As the COVID-19 epidemic is making neurological emergencies harder to treat--and potentially more dangerous for the patient--neurology providers at Duke’s three hospitals are rising to the challenge with robots, iPads, and an unprecedented level of collaboration.
The patient in Durham Regional Hospital was unresponsive to questions. The ambulance had brought him into the emergency room with meningitis, or inflammation around the brain--as well as symptoms that could have been caused by COVID-19.
Now, with the patient’s condition worsening, neurologist Matthew Ehrlich, MD, MPH, had to weigh the risks and benefits of examining him in person.
Were the benefits of confirming the patient’s earlier signs of seizure with an EEG worth the risk of possibly exposing an EEG technician (and possibly the rest of the hospital) to infection with the coronavirus? Could Ehrlich assess the patient’s condition using a virtual consult via an iPad or telestroke robot without exposing himself, or should he enter the room to give an in-person evaluation, opening an avenue for infection for himself, his colleagues, his wife, and family? And were the man’s symptoms due to COVID-19, or to any number of unrelated conditions, making all of these concerns irrelevant?
Like he had done many other times in the past few weeks, Ehrlich evaluated his limited information as best he could. An EEG was unlikely to alter the course of treatment for the patient, so that test could be postponed. On the other hand, an in-person neurological assessment would probably help Ehrlich decide on the next steps more effectively than a virtual consult. Ehrlich put on his mask and protective gear, and entered the room to see the patient.
Neurological emergencies were dangerous before the COVID-19 pandemic. Stroke, traumatic brain injury, severe seizures, and other conditions require a rapid, coordinated response by a team of experts. Emergency medical technicians, neurologists, advanced practice providers, emergency medicine doctors, imaging technicians, physical and speech therapists, and others all play a role in transporting patients, deciding on the proper form of treatment, and in beginning the long rehabilitation process.
The constant potential for COVID-19 transmission has disrupted the way hospitals respond to these emergencies. It may also be making these conditions more dangerous. Now, providers like Ehrlich have to decide how to provide treatment while also keeping our providers (and the hospital system) safe from infection. They’re making these decisions in close quarters, with limited supplies, without established procedures or guidebooks, and with our intensive care units more crowded than ever.
(Note: Do not hesitate to call 911 if you or someone you know is experiencing a heart attack or stroke. These emergencies require prompt medical care, and our hospitals are taking steps to make sure all of our providers and patients are safe. Delaying treatment increases the likelihood of early death or a permanent disability.)
Teams at Duke’s three hospitals have turned to a combination of technology and an unprecedented level of teamwork to rise to this challenge. Technology in the form of iPads and robots originally designed for telestroke visits, allow providers to interact with patients without ever having to come in close physical contact. And teamwork and communication, both within and across the hospital systems, allow the hospital neurology teams to share information and coordinate strategies in a situation that is evolving and changing on a daily basis.
The robot sitting in a corner
Over the past two months, office workers across the country have come to rely on teleconferences to connect with their colleagues. DukeHealth and other health systems have also accelerated their ability to provide virtual clinic visits. Hospital providers, however, can’t just Zoom in to a meeting with their patients.
To start, there aren’t enough desktop or laptop computers to go around. And in order to function and be safe, any teleconferencing device would have to be easily transportable, user friendly, and capable of being sterilized between users.
As it turns out, Duke Raleigh and Duke Regional Hospitals had been using equipment that fit all of those requirements for years. Both hospitals were already equipped with telestroke robots, or remote-controlled machines with two-way cameras. During night hours when a neurologist is not present, these machines allowed off-site neurologists to evaluate and treat patients who are having strokes.
Now, nurse practitioner Stacey Bennett, MSN, can give lessons about risk reduction, and answer questions about life after stroke without having to enter the same room as a potential COVID-19 patient. “We had previously only used the robots during off hours. During the day it just sat there in a corner. We took the initiative to use it to start talking to people.”
Other providers such as neurologists like Ehrlich, advanced practice providers, or speech or physical therapists, also use the robot interact with patients without potentially exposing themselves, their colleagues, or other patients to infection (a nurse or other caregiver who is already in the same room as the patient can help guide the robot and facilitate any provider-patient interactions).
The robots were especially useful during the earliest days of the pandemic, when masks and other protective equipment were in short supply, but they continue to be in use in both Duke Regional and Duke Raleigh Hospitals.
“These machines have made things safer for everyone while still allowing patients to get the care they need,” said Bennett. “We all feel really fortunate that we have it.” The Neurology team at Duke Regional has since supplemented their telestroke robot with eight modified iPads that allow provider-patient interaction via Facetime.
One of Duke Regional Hospital's eight modified iPads, nicknamed "Dr. K. Rona," allows patients and providers to interact without increasing the risk of spreading the coronavirus.
Working together, within and across Duke hospitals
More important than any technological advance, however, is the teamwork and communication that have allowed Duke’s providers to work in teams within and across hospitals to respond to this crisis.
Within Duke Regional, teamwork across service lines enabled the telestroke robot’s success. At first, every surface of the robot had to be thoroughly scrubbed and disinfected every time it went in and out of a room. This laborious process took nearly 10 minutes and potentially exposed a health-care worker to infection with every scrubbing.
Using draping equipment borrowed from Regional’s Surgery Department and under guidelines from their Infectious Disease colleagues, Bennett’s team were able to obtain sheeting that covered the robots and could be quickly replaced between uses.
The COVID-19 pandemic has also accelerated group trainings, communication, and shared standards of care for neurology care in Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital. This January, providers from all three hospitals held a hospital neurology summit to work together to identify problems, build on strengths, and find ways to help patients. This group was made of an inclusive group of providers, with advanced practice providers, stroke managers, and other experts as well as neurologists all taking part in the discussion.
“The summit really allowed us to ‘put a face to a name’ and identify as one team of neurohospitalists. We made a pledge to have each other's back and choose to work on things together.” said Bennett. “The goal became helping each other actually improve patient care instead of trying to get each other to be the same.”
Members of this summit from all three hospitals have stayed in touch throughout the COVID-19 pandemic, discussing how to protect themselves, how to deliver care at a distance, and ways that COVID-19 might influence what happens during a stroke or other neurological emergency. They’ve also undergone group trainings so that providers at one Duke hospital can cover colleagues at another if needed.
“We try new things together. We keep one another in the loop and let each other know how things are going. We are encouraging to each other. We respect our team members opinions and ideas. I have never felt more supported by my community as a healthcare worker,” Bennett said.
Ehrlich’s patient eventually tested negative for COVID-19. The patient did, however, have bacterial meningitis, an acute medical emergency, as well as a related infection in his bloodstream. Thanks to his prompt treatment, the patient was able to recover and has since returned home.
The steps Ehrlich takes to return home every day have evolved into a routine. He enters his house through the garage to prevent his dog or two-year-old daughter from jumping on him before he can strip, bag his work clothes and shoes, scrub his phone, keys, and wallet with Lysol, and hop straight into the shower. “It takes a while before I can go back to feeling like a human being again,” Ehrlich said.
Still, Ehrlich remains confident about his and his colleagues’ ability to provide care throughout the rest of the pandemic.
"The coronavirus pandemic has really shone a spotlight on the innovative, collegial, and collaborative nature of our stroke and neurohospitalist teams. Though we've sailed into largely uncharted waters over the past couple months, the incredible response from our Duke teams shows we can weather the storm, and continue to provide top-notch care to our patients during these difficult times," Ehrlich said.