Evaluation of a French Regional Telemedicine Network Dedicated to Neurological Emergencies: A 14-Year Study

Introduction

Neurological emergencies are frequent in emergencies departments. ^{1 –3} The number of practitioners has been decreasing for decades all around France and even more in rural areas. ⁴ Thus, telemedicine appears as the way of enabling equality to neurological expertise assessment. Moreover, telemedicine reduces costs and avoids useless or risky transfers. ⁵

If studies demonstrating the usefulness of telestroke at the acute stage are now numerous, less is known about the efficiency of a mutualized network dedicated to neurological, neurosurgical, or neuroradiological emergency. ^{6 –10}

We report the evaluation of a 13-year-old regional telemedicine network specialized in every kind of neurological emergencies. The aim of the study was to describe the evolution of neurological expertise and of interhospital transfer rates since the network deployment.

Materials and Methods

Results

A total of 23,710 patients underwent a telemedicine expertise for a neurological emergency from 2002 to 2015. As shown in Figure 1, the number of calls had tripled within the first six years and has rounded since then to 2,000 calls per year. The demands for expertise came from the entire region and all the community hospitals used the system. The needs of expertise were independent of the existence of a department of neurology.

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Fig. 1.

Evolution of calls.

Reason to call was in 30% stroke suspicion, in 36% head or spinal injury, 9% cerebral tumor discovery, and 24% other requests (headache, seizures, etc.), and this distribution had not changed within the 13 years analyzed.

The evolution of calls for each group of pathology during the two periods studied and according to the category of hospital that requested are summarized in Table 1.

Stroke patients

In the stroke group, the ratio of patients admitted for stroke and who underwent telemedicine stroke neurologist expertise peaked from 16% to 75.3% in the community hospital without neurologists on site. The evolution of calls for stroke had significantly increased between the two studied periods with a higher rate of tele-expertise for patients admitted in Neuro-neg community centers (Fig. 2).

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Fig. 2.

Evolution of ratio of neurovascular expertise Neuro-neg and Neuro-pos.

Since 2005, telethrombolyses were started. In 2015, the regional rate of thrombolysis was 9.9%. The number of telethrombolyses has increased dramatically. At the end of 2009, 29% of all thrombolyses were administered by telemedecine in Neuro-neg centers. At the end of 2015, 33.5% were done after a teleconsultation (Fig. 3).

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Fig. 3.

Evolution of thrombolysis.

Head injuries

Neurosurgeon expertise had also been required in head injury cases (Fig. 4). Comparing, the periods studied, the number of calls was significantly higher for Neuro-neg than for Neuro-pos between both periods.

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Fig. 4.

Evolution of neurosurgeon expertise in head injury.

The telemedecine network had also been used for patients suffering spinal traumatism with a significant increase of calls between both periods for patients admitted to emergency care department without neurological assessment (12% vs. 21%). Telemedecine use was less frequent for tumors and the increase noted between the studied periods was not significative (15% vs. 18%).

Evolution of transfers

Transfers have decreased for all pathologies since the creation of the network and had been divided by half through the first period (Fig. 5). The difference between the studied periods is statistically significant. During the same period, savings done by keeping patients on site were estimated to be 3.5 million euros (42 million USD).

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Fig. 5.

Transfers evolution.

Discussion

The increased use of our telemedicine system illustrates the need of neurological expertise in our rural region. The need is due to the high frequency of neurological emergencies up to 14% in Moulin's work and also the global lack of physicians in rural areas. ^{7,8,11 –18} The high use of the system for stroke patients can be explained by the high prevalence of stroke. Recent estimations indicated that the global prevalence rate was 5 per 1,000 person‐years, corresponding to 33 million people living after a stroke. ^{19 –21} Functional outcome of stroke patients can be enhanced by the thrombolysis if given within 4H30. ²² But this first curative treatment must be delivered by physicians specialized in stroke. Indeed, European and French approval of alteplase in acute stroke restricts application of treatment to physicians who are experimented and trained in neurological care. ²³ This neurovascular expertise can be given by telemedicine with the same clinical reliability and also the same efficiency and security. ⁸ At the beginning of our network, thrombolytic therapy was provided only in 0.6% of patients. In 2015, 9.9% of the patients admitted for stroke underwent thrombolysis. This enhancement was also found in previous studies but the rate of alteplase administration could probably be improved as shown in the Houston paramedic and emergency stroke treatment (HoPSTO) experimentation. ^8,9,24 The main findings of our 14-year experience of telestroke are the improvement in thrombolysis service and the large assessment to neurovascular expertise offering state-of-the-art acute stroke care.

Head injuries were the second most frequent reason to call in our experience. It can be explained by the frequency and the potential severity of this pathology. In fact, injuries are a leading public health problem worldwide; accounting for an estimated 10% of global mortality rate and in remote regions, the lack of equipment, insufficient personnel, or technical resources contributes to a less than optimal environment for acute injury management. ^25,26 In our work, ∼30% of patients admitted for head injury required a neurosurgeon expertise. This expertise based on clinical findings and neuroradiological information facilitated immediate decision-making. The consequence was a dramatic decrease of transfers since the deployment of the system. These observations were the same in other experimentations and no significant changes in mortality rate in the nontransferred patients were noted. ²⁵ The decrease of transfers noticed in our work induced obviously a cost reduction. This was also demonstrated in other drip and ship model networks. ^{26 –29}

This study has a few limitations. Our single network represents prospectively collected registry data. Therefore, selection and coding biases as well as data collected errors cannot be excluded. The analysis of secondary transfers is based on the recommendations of the physicians providing telemedicine consultations. These recommendations may not have been applied and some patients may have been transferred to other hospitals. Nevertheless, the lack of hospital in the region reduces this risk. The outcome of nontransferred patients is not known. Patients' and users' satisfaction were not taken into account.

Conclusion

The teleneurological emergency network RUN-FC is a model of mutualized regional network implemented for 14 years. This study illustrates the use and the effects of that kind of network. It may be informative for future experimentations since stroke management nowadays might require neurological, neurosurgical, and neuroradiological expertise.