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Rural North Carolina Gets Savvy With Teleneurology For Stroke

Cheryl Clark, for HealthLeaders Media, October 28, 2009

One by one across the nation, small rural hospitals are getting stroke smart.

And around this Thanksgiving, 87-bed Hugh Chatham Memorial Hospital in Elkin, NC, a Mayberry-like town of 4,000 residents, will become one more.

Hugh Chatham and three other rural facilities in the nation's so-called "stroke belt" will link up with a teleneurology system through Forsyth Medical Center, the first North Carolina hospital to receive Joint Commission stroke certification, 45 minutes away in Winston-Salem.

The other hospitals joining in are Brunswick Community Hospital, a 60-bed facility in Supply; Kernersville Medical Center, a 50-bed hospital nearing completion in Kernersville and Twin County Regional Hospital, a 141-bed facility in Galax, VA.

When they do, patients who come to the emergency room exhibiting symptoms of brain attack can be examined through a high-resolution, 30-frame per second camera by a trained stroke neurologist either at Forsyth, or thousands of miles way through a neurology physician service called Specialists On Call.

Their CT scans can be scrutinized by those same distant doctors to see if they are eligible for tissue plasminogen activator or tPA, the clot-busting drug proven to make at least 11% of ischemic stroke patients who receive it almost completely recover when they otherwise would be severely disabled for the rest of their remaining lives.

All told, an estimated 1,500 patients who have a stroke attack each year at the four hospitals will get better care, Forsyth officials say.

"Another unknown number of patients won't be cured, but they will do better than they otherwise would and require fewer resources," says Patrick Lyden, MD, who started a similar stroke network with rural hospitals in California six years ago.

"Every day, more and more rural hospitals are solving this problem for themselves with different models of teleneurology," says Lyden, now chairman of the department of neurology at Cedars-Sinai Medical Center in Los Angeles.

It's important that expert neurologists diagnose which patients who present with stroke symptoms have ischemic stroke, the type that benefits from tPA, and which ones have hemorrhagic stroke, for which administration of the drug could be harmful.

Also crucial, having expertise available to rural communities like these will make it much more likely that patients will be seen within the three-hour window that the drug can help.

At Hugh Chatham, the idea originated when Marc Womeldorf, administrative director of rehabilitation services, wondered why his facility wasn't receiving more stroke patients.

"I checked with North Carolina state statistics for what happens to stroke patients from our primary service area, which includes Wilkes, Alleghany, Yadkin and Surry counties," says Womeldorf. "And I learned that over half of the patients who suffer stroke who live here were going to other hospitals farther away for their care. It didn't make sense."

"Quite often, what these patients are doing is going straight to these other hospitals by driving," which adds another hour of brain cell death and make it nearly impossible for them to be eligible for tPA within the required three-hour window, says Womeldorf.

"They're not even accessing the 911 emergency medical system transport. Meanwhile, the clock is ticking and brain cells are dying."

Teleneurology could bring more patients to Hugh Chatham, he reasoned.

North Carolina is one of the so-called "stroke belt" states, along with Arkansas, Alabama, Mississippi, Tennessee and Oklahoma where death rates from stroke are the highest in the nation. North Carolina, the sixth highest stroke death rate, had 52.4 stroke deaths per 100,000 people in 2006, nine more than the national average.

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