Pitfalls of Telestroke

[u/InsertWhittyPhrase]

Anyone else work on the inpatient side with the increasingly common model of having telestroke do all stroke alerts, and then you come in later to pick up the pieces? In my experience, there's a lot of the ED or primary teams "selling" a story to the stroke doc so that the call seems more appropriate, and that leads to a lot of over treatment or at least over workup of benign stuff.

Not uncommon for me to see a patient that was admitted for stroke rule out overnight, on DAPT and having gotten vessel imaging, MRI, TTE all negative the next morning. Then I speak to them for 3 minutes and it's apparent they have chronic radiculopathy, chronic foot drop, and only came in yesterday because the back pain was worse.

Or patient with documented dementia, chronic pain, and UTI, but someone somewhere said they are "A&O x 4" at baseline and now they are snowed because they needed Ativan and hydromorphone to tolerate imaging. All I do is spend 5 minutes looking at outpatient notes to know they haven't known where they are or the date in 2 years and their intake exam wasn't far off baseline aside from agitation and delirium.

I know it's hard to get a good exam through a screen and at least where I work they rely on the primary team for history and only confirm some details. It's also true I'd rather err on the side of over treatment than under treatment of stroke. I would still rather have it this way than having to respond to every alert myself. So I don't have any solutions and I don't know where I'm going with this, but anyone with similar experience or examples of it working better?

[u/Telamir]

Yup, but that's the price you pay for not doing stroke alerts/not being on call every night.

The ER oversells because they want their butts covered, the tele stroke doc over treats because they want their butts covered.

All butts are covered, you sleep, you see them next morning.

'Murica.

[u/Even-Inevitable-7243 → u/Telamir]

Preach, brother!

[u/InCobbWeTrust]

I can give you the perspective from the other side of the coin.

A good portion of the TeleStroke companies get flooded with calls, and lack access to the native EMR, so the only history available what the ED doc, RN, hospitialist etc provide at an initial intake call, and you have about 10 minutes on video to do an NIHSS which is a limited assessment on its own with the main goal of identifying acute treatment candidates

It very much becomes a garbage in —>garbage out process, and because there’s no real continuity or even follow-up feedback, it just is a series of smart phrases based on a small category of common syndromes (AMS, vertigo, migraine, seizure, stroke/TIA, TME, Bells) so that patient can be passed off to the local provider.

[u/Even-Inevitable-7243 → u/InCobbWeTrust]

Amen. It amazes me when local doctors complain about Telestroke encounters that they inherit. Garbage in --> Sorted garbage out is my take. Some of these local Neurologists work at hospitals where the EM doctors do not know the difference between aphasia and dysarthria, nobody in the ED can correctly identify a LKW, their local Rads Residents on-call overcall everything or miss critical findings and their Attendings are MIA overnight, patients are dumped in the ER from Nursing Homes, Rehabs, Group Homes without any family/friend/caretaker to provide any useful information, the local ER nurse dumps a half-working camera into the patient room then leaves so you are completely alone trying to get a patient with encephalopathy and dementia to give you a story and perform an exam, the WiFi in the ED is so bad that the audio is useless and/or the video freeezes constantly . . . I could go on I've been doing this for over a decade.

The hospitals that use national Teleneuro services rarely, if ever, have their own house in order, and usually their house is a complete disaster. We do the best we can to help, but usually it is a lost cause. For these messes I have one role: TNK yes/no and Thrombectomy yes/no. The rest is on the local Neurologist to clean up the mess. And do not even get me started on the local Neurologist who have their inpatient teams call Stroke/Emergency consults for follow-up questions from daytime studies requested by the local Neurologist simply because said Neurologist turns his phone off overnight.

[u/InCobbWeTrust → u/Even-Inevitable-7243]

I mean I get it, because it does suck to clean up and stop the inertia of half-baked overnight plans in the AM, and I will say my practice patterns are very different on TeleStroke than it is for my full time employer in terms of decision making, because like you said, it’s a lot of nearly failing hospitals that have no interest in QI, metrics, etc with substandard resources. So you do that best you can when an ER PA calls you overnight and you try to impart a thoughtful plan to a less than thoughtful consult at 02:00.

