Teleneurology-Enabled Determination of Death by Neurologic Criteria After Cardiac Arrest or Severe Neurologic Injury

Abstract

Objective:To determine if providing teleneurology (TN) consultations aiding in determination of death by neurologic criteria (DNC) to a bedside intensivist is feasible; and whether timely access and expert input increases the quality of the DNC exam and identification of potential organ donors, we reviewed retrospective data related to outcomes of such consultations.Methods:Between March 2017 and April 2019, TN consults were requested for sequential ICU comatose patients. We recorded patients’ demographic information, causes leading to coma or suspected death by neurologic criteria and the results of TN consultations. We obtained data regarding the number of referrals to organ bank and number of organ donors.Results:Ninety-nine consults were performed with a median time from request to start of the consult of 20.2 minutes (IQR 5.4-65.3 min). Eighty consults were requested for determination of prognosis, whereas 19 consults were requested for supervision of the DNC examination. In 1 of 80 (1.2%) prognostication consults, the patient was determined by the neurologist to require assessment of DNC and was found to meet DNC criteria; determination of DNC occurred in 11 of the 19 (57.9%) consultations for supervised DNC exam. When comparing pre (94 months) and post teleneurology (17 months) periods, there was 2.56-fold increase in the proportion of patients meeting DNC criteria who were medically suitable for donation (pre-TN 8.9% vs. post-TN 21.1%, p=0.02) and a 2.12-fold increase in the proportion of donors (pre-TN 6.14%, vs. post-TN 13.1%, p=0.14).Conclusions:It is feasible to perform TN consultations for patients with severe neurologic damage and to allow expert supervision for DNC examination. Having a teleneurologist as part of the ICU assessment team helped differentiate severe neurologic deficits from DNC and was associated with increase in organ donation.

Digital Health for Oncological Care

“…Although this model emergently connects stroke consultants with bedside referring providers in emergency departments, the peer-to-peer model has been successfully used in non–acute care settings such as in clinics and inpatient wards. In the latter, it seems to increase specialty care access and reduce length of stay, or provide expert assessments for the determination of brain death and facilitate organ donation 38,39 . The success of the telestroke model hinged on quickly conveying high-yield stroke-relevant information from the spoke to the hub provider, which includes a rapid stroke-focused examination and expedited capture and transmittal of brain computed tomography images, both of which are key aspects of acute stroke therapeutic decision-making.…”

Neuroethics in the Era of Teleneurology

“…In perhaps the most consequential area of neurologic diagnosis, access to teleneurology services has been found to facilitate more timely diagnosis of death by neurological criteria/brain death and earlier determination of suitability for organ donation. [120][121][122] While preliminary results have been promising, further regulatory and ethical guidance is needed to inform appropriate, consistent, and guidelinecongruent utilization of teleneurology in the remote diagnosis of brain death.…”

TeleNeuroICU: Expanding the Reach of Subspecialty Neurocritical Care

“…2 ). 20 Furthermore, evaluation of comatose patients virtually assisted by neurointensivists can both identify the treatable and reversible cause of coma and recognize undiagnosed cases of brain death, which otherwise would result in potential loss of viable organ donors. Additionally, TeleNeuroICU consultations have the potential to help bridge the gap in underserved areas without access to neurointensivists.…”