At 9:50 PM, a man relaxing at home has a sudden, severe headache, and starts to slur his words. At 9:53 PM, his wife calls 911. At 10:13 PM, the ambulance arrives, and by 10:19, they are en route to their regional community hospital, 20 minutes away. At 10:42 PM, the patient is wheeled into the emergency department. The ED team rapidly determines that stroke is likely. At 10:55 PM, they send the patient for a CT scan. Then they call the MGH TeleStroke Center. Time is brain.
“There has been a fundamental transformation in the way intravenous tPA is delivered in this country,” according to Lee H. Schwamm, MD, Director of TeleStroke and Stroke Services at Massachusetts General Hospital. He’s talking about tissue plasminogen activator, the thrombolytic agent that has become the standard of care for ischemic stroke. “We now give almost three times as much tPA over our TeleStroke network as we do for patients arriving at the doors of MGH.”
At 11:02 PM, the ED doctor is in a video conference with the MGH stroke specialist. Together they perform a brief neurologic exam on the patient. The patient’s medical history and current medications are uploaded and the team discusses their implications. At 11:12 PM, the stroke specialist receives the brain image files, and begins to evaluate them.
Through the TeleStroke network, 30 emergency departments across the northeast have real-time access to stroke experts 24 hours a day, seven days a week. The videoconferencing system, which Dr. Schwamm describes as “Skype on steroids,” brings the expertise of the MGH staff into the emergency room whenever and wherever it is needed. “We are probably the largest continuously run academic TeleStroke center in the country, probably the world,” he says.
At 11:15 PM, the patient has a diagnosis: acute ischemic stroke affecting the left frontal lobe. The stroke specialist recommends administering tPA, and the ED physician orders the treatment. At 11:20 PM, 90 minutes after his first symptoms, the patient receives the treatment. Time is brain.
Stroke is among the top four killers in the United States, and the leading cause of major preventable disability, but it is financially impractical for many regional and local hospitals to maintain the stroke expertise they would need for around-the-clock coverage. Providing that coverage, and access to consultation with a world leader in stroke care, is the mission of the TeleStroke center.
“At first, hospitals may be a little threatened by the idea,” Dr. Schwamm says, over fears of losing control and revenue. “But then they realize we are not taking over. We can set up the program to have the local neurologist called first, or for us to only provide coverage at night. We are there to backstop them.” When a hospital joins the program, the center works with physicians, administrators, and IT personnel to make sure it works right out of the box, and that staff receive the training they need to make it run smoothly before the first patient arrives.
The TeleStroke system at MGH, and similar programs like it nationwide, has meant that thousands of stroke patients have gotten life-and function-saving treatment that they might not otherwise have received. “But there are still far too many hospitals that don’t have 24/7 coverage for acute stroke evaluation and thrombolysis when indicated,” Dr. Schwamm says. “Our job is not done.” Dr. Schwamm is leading efforts to standardize software programs and other systems to make the adoption process even smoother, and is engaged in education and quality improvement efforts for both the stroke centers and the local hospitals. “We believe the very best care is based on geographic networks of hospitals, from acute stroke-ready centers to primary stroke centers and up to comprehensive stroke centers, providing a seamless escalation of care as needed for patients. That involves education, team-building, and dialog between all the users.”
The next phase in remote neurology care will move beyond stroke, he says. In a project launching soon, neurosurgeons will be available to offer expertise in evaluation and treatment of newly diagnosed brain tumors. And the center is exploring the concept of providing general neurologic consultations to patients with other types of neurological problems. “These programs have the potential to address disparities in access to neurological expertise, and to shorten the time to evaluation for the patient,” Dr. Schwamm says. “We see that as part of our mission here at MGH.”