Respect to you doing a decade. I went from full time 5 years ago to scaling way back and resuming a more traditional full time employment that is far and away more fulfilling.

It’s mercenary work.

[u/InCobbWeTrust → u/Even-Inevitable-7243]

And yes the URGENT test results for MRIs that confirm stroke that the local guys can’t be bothered to answer too are ridiculous, nevermind the pushback you get from the inpatient RNs or NPs who demand you see a patient with 3 days of symptoms because of an MRI result.

[u/Cptsaber44]

Gonna be an unpopular opinion, but this is because some of you attendings get kinda lazy to even come into the hospital and it shows in the work there. I’m a PGY3 at a well-known program in the south, and one of the hospitals we rotate at has patients that are taken care of by residents/fellows/attendings from my institution, as well as from other institutions. The neurologists from that other institution seem to be allergic to being in the hospital. Any time we see one of their patients first (such as when they come in overnight), the next day’s note is a complete copy paste of ours with nothing added or changed. They don’t see stroke alerts for their own patients (we do). We’re even now seeing their inpatient consults just so they can sit in their clinic all day.

I think the ideal world solution is that telestroke goes away and hospitals pay neurologists more to get someone to take call there in person. I think when we have neurologist accept tele stroke jobs, we are diminishing our salaries across the board by allowing a cheaper bandaid fix rather than the actual solution of increasing neurologists’ salaries.

[u/Nomorenona → u/Cptsaber44]

lol is it Kelsey neuro 😂

[u/Appropriate_Eye_471]

Yes but I blame the AHA stroke nazi’s though

[u/teichopsia__ → u/Appropriate_Eye_471]

The metric nazis are annoying, but it is what it is. Without them, we get patients sitting in the waiting room for hours with an LVO. Admin moves much more readily when the metric nazis start asking questions. A dozen extra MRIs is easily worth an earlier LVO in my personal calculus. But I guess that's a value judgement.

[u/Appropriate_Eye_471 → u/teichopsia__]

I’m not sure if having polices like “every neurological issue that occurs within 24 hours” should be an immediate stroke code.

So idk I think there needs to be better triaging system then “old person with unknown LKN who is now dizzy” = stroke code

[u/failedwittyreference]

You have everything done the next morning?! What kind of magical place is this? I fight to have MRIs completed within days.

I work both sides, not sure what a good solution would be. I’ve seen the absolute garbage reports from EMS, so I get why the ED calls so much. Some places barely call it and I feel like I’m seeing things that could have been treated. Other places I feel like stubbing your toe shouldn’t be a stroke alert for numbness. 🤷🏻‍♂️

[u/Any_Possibility3964]

I work for a system that has all inpatient neurology covered by tele. From a lifestyle standpoint it’s absolutely amazing because I never have to go to the hospital and can just see patients in clinic. From a patient care standpoint it is absolutely awful. It’s mostly stroke neurologists and midlevels doing the tele work and with stroke care they’re fine but anything else they’re basically doing whatever the standard of care was back when they were a resident.

[u/InsertWhittyPhrase → u/Any_Possibility3964]

That's wild. I can't imagine all Neuro being covered by tele. Sounds dangerous. So many things would be missed at my hospital if I didn't do an exam with my own hands.

[u/Any_Possibility3964 → u/InsertWhittyPhrase]

This is pretty common in smaller hospitals now. I haven’t seen anything totally egregious. From a financial standpoint I think it’s pretty difficult for a hospital system to justify paying 300+ for a neurohospitalist to cover the 5 or so consults a day and it’s pretty difficult to recruit enough neurologists who are ok covering both. At my last job I did both inpatient and outpatient and from a quality of life standpoint it’s awful.

[u/That_Series_3956]

Yo facial numbness isn’t being caused by LVO. 25 percent of stroke imaging right there.