Safe rt-PA Administration for Ischemic Stroke During Telemedicine Consultation
Background: Telemedicine (TM) is emerging as a time-saving, efficient means for acute stroke evaluation. Absence of a local consulting stroke physician, and short therapeutic time window make TM an ideal alternative for providing patients at remote facilities optimal care. We describe our stroke treatment center (STC) experiences and report safety of rt-PA administration during TM consultation. Methods: The University of Maryland Medical Center (UMM) uses VTEL TC2000 units with triplexed ISDN line providing 30 fps video link to St. Mary’s Hospital, >100 miles distance. The Millard Fillmore Gates Circle Hospital (Gates) uses Sony TriniCom 3000 Plus Model 256 units with ISDN line at 256 Khz, linked to Millard Fillmore Suburban Hospital, 15 miles distance. An additional unit links to the stroke neurologist’s home. Both systems use pan, tilt and zoom camera with remote site control allowing two-way, realtime, audiovisual communication and CT transfer. Results: 2/18 patients received rt-PA during TM consultation with the UMM Brain Attack Team and 3/12 by the Gates stroke specialist. Two were treated from the home link, and three via ED to ED transmission. Transport to the consulting STC occurred after completion of lytic therapy in 4 cases; in 1 case transport occurred during treatment. 4 out of 5 patients had excellent recovery defined as NIHSSS ≤1; 1 patient initially improved, but later had clinical symptoms of reocclusion. No patient experienced complications. Remote ED staff enthusiastically request TM consultation because of 1) ease of adaptability to clinical and technical procedures, and 2) immediate two-way audiovisual access to stroke specialist. Patients and family members rate the TM experience highly at post-consultation interview. Conclusions: TM consultation increased rt-PA administration from 0% to 6%, and provided treatment options not previously available at the remote hospitals. Administration of rt-PA during TM consultation was safe and effective and the system was well-received by clinicians and patients. Lack of reimbursement for TM services will hinder widespread adaptation of this exceptional technology for remote acute stroke treatment.