Why TeleSpecialists uses SAVES to identify strokes versus FAST 

The FAST stroke screen (Facial drooping, Arm weakness, Speech difficulty, Time to call) was developed as a method of streamlining the triage of patients to determine if they have had a stroke. While this is a good start to identifying acute stroke symptoms, evidence has suggested that there are situations when a patient needs a more comprehensive examination to screen for stroke symptoms; just using FAST may result in a physician missing certain symptoms of a stroke.

Introduction to SAVES

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A new stroke screen using the acronym SAVES is designed to help physicians and first responders to pinpoint the signs of a stroke quickly and efficiently. SAVES stands for Smile, Arms,   Vision, Even balances and Speech — all key indicators that a person might have suffered from a stroke.

SMILE 

An asymmetrical smile may indicate the patient should be treated as a possible stroke victim. Cortical deficits often affect the lower region of the face, while patients with afflictions like Bell’s palsy or similar conditions typically present with weakness in both the lower and upper aspects of the face. If there is any doubt, however, a stroke alert should be called.

ARMS

A quick screen for sensory and motor function of patients is monitoring if there is a drift of the arms. The patient is asked to hold their arms in a supine fashion then close their eyes for 10 seconds. A slow downward drift of one side indicates that the patient should be placed under a stroke alert. Another screen involves having the patient hold their hands in front of them with their palms facing outward toward the physician. If there is a slow drifting of their fingers within 10 seconds of them closing their eyes, a stroke is likely indicated.

VISION

Patients presenting with blurred or double vision could indicate a stroke. However, using a visual field test is a more accurate indicator of the condition. The patient focuses on the physician’s nose as one or two fingers are held up in just out of the direct field of vision of the patient. Both upper and lower visual quadrants on both sides should be tested.

EVEN BALANCE

This portion of the screen is to determine if the patient has an apraxic gait. Physicians should look for a gait and stance that is wide based as they spread their legs to try to maintain their balance. Staggering and torso correction might also be noted. While dizziness or imbalance is certainly a symptom of a stroke, it is advised to be used in conjunction with another stroke symptom(s) as to not call an unnecessary stroke alert.

SPEECH

Speech is measured in two ways: aphasia (affects the expression or understanding of the written language) and dysarthria (affects the articulation of speech). The type of speech issues can also indicate where the stroke occurred. The frontal lobe of the brain is responsible for articulation so deficits in that area indicate a stroke has occurred in that region, while temporal lobe is where comprehension is centered, physicians can assume that a stroke has taken place in that area of the brain.

The easy-to-remember stroke screen, SAVES, provides physicians and first responders with valuable information in a simple and timely manner. This can lead to a quicker stroke alert and a better outcome for patients. TeleSpecialists’ average time from receiving the stroke alert call to physician arriving to tend to the patient via video cart to the patient’s bedside is 4 to 6 minutes.

For more information on how TeleSpecialists can create or enhance your TeleStroke program, visit our website at www.tele-specialists.com.

 

Photo by Pixabay on Pexels.com

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The DAWN Trial and how it could affect stroke care at your facility.

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The Background:

The DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo), was created to measure the effects of stroke treatment in the timeframe outside the AHA and ESO guidelines of 6 hours. Funded by Stryker Neurovascular, Dr. Nogueira and Tudor Jovin, MD were named Coprincipal Investigators and led the DAWN Trial.

A 2016 analysis suggested that the benefit of thrombectomy rapidly decays over time and may no longer exist beyond 7.3 hours from stroke onset (or TLSW). (Saver et al, JAMA. 2016). The results of the DAWN are particularly beneficial for patients with wake-up strokes, strokes with an unclear onset time or witnessed late presenting strokes, which represent a large portion (around 40%) of LVO (Large Vessel Occlusion) Stroke, which previously had no proven treatment options.

The Study:

A total of 206 patients were enrolled in the study and randomly assigned a group based on factors such as site of the stroke occlusion and the time-from-last-seen-well; 107 in the thrombectomy group and 99 to the control group. Patients were randomly assigned to thrombectomy (using the Trevo device) plus standard medical care (the thrombectomy group) or to standard medical care alone (the control group). The median time of patients having received treatment in the DAWN trials was 12.2 hours and 13.2 for the control group. Patients were then followed for 90 days for results.

The Conclusion:

The study concluded that across all factors, treating stroke with endovascular thrombectomy in DAWN-eligible patients from 6 to 24 hours of symptom onset showed considerable improvement in functional independence and wellness at 90 days, versus standard care alone. Stroke can be tricky to identify but thanks to the DAWN trials, we now know that there is a larger window to treating stroke than once thought.

Tudor Jovin, MD, University of Pittsburgh School of Medicine, Pennsylvania, the study’s lead investigator, summarized: “These results greatly expand the population of patients who can benefit from mechanical thrombectomy for stroke, to significantly reduce functional impairment in the mostly severely affected patients,” he added. “Time is still obviously very important and the earlier the treatment is given the better the results, but we have shown in this trial that it shouldn’t be the only factor that determines whether we consider endovascular therapy.”

