Every minute counts during a stroke. Blood-thinning drugs and surgery can prevent traumatic brain injury, but doctors must act fast: A lifesaving procedure called a clot retrieval, for instance, is only effective within about eight hours of a stroke’s onset. A drug called tPA, which dissolves stroke-inducing blood clots, must be administered within about four hours.
Moreover, a wrong move can be deadly when treating a stroke patient. Few rural emergency room doctors are trained to confidently make such high-stakes calls.
As a result, only a tiny fraction of rural stroke victims eligible for the lifesaving blood thinner actually get it, said Howard Yonas, a neurosurgeon at The University of New Mexico. Instead, many rural doctors opt to fly patients by helicopter to the state’s only Level 1 trauma center, in Albuquerque, a costly and sometimes unnecessary measure that consumes precious hours.
Now, Yonas and other New Mexico doctors are turning to the power of remote medicine to help stroke patients avoid expensive flights and receive timely procedures. The strategy is to loop Albuquerque specialists into rural emergency rooms by video and immediately share brain scans before deciding to transfer the patient. The program, called Access to Critical Cerebral Emergency Support Services, or ACCESS, started in 2014 with a $15.1 million grant from the U.S. Centers for Medicare and Medicaid Services.
In the two years since, one hospital in Roswell has gone from shipping about half its brain trauma victims to Albuquerque to transferring just 6 percent. Another hospital, in Santa Rosa, has more than doubled how often it gives patients tPA. Nine hospitals statewide use the ACCESS system, and five more will join soon.
Yonas hasn’t studied individual patient outcomes yet, so there’s no hard evidence showing whether people receiving care in rural settings survive strokes at the same rate or with similar physical outcomes as those transferred to Albuquerque. Studies of other telemedicine programs, however, have shown outcomes are nearly identical, and doctors and nurses using the program in New Mexico say their patients are doing at least as well as they were before ACCESS began.
Stroke is the fifth-leading cause of death in New Mexico and a leading cause of adult disability. In 2014, 822 New Mexicans died from a stroke — more than those who died from drug overdoses and homicides combined.
ACCESS started with a simple observation. Yonas noticed something peculiar about patients who arrived on stretchers at his Albuquerque medical center: About 1 in 4, he estimated, didn’t actually need to be there. Their strokes and other brain injuries weren’t as bad as doctors initially believed, and their brain scans showed nothing significant. If rural doctors had better information, Yonas said, the patients could have been treated in their home hospitals, sparing tens of thousands of dollars for a medical flight and several hours of driving for concerned family members.
Yonas conducted a study to test his theory. For a year, he tracked head trauma patients at seven rural New Mexico hospitals. He discovered that after hospitals began sharing brain scan images and consulting with Albuquerque doctors, they cut the number of flights nearly in half, treating twice as many patients locally.
Yonas’ findings led to a massive three-year federal grant to launch the ACCESS program at a handful of hospitals across the state. The program bought new computers and cameras to live-stream video from rural emergency rooms, paid for doctors’ consulting time and created a web-based system for quickly transferring brain scans between hospitals. Local emergency room doctors now have the ability to consult one of eight UNM neurosurgeons, like Yonas, before deciding how best to handle brain trauma patients.
“You can talk to the patient, you can see the patient, you can ask the patient to do certain tests,” Yonas said. “All of that can happen within about 30 minutes of the time they come [into the emergency room].”
National research suggests telemedicine can increase how often stroke patients who need tPA actually receive the drug. A study of the University of Pittsburgh’s telestroke network, for instance, showed that the rate of stroke patients who received tPA more than doubled after starting a telemedicine program.
One early adopter was the Eastern New Mexico Medical Center in Roswell, a city of 48,000. In 2015, emergency room doctors there consulted with UNM specialists on 354 brain trauma patients — victims of everything from strokes to headaches to gunshot wounds to the head. Prior to the ACCESS program, roughly half those patients would have been transferred to Albuquerque’s trauma center, said Rod Schumacher, the hospital’s CEO.
Last year, however, the hospital transferred just 12.7 percent of those brain trauma patients. In 2016, the hospital has transferred only 6 percent.
Adding a consultation with a neurosurgeon — even through a computer screen — creates a more sophisticated system of care, Schumacher said.
“The ER doctors will tell you, there’s great comfort in having the neurosurgical consult before we [treat],” he said.
Using technology to connect patients with a doctor far away — a field broadly known as telemedicine, or telehealth — is not new, and ACCESS is just one of several such projects in the state. The nationally recognized Project ECHO, for example, has trained rural doctors in New Mexico via teleconferencing for the past decade, and it has expanded across more than 10 states, as well as India and Northern Ireland. Nationwide, more than half of all states have some sort of telestroke program, though most are less than a decade old.
While telemedicine isn’t yet the norm in rural health care, it’s a growing trend, said Dale Alverson, who runs UNM’s Center for Telehealth. One reason is the growth of cheaper technology. In the late 1990s, a telemedicine setup cost about $100,000 to install, Alverson said. Today, a comparable outfit costs less than $10,000.
Another reason is consumer demand. In the past two years, two wrongful death malpractice lawsuits against rural New Mexico hospitals claimed a patient would have lived had a doctor used telemedicine, Alverson said. Both cases were settled out of court, setting no legal precedent. But for Alverson, the suits raised an interesting question: When will telemedicine become an expectation for health care providers, rather than an exception?
“It’s going to put pressure on rural hospitals who want to avoid expensive lawsuits to use telemedicine,” he said.
For rural doctors, the incentive is more than just avoiding lawsuits. It’s about providing better care in their community.
“There’s this idea of keeping the right patients in the community, if you can,” said Yonas, the UNM neurosurgeon. “That’s good for the family, it’s good for the patients, it’s good for the hospital.” Rural hospitals lose revenue each time they transfer a patient — money many hospitals need to remain viable, Yonas said.
In Santa Rosa, a town of 3,000 people, Guadalupe County Hospital now treats some patients who previously would have been transferred, said Antonia Lucero, a nurse who runs the hospital’s telehealth program. Before ACCESS, years would go by without the hospital administering tPA, she said. So far in 2016, she and her staff have already given the drug three times — each time with advice from a neurosurgeon in Albuquerque.
“We give it with more confidence now,” Lucero said.
Because ACCESS hasn’t yet been subject to comprehensive study, the best evidence about the program’s patient outcomes is anecdotal. So far, Lucero said, not a single head trauma patient treated through telemedicine at her hospital has died.