Ten years ago when we made our first forays into teleneurology, our efforts were met with doubt and suspicion.
Fast forward to today, and it’s rare to find a hospital — from a comprehensive stroke center to the smallest rural hospital — that doesn’t use some form of teleneurology. In fact, it’s probably fair to say that you can’t have an effective neurology program today without it. While this was true before the coronavirus pandemic, our national emergency has exponentially accelerated the demand for virtual care solutions.
In this article, we share some thoughts on how our specialty will continue to evolve over the next several years.
Force Multiplying Neurologists Through Virtual Care
Over the past decade, it’s become clear that the relatively small number of practicing neurologists can’t meet the needs of a rapidly aging population by using traditional in-person care models. Instead, we must innovate solutions that allow individual neurologists to care for more patients across a wider geographic area.
When it comes to treating acute stroke medicine has advanced to the point where timely administration of thrombolytic therapies can save many patients from a lifetime of disability. Because these drugs must be administered within a narrow window (under 30 minutes is currently the gold standard), there is zero time for an on-call neurologist — who is likely not a stroke specialist — to drive to the hospital and perform a workup.
Telestroke programs will continue to serve as the most cost-effective and high-quality way to bridge this gap. In particular, this model ensures that subspecialists who treat high volumes of stroke cases each week are the ones delivering care – even in remote locations. The next generation of telestroke care will likely integrate artificial intelligence (AI) to support neurologists’ diagnostic decisions, leading to faster, more targeted treatments. This technology may act as an additional force multiplier, allowing a single stroke neurologist to manage more patients.
Research suggests that continuous EEG (cEEG) monitoring of patients in neurocritical care units lowers mortality by up to 20%. Specifically, cEEG can help to detect and differentiate seizure activity, allowing for early and effective intervention. CEEG can also improve outcomes for NICU patients who experienced hypoxia during birth, hospitalized epilepsy patients, and any patient with altered mental status.
Despite its benefits, cEEG remains underutilized, in large part because there aren't enough clinical neurophysiologists to manage this vital service. The pandemic has only deepened the shortage. Fortunately, cEEG technology has advanced to a degree that lends itself to remote monitoring. This allows off-site neurologists to direct the care of multiple patients from almost anywhere.
Mobile Stroke Units
COVID-19 has caused significant upheaval in the care continuum. Ten weeks into the pandemic, stroke-related ED visits had declined by 20%. Patients who did visit were often outside the treatment window for thrombolytic therapy and at-risk for poor outcomes. Some had been experiencing serious stroke symptoms (like weakness) on one side for days. Also, the demographic of stroke patients has shifted younger due to complications resulting from COVID-19. Reports from New York City hospitals demonstrate that the mean age for stroke patients testing positive for COVID-19 is 59 years, compared to 74 years for patients testing negative for the coronavirus.
While ED visits have slowly rebounded, this experience revealed a weakness in our existing system. When we expect patients to travel to the ED for care, we increase their risk for delays and resulting complications. The pandemic has highlighted a bigger underlying issue and may give us the push we need to shift to a new paradigm: delivering acute care where and when patients need it.
In the next few years, we expect to see an expansion of telestroke programs that pair neurologists with mobile stroke units — ambulances equipped to perform CT scans and administer thrombolytic therapy in the field. Working together, the neurologist and paramedics can identify patients who would benefit from advanced interventional treatments and transport them to a hospital with these capabilities.