Three hours – that’s the tiny window of time that ticks away much too quickly for an ischemic stroke victim. Immediate treatment with the clot-busting drug, tPA (tissue plasminogen activator), within this time period could minimize life-changing, long-term effects. But, many patients, particularly those in rural areas, just can’t get to a neurologist that fast. The smaller the hospital, the less likely it is to use tPA.

 

According to the American Heart Association’s Heart Disease and Stroke Statistics for 2010, Louisiana has the fourth highest mortality rate for stroke in the nation. Recognizing this startling stat, neurologists at Ochsner Health System took action. Last year, Ochsner developed the Ochsner Acute Stroke Intervention Service (OASIS), a real-time audio/video system which allows the main facility to interact with any emergency room in the Ochsner system – and beyond. Using telemedicine, a vascular neurologist at Ochsner’s main campus can immediately connect with another hospital’s emergency department to evaluate a stroke patient, talk to the ER docs and staff, review the patient’s CTs and other scans, then make acute treatment and triage decisions. “We have started off by trying to deal with some of the issues of acute stroke care delivery, which is largely the time-sensitivity of most of the new treatments and limited expertise available for emergency rooms and in-hospital strokes, to try to get people evaluated and treated quickly,” explained Dr. Kenneth Gaines, vascular neurologist and chairman of the Neurology Deparment at Ochsner’s main campus, Ochsner Medical Center in New Orleans. “A lot of the technology is there, like CT scans, to help, but the neurological expertise often is not available. So we’ve developed this as a way to try to combat some of those problems of access to care, and the fact that so many stroke patients that are even eligible for the acute treatments don’t get them because of these time constraints.”

 

From the “hub” hospital on the main campus, Ochsner installed the REACH 3.0 turn-key telestroke and telehealth service to provide consulting services to its “spoke” community hospitals. Starting in August with Ochsner Baptist Medical Center in uptown New Orleans, the service expanded to Ochsner Medical Center-West Bank in Gretna, Ochsner Medical Center-Kenner and Ochsner St. Anne General Hospital in Raceland. In February, 2010, the system went live at Ochsner Medical Center-Baton Rouge. The demand for this service exceeded all projections. “We did 30 to 40 telemedicine consults in two months, which was actually a lot bigger number than we had thought for something starting up,” Gaines said. “We were surprised at the need and the volume out there.”

 

With OASIS, system hospitals contact Ochsner’s main campus for any stroke victim who comes into the ER within 12 hours of symptom onset. If within the three-hour window, qualified acute ischemic stroke patients can receive the clot-busting drug, tPA. Beyond that limited time frame, doctors have other options, such as using a Merci® Retriever device to grab the blood clot, or the Penumbra Stroke System to suction it. “There are very strict time restrictions – some can go up to six or eight hours – but that’s not very much time, because it can sometimes take one to two hours to get to the ER,” Gaines observed. “So, anything we can do to make the process happen faster is a step in the right direction. Because, if you have a stroke, you are certainly better off at being treated two hours after your stroke than you are at eight or 12 hours. Time really matters with these types of therapies. And, we do the same thing for hemorrhagic stroke, but it’s more a matter of triage and transfer for those patients.” 

 

Installing the OASIS system at Ochsner’s community hospitals took two to three months. “There’s a lot of groundwork that has to be done to get CT access, and a lot of training involved to get the nurses and physicians in the ER comfortable with this type of system,” Gaines explained. “And our vascular neurologists at Ochsner have to be on the staff at all of these hospitals in order provide these kinds of consultations.”

 

Once in place, OASIS is pretty simple. When a stroke patient arrives at a networked hospital, its emergency department activates the system. Immediately, a neurologist at Ochsner’s main campus is notified through the transfer center that a consult is needed. The attending neurologist then activates his laptop, which has a built-in camera. “Literally, within five minutes, I can be on the scene, and talk to the patient and family, and get a history,” Gaines explained. “Most of the consults take about 25 minutes to do from start to finish.”

 

Now that its spoke hospitals are in the system, Ochsner is entering the next phase – reaching hospitals outside of its network. Recently, the Centers for Disease Control awarded a three-year grant to the La. Department of Health and Hospitals Heart Disease and Stroke Prevention Program to develop a telestroke network in partnership with Ochsner and the American Heart Association. The funds will help underwrite the costs for other hospitals, particularly smaller ones, to enter into a telestroke network. Another purpose of the grant is to educate the community about heart disease and stroke risk factors, as well as the importance of seeking immediate treatment when symptoms occur.

 

The first hospital outside of the Ochsner system to go online was St. Charles Parish Hospital in Luling, La. Prior to implementing REACH, St. Charles Hospital had to transfer acute stroke patients to Ochsner in New Orleans. “Ochsner has always been great about accepting patients,” said Dr. Brent Giuffre, emergency medicine physician at St. Charles Parish Hospital. “But, it was the delay in care sometimes that was a problem. Some of the things you like to do, you actually have to have a neurologist present looking at the patient to guide with some of the treatments.”

 

With OASIS, patients at St. Charles Hospital have access to a neurologist at Ochsner’s main campus in minutes. “The main reason we joined was because it gives us access to full-time neurology coverage, so it allows us to handle stroke and seizure patients without having a neurologist in-house,” Giuffre reported. “It literally places a neurologist in the room with the patient.”

 

Since becoming part of the program two months ago, St. Charles Hospital has used the program three times without a glitch. While the hospital had not used it for tPA as of press time, Giuffre finds it valuable for patients seen outside of the three-hour window. “We are still treating patients sooner with this capability,” he observed. “We are able to get the medicine, and they can reverse the stroke at a quicker time, which benefits the patients.”

 

Giuffre highly recommends the OASIS system to other hospitals. “It’s helping the patients and giving them what they need sooner, especially with some of the outlying hospitals, where they are not even close to a neurology specialist,” he said. “With some of the hospitals that are farther out, I definitely see a need for it.”

 

Soon, Ochsner will start collecting data regarding the outcomes for stroke patients in the telestroke system. Over the next few years, Ochsner plans to expand OASIS to other hospitals in the South Louisiana area. “We would like to see it expand,” Gaines said. “I think there’s a huge need. The problems of stroke here in the State of Louisiana is significant.”

 

For more information about OASIS, contact DHH, the American Heart Association, or Ochsner’s neurology department coordinator, Liz Allen, at (504) 842-3980.