New, Faster and Saving Lives

With an innovative system using a robot and neurologists on call round the clock, stroke victims now have a better chance for most positive outcomes.

Northside Hospital is proud to announce the start of a new tele-stroke program with Telespecialists, LLC, a leader in remote telemedicine physician services. A collaboration that has been developing over the last four months, this innovative program rolled out on November 3, 2014, and will improve patient and physician access to neurology expertise within minutes of presentation of stroke symptoms.With an innovative system using a robot and neurologists on call round the clock, stroke victims now have a better chance for most positive outcomes.

In the 20 or so minutes it takes a neurologist to rush to the hospital for a stroke call, a patient will lose as many as 30 million nerve cells.
Without a neurologist’s exam and confirmation of stroke, emergency department staff can’t start a patient on the drugs that will restore blood flow and halt damage. Neurologists, who run private practices, don’t hang out in emergency departments waiting for stroke patients to show up.
The longer the clot goes untreated, the greater the likelihood of death or permanent disability.
Solution?

Quit dispatching the neurologists and—get your sci-fi on—beam them in via robot instead.
That’s right. NCH Healthcare System recently formed a partnership with TeleSpecialists of Fort Myers, which provides round-the-clock access to neurologists who perform remote exams with the help of a robot.
“(The staff) immediately went into stroke action … and then there’s this robot who started following—I tell you I felt like I was in the twilight zone,” says Susan Lindner, 58, a North Collier resident who’s now able to laugh good-naturedly about a stroke scare that had happened just days before. She’s one of the first NCH patients to use the telestroke program.

It works like this: The emergency department contacts TeleSpecialists’ on-call neurologist when a patient arrives showing stroke symptoms. The neurologist pilots a special robot that includes a monitor and two-way communication capability. He or she guides the patient and attending hospital staff through an assessment. The neurologist can zoom in on a person’s body part, looking for telltale markers, such as a facial droop or partial paralysis. He or she can ask patients questions to determine whether they are able to understand and communicate. The specialist also receives, in real time, results of diagnostic tests that confirm stroke and indicate whether a patient is a candidate for the clot-busting drug tissue plasminogen activator, or tPA.
“We can evaluate the patients very quickly—within a matter of minutes—and we can make a decision on whether we can give them the clot-buster medicine,” says Dr. Nima Mowzoon, a neurologist and the CEO of TeleSpecialists. “It’s instantaneous.”

Within a week of the telestroke program going live last November, the response time had been cut in half—to 12 minutes, according to Robin McCarl-Galbavy, the nursing director for NCH’s stroke program. She expects even more improvement as the system matures.

“It’s an exciting and a wonderful thing for our community,” McCarl-Galbavy says. NCH sees about 600 to 700 cases of stroke and “mini-stroke,” or transient ischemic attack (TIA), per year. About 80 percent of those are caused by blood clots in the brain; the other 20 are hemorrhagic, or “bleeding,” strokes generally related to a ruptured aneurysm.

The national goal in stroke care is to administer the intravenous clot-busters within 60 minutes of arrival, the so-called “door-to-needle” time. Patients who don’t respond to the drugs—or who cannot take them—are whisked instead to Dr. Mazen AbuAwad, NCH’s interventional radiologist, who snakes a special catheter-like device through a patient’s arteries and into the brain where he can break up the clot or retrieve it from the body.

“This is state-of-the-art technology we are using to care for stroke patients,” Dr. AbuAwad says. “Our population here is elderly, and they’ll get a great benefit from this technology. … The faster you can give the medication, the better the results.”

Both NCH campuses are fully wired, and the robots are programmed to maneuver to any bed in the hospital they’re summoned to, Dr. Mowzoon explains. In addition to responding to emergency stroke cases, the TeleSpecialists neurologists are on-hand to assist with inpatient neurologic emergencies—a middle-of-the-night episode in the intensive care unit, for example.

“It was kind of comforting, to have immediate response,” Lindner says. A native of Indianapolis, she used to think Naples was kind of behind the times. “I don’t think that way any more,” she says.

Tele-neurology was born out of the realization that too many people were dying or suffering permanent disability because their community hospitals weren’t equipped to diagnose stroke or administer tPA. Urban or academic medical centers—and now practices like Mowzoon’s—began setting themselves up as “hubs” that directed stroke care for their “spokes,” or partnering hospitals, using new telemedicine technology.
Studies suggest the strategy is working: A review of the 32-hospital Michigan Stroke Network, published in the February 2013 issue of the journal Neurology, found that 36 patients over a six-month period received tPA after a video consultation. Half of those consultations achieved a door-to-needle time of 60 minutes or less—“notably” higher than the 29 percent of patients nationally who are treated in hospitals that follow American Stroke Association protocols.

