Web-based program optimizes stroke care in rural areas

September 18, 2003

Stroke patients in rural communities can be assessed and treated essentially as well by a neurologist via a wireless Internet program as they can in person, according to a new study.

Treatment includes giving the clot-dissolving drug, tPA, when appropriate to help rapidly dissolve stroke-producing clots and minimize brain damage, said Dr. David Hess, chair of the Medical College of Georgia Department of Neurology and a co-author on the study published in the October rapid access issue of Stroke: Journal of the American Heart Association.

tPA was approved by the Food and Drug Administration in 1996 to treat stroke but still is given to less than 5 percent of patients, in part because stroke patients are not evaluated by a neurologist rapidly enough to receive the drug within the first three hours after symptoms begin, Dr. Hess said.

"We literally can be there at the speed of light," said Sam Wang, MCG research scientist and principal author of the Stroke paper that compared in-person exams of 20 stroke patients over a six-month period beginning September 2002 with those via a Web-based system developed by Mr. Wang. During those six months, stroke patients who arrived at MCG Medical Center were seen immediately by the stroke team per standard protocol, then, within the hour, a second neurologist did the same evaluation - from his home or office - via the REACH system, or Remote Evaluation for Acute Ischemic Stroke.

Neurologists used the standardized National Institutes of Health Stroke Scale Evaluation to assess critical functions such as the patient's ability to think, move and speak. The REACH system enables neurologists to hear and see the patients in real time. Also per standard treatment, patients get a computerized tomography scan, or CT, to help pinpoint the cause and location of a stroke; those CT images also are immediately available for review via the REACH system.

The published report showed no significant difference in the diagnosis and subsequent treatment recommendations made by neurologists in person and via the REACH system. For example, patient scores based on the NIH evaluation varied no more than 3 points.

In March 2003, the MCG Health System and the Department of Neurology began using the system to make MCG stroke team members immediately available to examine patients at distant, rural hospitals around the clock. Participating hospitals include McDuffie Regional Medical Center in Thomson, Ga.; Wills Memorial Hospital in Washington, Ga.; Jenkins Hospital in Millen, Ga.; Emanuel Hospital in Swainsboro, Ga.; and Washington Hospital in Sandersville, Ga.; and the list is growing, Dr. Hess said.

"These rural hospitals have been outstanding in their support and their enthusiasm; the outlying doctors have been great to work with," said Dr. Hess. "This is a win-win-win situation for the patients, those hospitals and for us."

Time is a critical factor in stroke treatment that starts ticking away as patients and family members begin to realize that a stroke is occurring then make their way to hospitals that provide intervention, Dr. Hess said. Even if a referring hospital is only a half-hour away, the valuable first few hours can be lost, he said, because of transportation and other problems.

Although the FDA suggests treatment within three hours of symptom onset, Dr. Hess said the evidence suggests the benefit is even greater within two hours. That 'the earlier the better' approach is the goal of REACH, he said.

Mr. Wang, who has a master's degree in immunology and microbiology, was working in Rochester, N.Y., in the dot-com industry when he began consulting with MCG neurologists to develop an efficient, effective system that optimizes stroke treatment for patients who otherwise would not have immediate access.

The result was the Web-based system which, at the remote site, has a cart equipped with a video camera and a personal computer with wireless Internet access that can go wherever the patient is. The health care provider with the patient simply calls the 24-hour Emergency Communications Center in the Emergency Department of the MCG Medical Center, the communications center pages the neurologist on call for REACH who goes to a computer, uses a password to access the confidential site and immediately begins talking with and seeing the patient and provider, Mr. Wang said. The REACH system even has a program for calculating the precise tPA dosage patients need. To date, 18 patients have been evaluated using REACH and three have received tPA.

Mr. Wang, who relocated to Augusta to work more closely on the project, said a map of the United States that plots out the stroke belt which laps across the Southeast helped him decide this was a project worth pursuing. "I felt I could seriously make a dent in something important," he said.

Other co-authors on the paper include MCG stroke team members Drs. Fenwick T. Nichols III and Robert J. Adams; Dr. Sung Bae Lee, a neurology resident at the Mayo Clinic; Davinder Ramsingh, MCG medical student; Dr. Hartmut Gross, MCG emergency medicine physician; Dr. Jennifer Waller, MCG biostatistician; and Carol Pardue, a nurse and assistant clinical professor of neurology at MCG.

A patent for REACH system has been filed by the MCG Office of Technology Transfer and Economic Development.

Medical College of Georgia at Augusta University

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