Early in the morning on Thanksgiving day, Susan Evans, 70, had a stroke. Turning on the TV, she saw not one, but two identical TV weather forecasters stacked atop each other. Nausea and dizziness followed. Lurching to the phone, she called 911, and soon found herself in the emergency department at the Yale-New Haven Hospital Saint Raphael Campus. With Evans’ permission, the physician on duty rolled a computer monitor and camera to the foot of her bed, and a Yale stroke specialist appeared on the screen and began to talk to her.
Hooked to a secure, high-speed data connection, that camera is a 24/7 link to the nationally recognized Yale-New Haven Hospital Stroke Center, and part of a larger “telestroke” system that includes eight partner hospitals. The system allowed Joseph Schindler, M.D., a Yale Medical Group board-certified vascular neurologist, to examine and diagnose Evans immediately from a remote location, then make a fast treatment decision.
“Dr. Schindler literally watched me having the stroke,” Evans recalled.
Telestroke expansion is timely
Yale’s program now provides ’round-the-clock remote-link stroke consultations to Lawrence and Memorial Hospital (New London), the first hospital to join in 2008; Griffin Hospital (Derby); Manchester Memorial Hospital; Middlesex Hospital (Westbrook); Milford Hospital; Rockville General Hospital; Sharon Hospital; and the YNHH Saint Raphael Campus. There are plans to expand to Rhode Island this year.
The program has been a great success at L&M, with data showing a 90 percent increase in the rate of IV tPA administration after the telestroke service was launched, Dr. Schindler said. Clot-busting tPA is the only FDA-approved stroke medication.
The cooperative and growing stroke-care effort is timely. Stroke is a leading cause of death in Connecticut. Between 2010 and 2013, Connecticut added some 39,000 residents over the age of 65. It is this age group, Connecticut’s half-million elderly, in which three-fourths of strokes occur.
Why speed is so important
Ten board-certified Yale vascular neurologists assess eight to 12 patients per month at the eight hospitals using high-definition videoconferencing equipment and image-sharing technology. Many of these patients turn out to be experiencing true strokes, some with such common symptoms as sudden facial droop, arm weakness or speech difficulty, and others with less common symptoms like Evans had.
Speed is key, because when stroke hits, the clock starts ticking, and every minute is precious. The medication tPA must be given within four-and-a-half hours of the onset of symptoms. Not all patients are right for the drug, and deciding who is eligible isn’t easy, particularly for nonspecialists. Staffing community and rural hospitals with on-call neurologists is difficult. “Telestroke has been a great way for us to help patients who otherwise were not getting the proper acute care,” said David Greer, MD, director of the Yale-New Haven Stroke Program.
When paged, a Yale stroke specialist goes immediately into action. Turning to a dedicated hospital or home terminal, he or she connects to the partner hospital’s terminal via a state-of-the-art data port. For partner hospitals, the process is easy, said program coordinator Karin Nystrom, MSN, APRN. “We just ask [them] to make sure the monitor is on and at the foot of the bed.”
The Yale specialist follows the event closely and gives instructions. “You can imagine a video can really paint that clinical picture,” said Schindler, who is the director of the telestroke program. It certainly did in Evans’ case. Schindler observed carefully as the emergency physician performed a neurological examination. He reviewed Evans’ CT scans and lab data, which he received electronically. Talking directly to Evans and her caregivers, Schindler diagnosed a brainstem stroke and recommended clot-busting medication.
Difficult decisions about tPA
Many stroke patients benefit from tPA, which must be given through an IV. However, tPA can be a double-edged sword. Although it can reverse deficits like paralysis and speech loss in some patients with ischemic stroke, it can also cause hemorrhage in the brain. Minimizing that hazard without missing opportunities to treat depends upon a fast, highly detailed assessment of the patient.
For Evans, tPA was crucial. Hours after she began receiving the medication, most of her symptoms cleared up completely. She was back to work less than a week later. “I’m very, very impressed,” Evans said. “To have a neurologist right there, and for them to know they could give me that tPA because I was well within timeframe—what more can you ask?”
Evans can’t imagine a patient declining a telestroke evaluation. “To have that monitor there, to me, was worth its weight in gold,” she said.
To contact the Yale-New Haven Hospital Stroke Center, call 203-737-1057.