How will this impact facilities that have the capability to treat stroke patients? Patients that typically would have fallen outside of the treatment window now may benefit from thrombectomy and standard care. Any medical facility that could receive a stroke patient should review protocols to transfer patients to an EVT (Endovascular Treatment) facility as more patients can benefit from EVT. While this is certainly a pathway to a wider treatment window, “time is brain” still applies and each acute stroke case should still be treated as quickly as possible.

With the opening of this window of EVT treatment, more neurologists may be needed to assess and treat the influx of patients that now qualify in the 6-24 hour timeframe, instead of sending them straight to standard care. TeleSpecialists can implement a turnkey TeleStroke program, proving Board-certified neurologists via cart (licensed in your state and credentialed in your facility), fill any gaps in neurologist scheduling, assist your facility in stroke certification, and lower transfers of stroke patients to other facilities.

For more information on how TeleSpecialists can assist in building your TeleStroke program, contact us.

Survey: Telehealth Increases Access to Care, Continuity

Michael Laff Minneapolis – November 11, 2015 04:12 pm

Your patients depend on you for the best medical care, and thanks to technology, they don’t necessarily need to visit your office to receive it.

As more family physicians begin using telehealth systems, speakers at the AAFP State Legislative Conference, held here Nov. 6-7, discussed how the technology can enhance patient care and sharedfindings from a survey(www.graham-center.org)(22 page PDF) of family physicians’ thoughts about and use of telehealth.

Researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care said 15 percent of the 1,557 physicians who responded to the survey reported using telehealth in the past year. The survey contains some bias because respondents were more likely to use telemedicine, explained Megan Coffman, M.S., a health policy administrator for the Robert Graham Center who presented the research.

Respondents said the technology’s strongest points are improving access to care and providing continuity of care. Obstacles they cited included the cost of equipment, lack of training and potential liability.

A profile of the typical telehealth user emerged as one who:

  • is more likely to be practicing in a rural area (76 percent),
  • works with six or more family physicians (40 percent) and
  • uses electronic health records (98 percent).

When physicians were asked how they used telehealth, the leading responses were diagnosis or treatment (55 percent), chronic disease management (26 percent) and patient followup (21 percent). Physicians, whether they use telehealth or not, agreed that the technology improves access to and continuity of care. The question of whether it reduces cost has not been answered.

“There is not enough data on whether telemedicine saves money,” said Coffman. “That is yet to be seen. From a patient perspective, it saves time and money, but there is not enough information.”

Telehealth systems are good for increasing efficiency, said William Thornbury, M.D., R.Ph., the founder of an online appointment site called meVisit.(www.mevisit.com)

“We take 60 patents per day at the clinic,” said Thornbury, who also serves as medical director at the Medical Associate Clinic in Glasgow, Ky. “I can’t take any new patients. The real problem is 30 percent of my patients don’t need to be in the clinic, but the only way to get paid is to see them there. ”

meVisit’s telehealth application, available on mobile phones and computers, is designed to allow physicians to address minor health problems that do not require an office visit. Patients can select a reason for a consult from a menu or type it in themselves, and they can upload photos.

Thornbury said family physicians should consider telemedicine because retail health clinics are doing so. Walgreens plans to launch a telehealth mobile application in 25 states starting in January 2016.

“How is our health system going to compete in this arena?” Thornbury asked.

Thornbury said most patients pay a $37 copay for telemedicine visits. One of the concerns among insurers is that ease of access could lead to frequent, unnecessary consults, but Thornbury suggested that copays could be raised to solve that problem, should it arise.

States are beginning to recognize the value of telemedicine and are requiring insurers to do the same. Montana, for instance, passed a law requiring insurers to pay for telemedicine on terms equal to those for office visits.

As the medical profession moves to greater efficiency with an emphasis on reducing costs, Thornbury said family physicians should press hard for fair payment.

“Radiologists are benefiting from new technology that allows them to work faster, and they are not being asked to take less money,” he said. “Why are we being penalized for it? If we are more efficient and take on more liability, care is care is care.”

Related AAFP News Coverage
Gauging the Promise and Perils of Telemedicine
AAFP Calls for Adequate Payment, Fewer Restrictions

(6/24/2014)

Robert Graham Center Forum
Telemedicine Can Build Bridge to Expanded Health Care, Say Panelists

(2/5/2014)

More From AAFP
Member Interest Group: Telehealth

Family Practice Management: Should You Treat Your Patients Virtually?

Link to original article on AAFP

Walgreens’ Telehealth Grows As We Warm To Digital Doctors

By: , November 12, 2015, 2:48 PM

It has also updated and improved the app, which provides round-the-clock access to MDLive’s network of U.S. board-certified doctors.

“Walgreens app-based approach is different than CVS’ in-store telehealth offering, and we’re still waiting to see what Walmart will do when it begins to roll out its option, but it’s clear telemedicine is gaining rapid acceptance,” says Jonathan Linkous, CEO of American Telemedicine Association, based in Washington, D.C. “We’ve seen more growth in the last two years than we have in the previous 20.”

