March 1, 2018

Initiative gives rural residents access to stroke care advances

A Vanderbilt University Medical Center telemedicine initiative seeks to broaden access to advancements in stroke care for residents of rural counties in Tennessee.


A Vanderbilt University Medical Center telemedicine initiative seeks to broaden access to advancements in stroke care for residents of rural counties in Tennessee.

Fifteen ambulances will be equipped with high-definition camera systems and accessories to set up a telemedicine network, enabling EMS personnel in Overton, Jackson and Pickett counties to consult with neurologists at the Vanderbilt Stroke Center. The neurologists will help EMS personnel diagnose strokes and identify which stroke patients should be airlifted to VUMC.

“There are multiple prongs to this,” said Kenneth Gaines, MD, MBA, professor of Clinical Neurology. “First let’s identify the stroke correctly. That would change our parameters around how urgently we need to act. Secondly, let’s identify the patient who would be the correct patient for an interventional procedure. And finally, let’s figure out the most appropriate triage, be that by ground or by helicopter and whether we would transport that patient from the helicopter pad to Vanderbilt.”

The pilot project is funded by $269,792 in Rural Development funds from the U.S. Department of Agriculture. The target time for the system to be up and running is early 2019.

Gaines said this telemedicine initiative is a step toward building a system to better equalize access to advances in stroke care.

The Vanderbilt Stroke Center is at the forefront of new protocols that have extended the time window for surgical interventions with ischemic strokes. VUMC is one of 38 medical centers in the U.S. that participated in a study that determined a thrombectomy — threading a catheter with a stent retriever through a main artery and directing it to the brain to remove a blood clot — can be beneficial for as long as 16 hours after a stroke has occurred in some large vessel occlusion patients. Another similar study indicated that window could be extended as long as 24 hours.

However, identifying those patients requires imaging technology and medical expertise not typically available at rural and community hospitals. Nor are ambulances equipped with this imaging technology.

Stroke specialists at VUMC can evaluate clinical conditions, components of the National Institutes of Health stroke scale and other criteria to determine patients that may be candidates for thrombectomies.

“The idea is to pick the right patient,” Gaines said. “Otherwise, we bring every stroke patient potentially to Vanderbilt, which is totally inappropriate and unnecessary so you would be creating a huge transportation cost, a huge inefficiency for patients and an inconvenience for patients who would much rather stay where they live.”

Patricia Commiskey, DrPH, the principal investigator of the pilot study, said the three counties are sparsely populated, with higher percentages of people who are disabled or 65 and over than the state average. Pickett County is the least populated of any county in the state with 5,142 residents, according to the U.S. Census Bureau.

VUMC is partnering with ambulance services in each county in setting up the telemedicine initiative. Livingston Regional Hospital in Overton County is partnering to provide administrative space for the project.

Commiskey said she views them as equal partners.

“The first piece of this, really for us as well as them, is to look at what they are doing well and look at what’s more difficult in term of stroke assessment, and get a sense of that. Before we launch into this project, we are going to get everyone involved.”

Gaines said he looks forward to expanding the initiative.

“We see this as a mechanism to go further,” he said. “We started out with these three counties. We certainly don’t see that as the end of the road.”