A Telestroke of Genius
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The scenario goes something like this: A patient with stroke symptoms presents to the emergency department of a hospital that lacks comprehensive stroke-care capabilities. The miniscule window for administering the clot-busting drug tissue plasminogen activator (tPA) is quickly shutting, and without the help, knowledge, or expertise of a neurologist—or detailed training in this specific type of care—the ED physician must decide: Is the patient’s stroke ischemic or hemorrhagic? Will tPA save her life?
Stroke rounds out the top three causes of death in the United States, falling in behind heart disease and cancer. That’s partially because, according to the American Stroke Association, a division of the American Heart Association, only 5% of people who arrive at a hospital with strokelike symptoms make it there in time to be considered for tPA. On top of that, tPA is complex.
The intravenous drug only helps patients suffering from ischemic stroke (and can pose danger to patients with hemorrhagic stroke), it’s difficult to administer, and it’s effective only when given during the appropriate period of time. When the Food and Drug Administration approved tPA in 1996, the limit was three hours from symptom onset. In 2009, the AHA upped that to 4.5 hours. But an extra 90 minutes helps little if the physician looking at the brain scan doesn’t feel comfortable labeling a patient’s stroke as ischemic or hemorrhagic and has no expert to consult.
“For most hospitals, it’s not practical for a neurologist to give input” under these circumstances, says Lee Schwamm, MD, director of telestroke and acute stroke services at 900-staffed-bed Massachusetts General Hospital in Boston. “It falls back on the emergency physician to make the decision.”
To alleviate this burden, more hospitals are turning to telestroke, becoming a hub (the facility offering services) or a spoke (a smaller facility utilizing them) in the wheel that is stroke care. What each hub offers will depend on the spoke facilities’ needs, but typically includes round-the-clock neurology consultation and remote treatment of stroke patients via teleconferencing. “If I can see the patient and I can see the scan, I can make a really useful recommendation,” Schwamm says. “Otherwise, I am simply repeating back what they could’ve read in the literature.”
It’s a care model gaining traction as hospitals innovate to fill their beds, build relationships with nearby institutions, give smaller hospitals the ability to treat stroke patients, and most important, provide better overall stroke care. “Telestroke is such a perfect storm,” Schwamm says. “All the pieces are there. The pieces missing are image interpretation and the expertise. [Telestroke] eradicates the barriers to providing evaluation and treatment.” Sounds great, but a successful telestroke program requires planning, cooperation from the right people, and a host of other pieces falling into place.
Success Key No. 1: Leadership and cooperation
Incorporating a partnership program such as telestroke into an already established hospital, whether as a hub or a spoke, requires physician openness, both in accepting the program’s basis—offering guidance to or taking help from another facility’s doctors—and learning its logistics. When one of the hub’s doctors becomes a program champion, colleagues there and at spokes fall in line more easily, says Nicholas J. Okon, DO, a stroke neurologist and neurohospitalist at Providence Brain Institute in Portland, OR, part of the Providence Health & Services network. “There’s a clinical person needed to help arrange the services and meet with providers in outlying areas,” he says. Once there, the representative outlines the program and the partnership.
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