neurologists determine whether the patient should receive the drug. Knowledge about how to use t-PA and which patients are the best candidates for it has increased greatly, since it first received FDA approval, Keyrouz said, making its use much safer than early reports had indicated.

"We know that with t-PA the earlier you give it, the more likely it is to exert its beneficial effect, and the less likely it is to cause bleeding," he explained. "If a patient comes in within 15 minutes of onset, that's much better than infusing the medicine at 2 hours and 50 minutes. That's still within the guidelines, but the risks are much greater."

The first partners in the program were the UAMS Center for Distance Health, the state Health Department, Sparks Regional Health System in Fort Smith, Booneville Community Hospital, Johnson Regional Medical Center and Mena Regional Health System. In February, McGehee-Desha County Hospital and DeWitt Hospital were in added to the program. Three more hospitals, Helena Regional Medical Center, White River Medical Center, and Baxter Regional Medical Center are new partners this month, and in May, Baptist Health Medical Center in Arkadelphia will be the last partner added this fiscal year.

Julie Hall-Barrow, Ed.D., education director for the UAMS Center for Distance Health, said plans called for nine additional hospitals to join the program in the next fiscal year.

"We want the program to grow and really transform stroke care throughout the many rural areas of the state," Hall-Barrow said. "Hopefully, DHS will continue to renew the contract annually and we'll eventually be able to have some dollar figures for them that demonstrate Medicaid cost savings."

The most recent statistics from the national Centers for Disease Control and Prevention show that Arkansas had 1,847 stroke-related deaths in 2005, which dwarfs Arkansas' other major causes of death. Arkansas ranks third highest among all states in stroke deaths, with 61 per 100,000 residents. Only Alabama and Tennessee had a higher number. The nationwide direct and indirect cost of medical and institutional care of permanently disabled stroke victims was $57.9 billion in 2006.

"The UAMS Center for Distance Health wanted to capitalize on the model we've used for maternal fetal medicine in the state, the ANGELS program," Hall-Barrow said. "We used the same concept, that we would have to deliver those services in a different way, through telecommunications connections in the ERs."

She said program leaders spend a lot of time training the local hospital and emergency staff on acute stroke treatment procedures that need to happen before the specialist comes online.

"The local hospitals learn to coordinate all the things that need to happen for that patient as soon as they come in that door. The whole team is synchronously going in the order that will mediate the fastest amount of time from coming in the door to seeing a neurologist with the telemedicine unit."

Once the other pieces of the care are in place, the on-call neurologist can be online via the telemedicine equipment in five minutes. The specialist, who has immediate access to all the labwork and CT scans, works with the ER physician, nurse, patient and family to examine the patient.

"We thought it might be weird for the patients to be examined by a guy on a TV screen," said Terri Stumbaugh, assistant administrator of patient care at Johnson Regional Medical Center in Clarksville, one of the pilot participants in the program. "But the patients and families just love it. Our staff prepares them for what to expect and lets them know that their loved one is being seen by the best stroke doctor available in the state. They are grateful, and because it's a very interactive examination with lots of two-way communication from everyone, they can be involved and helpful."

Johnson Regional treated the first SAVES patient with t-PA within a few days of the program's inception. Quite a few patients do not meet the criteria for the SAVES evaluation, often because they do not get to the hospital within a three-hour window of having the stroke. In the first three months of the program, 14 patients across the state qualified for and received the SAVES evaluation. Two of those were deemed good candidates for t-PA.

Keyrouz said the program's success is highly tied to public awareness. "Timing is the big impediment to this drug. Very few of the patients make it to the hospital in that time frame. It's believed that we are only using the drug in 2 percent of the population, but we can use it much more through educating the public and educating ER physicians on how to administer the medicine," he said.

Hall-Barrow agreed. "We can have the best neurologists in the world, the best technology," she said, "but if patients aren't walking through the door in time because they don't recognize the signs and symptoms, it doesn't help anybody."

Public awareness campaigns in these hospital's communities are getting underway with SAVES billboards and radio ads about stroke signs and symptoms supplementing the hospitals' own outreach efforts. Hall-Barrow said SAVES would soon be deploying two full-time health educators to work in these communities.

Arkansas SAVES is a unique model, she said, because of its statewide reach and collaboration.

"It's really a little bit different than any other telestroke program in the country. Most of them are for a big hospital that supports their smaller hospitals. It's a statewide project, not a true hub and spoke model. Our hub is our neurologists," she explained. "It doesn't matter whom you refer to, we just make sure we have a monitored bed available for anyone receiving t-PA and transport to that bed arranged before we give the drug."

Stumbaugh said that the first SAVES t-PA patient has already returned to the hospital a month later in need of the telemedicine equipment—but this time, for a follow-up consult.

"Because she is elderly and it is difficult for her to travel, she's also coming back here to have a follow-up appointment on the same equipment, so she doesn't have to find a way to the specialist." Stumbaugh said. "We're all very excited about the many applications of this technology, besides the stroke program and the ANGELS program we were already doing. This is just the beginning, I think; the possibilities for it are almost endless."