Telemedicine May Open tPA's Window

SAN DIEGO — Physicians in rural Georgia are achieving the optimal window for administration of tissue plasminogen activator to stroke patients thanks to a telemedicine network spearheaded by the Medical College of Georgia, Augusta.

Known as the Georgia REACH Telestroke Network, the setup involves the use of phone consultations, videoconferencing, audio recording, review of images, and other aspects of telemedicine delivered by a neurologist to physicians in rural hospitals who don't have the benefit of a neurologist on staff or on call when a stroke patient presents to the emergency department.

“The idea is that you're getting tPA [tissue plasminogen activator] use out to community hospitals or to sites where it would not be normally administered because there is a lack of expertise,” Dr. David C. Hess said at the International Stroke Conference.

According to the American Hospital Association, there were 2,003 rural hospitals in the United States in 2006. Of these, about half have fewer than 100 beds and most likely are not equipped to administer tPA to stroke patients, said Dr. Hess, professor and chairman of the department of neurology at the Medical College of Georgia.

“They are neurologically underserved. This doesn't just happen at rural or suburban hospitals; some of our urban hospitals in the United States don't give tPA and are outside the loop of up-to-date, quality stroke care. We can extend our expertise by using telemedicine.”

Other trends in the medical field are complicating efforts to provide optimal stroke care. Many emergency department physicians are reluctant to use tPA without the presence or guidance of a neurologist. “If they have a neurologist to help them with the decision making, they're much more likely to give it, but many neurologists are abandoning emergency department call altogether,” Dr. Hess said.

A decline of young physicians choosing careers in vascular neurology isn't helping matters. According to the Accreditation Council for Graduate Medical Education, in 2006–2007 there were only 32 physicians enrolled in vascular neurology fellowships in the United States, while 2,300 physicians were enrolled in cardiology fellowships.

Launched in 2003, the Georgia REACH Telestroke Network includes 10 rural hospitals located 30–200 miles from Augusta, with 10–191 beds at each location. To date, 156 patients with a mean age of 66 have been treated with tPA. More than half (56%) were female, 40% were African American, and their mean National Institutes of Health Stroke Scale score was 13.

The mean “door to needle” time was 80 minutes. Almost half (47%) were given tPA less than 2 hours after their initial presentation and 16% received tPA in less than 90 minutes. “For about every 2,000 emergency department visits in rural hospitals, we treat about one patient with tPA,” he said at the conference, which was sponsored by the American Heart Association. “There is no hospital too small to be helped.”

Dr. Hess noted that the old paradigm for stroke care in rural locations was ship and drip. The new paradigm “is drip and ship,” he said.

One key hurdle to developing a telestroke network for clinical stroke trials is obtaining informed consent from patients and their loved ones. “We could have Power Point presentations, video conferencing, or record the interactions for the consent, but I think the bigger challenge relates to pharmacy,” he noted. “One of the reasons we really can't start an experimental treatment in these hospitals is that there is no pharmacist in the middle of the night to mix up the experimental drug. This is going to be a major hurdle.”

He views telemedicine as an “early warning system” to identify potential clinical trial patients. “Enrolling patients from community sites into telestroke may allow faster dissemination of clinical results into the 'real' world,” he said. “Also, enrolling patients into trials via telestroke may allow us to treat and enroll more diverse patients.”

Dr. Hess disclosed that he is the cofounder of Reach Call Inc., and is on the speakers bureau of Genentech and Boehringer Ingelheim.