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Wiring up hospitals to speedily treat stroke

Medicine@Yale, 2008 - Nov Dec


New telemedicine program helps emergency personnel in race against the clock

When Jeanne Munnelly went for a swim at a high school in East Lyme, Conn., one August morning, she had no idea she was about to have a stroke—or that she would make medical history in Connecticut.

At about 8:15, as she swam in the school’s pool, Munnelly became weak on her right side and unable to speak. Lifeguards pulled her out, and emergency personnel based at a fire station across the street arrived within five minutes. She reached New London’s Lawrence and Memorial Hospital in just 15 minutes.

That’s when Munnelly, 67, became the first patient to benefit from the Yale-New Haven TeleStroke Network, a program modeled on a similar initiative at Massachusetts General Hospital in Boston. The new network allows area hospitals to call upon Yale neurologists’ expertise in assessing stroke victims using Internet-based videoconferencing and image-sharing technology. Neurologist Joseph Schindler, M.D., evaluated Munnelly via computer from Yale-New Haven Hospital (YNHH), then gave the green light to physicians in New London to use the clot-busting drug tissue plasminogen activator (tPA). Munnelly received the drug only 37 minutes after reaching the hospital—much more quickly than if she had been transported to YNHH first.

Speed and decisiveness are critically important in treating stroke victims. Most blood clots that cause ischemic strokes can be dissolved by tPA, but this medication can also cause bleeding in the brain, a risk that significantly increases three hours after the patient’s first symptoms. To meet that three-hour deadline and try to prevent this complication, doctors must ensure that a patient is an appropriate candidate for tPA. Yet in most hospitals, neurologists are not always available to assist emergency physicians with the evaluation and treatment decision. As a result, many patients who might benefit from tPA do not receive it.

Schindler says the process of evaluating a stroke patient via TeleStroke is the same as when he sees a patient in YNHH’s emergency department. “It’s no different; it’s just the use of technology to do it remotely,” he says.

While seated at a computer 50 miles away from the patient, Schindler, the clinical director of the Yale-New Haven Stroke Center (YNHSC), used the center’s high-speed Internet connection to speak with the patient, family and clinical staff and to review Munnelly’s medical history, blood tests and brain scan. He also examined her using a camera with a zoom feature. She was, he determined, a good candidate to receive tPA, and shortly after receiving the drug, Munnelly regained the use of her right leg as well as some ability to speak.

Schindler, who is optimistic that Munnelly’s condition will continue to improve, was pleased not only that the technology worked but also that he and the team in New London could act so quickly. “We’ve done it at Yale when the entire team was already in the Emergency Department; we assessed and treated the patient in a similar time. But to have that done remotely, it’s wonderful.”

Lawrence and Memorial is Connecticut’s first hospital to link up to the YNHSC via the TeleStroke network. Both Lawrence and Memorial and the YNHSC have been designated Primary Stroke Centers by The Joint Commission (an independent, non-profit organization that accredits health care organizations in the United States), the Brain Attack Coalition and the American Stroke Association, a classification that recognizes an institution’s commitment to excellence in stroke management.

“The implementation of TeleStroke programs have demonstrated that telemedicine conferencing between outlying emergency departments and trained stroke neurologists can enhance the use of tPA at those facilities that do not have 24/7 access to neurological expertise,” says Schindler. “We are hopeful that more hospitals throughout Connecticut will join this vital lifesaving network.”

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