Two years ago, he says, consumers had 800,000 tele-consultations with doctors, and that’s increased to 1.2 million this year. The biggest use is for urgent-care consultations with primary-care doctors, followed by mental health. And he expects a growth rate of at least 20% to 25% next year. “That’s pretty rapid, but it’s still only a drop in the bucket compared to its potential.”

“We have seen that telehealth solutions play an important role in helping to improve patient outcomes,” says Adam Pellegrini, Walgreens VP of digital health, in its release, “and we will continue to work to evolve our offerings to ensure our patients can choose what’s most convenient for them, whether that’s live doctor consultations, digitally chatting with a pharmacist or visiting a Healthcare Clinic.”

At its Minute Clinics, CVS uses telehealth to help handle patient overflow during busy times, giving customers the option of stepping into a private room for a tele-consult rather than waiting. In a recent study, it found that 95% of patients said they were highly satisfied with the quality of care and ease of use. One-third even said they preferred a telehealth visit to having a clinician in the same room.

For consumers, telehealth offers convenience and often a much lower cost than an in-office or even in-clinic visit. But Linkous says telehealth is also gaining traction because so many doctors and providers, who have been required to build elaborate patient portals, would like to offer it on their own platforms.

In a sign that Americans are cozying up to the idea of seeing a doctor via smartphone, Walgreens says it is expanding its partnership with MDLive to an additional 20 states. The retailer, which began testing the service back in December in California and Michigan, expanded to five states in June.

Link to original article in Media Post

Bipartisan Senate bill aims to waive telemedicine restrictions for VA docs

A Senate committee heard testimony Wednesday on a bipartisan bill meant to ease telemedicine licensing requirements and facilitate mental health e-visits for Veterans Affairs healthcare professionals.

Current rules call for physicians using telemedicine to be licensed in the state where the patient resides.

According to bill sponsor Sen. Joni Ernst (R-Iowa), state licensure requirements are waived for the VA if both patient and doctor are in a federal facility during the e-visit. Home e-visits are allowed only if the two parties are in the same state. Ernst’s “Veterans E-Health and Telemedicine Support Act of 2015” would allow home e-visits regardless of where the VA clinician is located or licensed. This would apply to both VA-employed physicians and those under contract to deliver care outside of VA facilities.

“That’s a very important issue,” said Dr. Maureen McCarthy, acting VA assistant deputy under secretary for health for patient care services. She added that, under current practice, providers under a national service contract could find it necessary to get licensed in all 50 states.

Some 677,000 veterans received telemedicine services last year including 122,000 who received mental health e-visits in their homes, McCarthy said. She added that this has led to decreased hospital admissions, lower travel costs and fewer missed appointments.

“Telehealth care is an innovative and important means to meet the wide-ranging needs of veterans in Iowa and nationwide, including the invisible struggles of mental healthcare,” Ernst said in a news release.

The bill is sponsored by lawmakers from mostly rural states. It’s main co-sponsor is Sen. Mazie Hirono (D-Hawaii), who says the issue of access is of particular concern to residents of her state.

“Hawaii residents often are forced to drive for hours to see their physician or spend thousands of dollars to fly to Oahu and the mainland to seek care from a specialist,” Hirono said in a news release. “The TELE-MED Act will help to eliminate the financial and physical stress of seeking quality medical care by allowing seniors access to Medicare-participating physicians from the convenience of their home or local doctor’s office.”

The bill had 11 other co-sponsors before the hearing. This was increased during the hearing when the panel’s ranking Democrat, Sen. Richard Blumenthal of Connecticut, added his name to the roster.

Committee Chairman Johnny Isakson (R-Ga.) praised the bill.

“Legislation like this is a godsend, I suspect, and helps us solve a significant problem,” Isakson said.

Along with easing licensing restrictions, the bill calls for assessing patient satisfaction with the service, provider satisfaction, frequency of use, wait times and the effect on access to care.

Though McCarthy said the VA is “thrilled” with the bill, it had some concerns about creating additional reporting requirements – such as provider satisfaction. She added, however, that for the most part, the concerns were over “minor details” that could be resolved.

The bill has been endorsed by the Veterans of Foreign Wars, Paralyzed Veterans of America, the American Legion, Concerned Veterans for America and the American Telemedicine Association.

The Federation of State Medical Boards adheres to the principle that the practice of medicine occurs in the state where the patient is located, which it says ensures oversight and accountability if a patient is harmed.

“In its current form, the proposed VA legislation falls short of ensuring these protections, and it should be amended to strengthen them,” said FSMB Chief Advocacy Officer Lisa Robin.

To facilitate telemedicine access to patients in rural or remote areas, the FSMB advocates states join the Interstate Medical Licensure Compact that was created to streamline the licensing process for doctors practicing in multiple states. So far, 11 states are participating in the compact and legislation to do so has been introduced in nine more, Robin said.