Telemedicine As A Unique Intervention

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The brain attack coalition (BAC) and more recently the American Heart Association have offered consensus guidelines for criteria designating a primary stroke center, including acute stroke teams, stroke units, written care protocols, an integrated emergency response system, around-the-clock availability, and interpretation of computed tomography (CT) and rapid laboratory testing.3,12 However, a recent U.S. survey revealed that less than 10% of hospitals met the BAC criteria for a primary stroke center, although 75% of responding neurologists, neurosurgeons, and emergency physicians believed that their own hospital did meet guidelines. This disconnect is not trivial; a community hospital in suburban Maryland is among many to have implemented guidelines, increasing the proportion of patients safely treated with IV rt-PA.13 Implementation of BAC guidelines in New York State improved the frequency of rt-PA delivery, decreased protocol violations, and shortened pretreatment latency.14

If a community hospital cannot provide the radiological and clinical stroke expertise to meet these guidelines, participation in a TeleStroke network may help a hospital to meet guidelines for stroke center designation. As a TeleStroke-networked stroke center, a community hospital can seek to increase the access to and appropriateness of rt-PA delivery, reducing peristroke complications without the costly addition of equipment or personnel. Triage, evaluation, and treatment at local centers prior to transportation would provide rapid management with an efficient use of resources. In a fraction of the time that sick and unstable patients can travel to a center of expertise, telemedicine collapses the boundaries of time and space to permit the expertise itself to travel instantaneously over great distances. Telemedicine-enabled support for the delivery of IV rt-PA to patients had its first success in patients with myocardial infarction; rapid delivery of rt-PA to patients in rural Greece was enabled after the history, physical examination, and an electrocardiogram were reviewed by telephone and fax by physicians in Athens. Door-to-needle times were 20-30 minutes.15

The telemedicine-based evaluation of acute stroke is especially challenging. It requires a rapid neurological assessment, CT image acquisition and review, and a detailed history for rt-PA exclusion criteria. Low-cost teleradiology systems are now available for the transmission of compressed CT images viewable on a conventional personal computer (PC) monitor, in accordance with published standards.16,17 The decreased cost of professional videoconferencing equipment can now empower a physician with clinical and imaging stroke expertise to conduct a remote history, physical exam, and radiological interpretation in real time for the purpose of diagnosing and managing patients with stroke symptoms.18

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