NCH will continue monitoring and studying its response times as the partnership develops; the first patient to receive tPA after a telestroke diagnosis received the drug well within the 60 minutes, McCarl-Galbavy says.

Fear not—robots and remote specialists aren’t replacing hands-on care. Local neurologists take over after the initial emergency has passed and see the patients through their recoveries. And both NCH campuses are staffed 24/7 with critical care nurses who are specially trained to assess and treat stroke. They—along with a stroke navigator who coordinates a patient’s care—are bedside the whole time.

Patients have embraced the new system, McCarl-Galbavy says. The clarity of the picture and audio make them, the in-house staff and family members feel as if the specialist is in the room.

“You forget it’s a robot,” she says. “(Patients) have felt the quick response time certainly makes up for the neurologist not standing there at the bedside; however, we have many caregivers there with the patient and family.”

You can expect to see more applications for telemedicine. Neurology is the biggest player so far, but Dr. Mowzoon’s practice is exploring uses ranging from orthopedic to behavioral health consultations.
“Telemedicine is exploding,” he says.

Lindner, the patient, thinks the technology is great. After a battery of tests, doctors believe she had experienced a mini-stroke, or TIA. She was prescribed the blood thinner Plavix, and her physicians will continue to monitor her. Lindner suffered a heart attack 11 years ago; she knows the importance of a quick medical response.

“Time is critical,” she says.

Further advancements in stroke care
NCH has been pouring resources into advancing its response to and treatment of stroke, the nation’s fourth-leading cause of death and a leading cause of life-altering disability. Within the last year, it has:

  • Hired Dr. Mazen AbuAwad, an interventional radiologist who can provide cutting-edge procedures in the treatment of both ischemic stroke (blood clots) and hemorrhagic (bleeding) stroke
  • Trained NCH staff across all departments on the recognition of stroke so they respond quickly and appropriately—whether at work or out in the community
  • Implemented the telestroke program
  • Received state designation as a primary stroke center
  • Received the seal of approval by The Joint Commission, a national health care-accrediting agency,for its “disease specific care for the treatment of stroke.”

Now, the system has unveiled another set of advancements: The opening of a “biplane operating suite” last fall that allows Dr. AbuAwad to perform additional advanced neurosurgical procedures, including the treatment of aneurysms—bulges in the blood vessels in the brain that are at risk of rupturing and causing hemorrhagic stroke—in a minimally invasive way. He inserts a catheter into an artery, guiding it to the aneurysm and snaking tiny coils through it. The coils fill the bulge, blocking blood from flowing into it and thus minimizing the risk of rupture.

In the past, patients with aneurysms had to be transferred to other hospitals.
The addition of aneurysm care qualifies NCH to be designated as a “comprehensive stroke center” by the state Agency for Health Care Administration. The system was awaiting word on its application at press time.
“I felt the care I got there from this team of doc and nurses was professional and superior to anything else I had ever experienced,” says Roseann Kozloff, 70, of Bonita Springs, who had a stroke last fall and was treated by Dr. AbuAwad.

She awoke on Sept. 12 unable to speak and experiencing weakness in the left side of her body—her dominant side.

“My husband noticed I was in big trouble and took me in right away,” says Kozloff, who went to the emergency room at NCH North.

NCH emergency staff transferred her to the downtown hospital, where Dr. AbuAwad removed the clot manually through her arterial system. She was not a candidate for general anesthesia but had a light sedative and can remember almost everything.

“I can see, I can hear, I can understand. But I can’t communicate—anything,” Kozloff recalls. “There was this one nurse in particular, who spoke to me the whole time. Somehow, she knew I could understand, I just couldn’t speak. She was very compassionate, very professional. … I asked her later on how she knew that, and she said, ‘I could tell by your eyes and by the look on your face.’”

By the time she was in the elevator on her way to her room, Kozloff was talking again. Two months later, she had only the slightest of aftereffects, an occasional failure to retrieve a word while in conversation. But even that had gotten better, she says.

“To tell you the truth, without that procedure he did, I wouldn’t be here,” she says.

BOX: Stroke Symptoms
The three most common symptoms are:

  • Facial drooping
  • Arm numbness
  • Difficulties speaking

Other symptoms include:

  • Sudden numbness or weakness of the leg, arm or face
  • Sudden confusion or trouble understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, or loss of balance or coordination
  • Sudden severe headache with no known cause

Call 911 immediately if you or someone you know is experiencing these symptoms. Time is the single most important factor in surviving a stroke and minimizing disabilities.
—Source: American Stroke Association

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