Stroke units save lives because specialist treatment is absolutely crucial for stroke patients. However, not all clinics have neurological specialists available 24/7, so telemedicine provides a good solution to the problem. Studies show that telemedical consultations can considerably improve the treatment of stroke patients.
When someone has a stroke, which is a sudden circulatory disorder in the brain, they require immediate help. Brain cells start dying when they are deprived of oxygen and the patient may lose memory and muscle control, leading to severe disability or even death. The German healthcare system relies on specialised stroke units certified by the German Stroke Aid Foundation for improving the treatment of stroke patients. These stroke units treat patients quickly and professionally. The units have to meet certain requirements in order to be able to invoice their services. This includes, for example, the capacity to perform computed tomography (CT) examinations within thirty minutes of a stroke occurring.
Studies show that the high demands placed on stroke units pay off. The survival rate of stroke patients has increased significantly and the number of disabilities resulting from strokes has been reduced. In Baden-Württemberg, the first stroke treatment concept was developed on behalf of the Baden-Württemberg Ministry of Social Affairs and Integration back in 2013, and adapted to new technical standards in February 2017. Stroke treatment requirements are defined in the so-called “standard operating procedures” (SOP).
The neurological teleconsultation service, operated by the Freiburg University Medical Centre on behalf of several stroke units at Baden-Württemberg hospitals, was launched to ensure that these high requirements are met. Prof. Dr. Bardutzky, managing senior physician in the Department of Neurology and Neurophysiology at the Freiburg University Medical Centre explains the procedure: “When ambulance personnel or the emergency doctor suspect that someone has had a stroke, they call the hospital to announce their arrival. As soon as the patient arrives at the hospital, a doctor, usually an internal medicine specialist, examines the patient and contacts us if the initial suspicion of stroke is confirmed.” A neurologist is always on duty at the telemedicine centre in Freiburg. After a CT or CT angiography (CTA) has been performed in a regional hospital, the hospital in question contacts the neurologists in Freiburg via the "TeleDoc". Doctors and patients can see one another on this mobile workstation and it is also used to transmit clinical data. "After 20 minutes, a decision can be taken on how to proceed,” says Bardutzky. If it turns out that the patient has to undergo thrombectomy, i.e. the surgical removal of the blood clot (thrombus), he or she is referred to a neurology department. "Patients are usually referred to Tübingen, Stuttgart or us," explains Bardutzky. Thrombolysis is initiated in the local hospital and the patient taken by ambulance to the hospital department that will perform the thrombectomy.”
Certified stroke units must always have a specialist, i.e. a neurologist, on duty. A telemedicine service is permitted to provide this. "Our specialists have been working with strokes for years. Internists and non-neurologists are not usually able to give a diagnosis,” says Bardutzky. The specialists from Freiburg look after some hospitals solely at night or at weekends as part of neurological emergency care. These are hospitals that do not have the personnel and capacity to staff their own neurology wards around the clock. Some hospitals with no neurology department are offered a 24-hour telemedicine service. “This is a win-win situation for everybody concerned. The telemedicine centre is staffed with neurologists 24/7. Normally, you’d need a large number of doctors to adequately staff neurology departments. Our services therefore help hospitals save money,” said Bardutzky.
The project was launched four years ago with three hospitals from Tuttlingen, Mühlheim and Waldshut. All these hospitals had a stroke unit, but were experiencing difficulties filling their neurologist positions. Without telemedicine, the hospitals would not have been able to maintain their stroke patient treatment services. After failing to acquire funding, the three hospitals joined forces with the Freiburg University Medical Centre. The Department of Neurology and Neurophysiology at the Freiburg University Medical Centre, which has a stroke unit, is a certified supraregional stroke unit.
“Initially, we offered our consultation services voluntarily over and above our normal working hours," says Bardutzky. "Now that so many hospitals have joined, we have enough money to pay six doctors who are available to work 24/7 throughout the year." The model is thus self-financed by participating hospitals and, according to Bardutzky, everybody involved is happy with how it works. The Freiburg University Medical Centre can bill its telemedical care services as DRG- (German Diagnosis Related Groups) based flat-rates using the operation and procedure code OPS 8-98b (other neurological complex treatment in patients with acute stroke)1.
"From a medical point of view, our services are equivalent to those that hospitals would offer on site," explains Bardutzky. Bardutzky also points out that the services save the hospitals money. The TEMPiS (Telemedical Project for Integrated Stroke Care in the Region of South-East Bavaria) has been in existence for a long time and has shown that using telemedicine significantly improves patient prognosis2. "However, the two projects differ quite a bit,” says Bardutzky. The Bavarian project received a grant from the “Zukunftsoffensive Bayern” programme, while ours had no such grant. "Our system is up and running now, but in the first two years you have to invest yourself, which is not always easy. This applies to many projects of this kind. They all depend on own initial investments,” says Bardutzky. But although the network of the Freiburg University Medical Centre is not yet as extensive as TEMPiS, the participating hospitals and the Freiburg University Medical Centre have been making good progress since 2014. A project called "Digital image processing in acute stroke in a transregional hospital network" funded by the Baden-Württemberg Ministry of Social Affairs and Integration at the Freiburg University Medical Centre will further support the concept3.
1 OPS Version 2018 chapter 8: Nicht operative therapeutische Maßnahmen https://www.dimdi.de/static/de/klassi/ops/kodesuche/onlinefassungen/opshtml2018 /block-8-97...8-98.htm
2 Lancet Neurol. 2006 Sep;5(9):742-8, Audebert et al., Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. https://www.ncbi.nlm.nih.gov/pubmed/16914402
3 The Baden-Württemberg government funds telemedicine projects with a total of 4 euros https://www.telemedbw.de/de/fachartikel/land-unterstuetzt-projekte-mit-4-millionen-euro/