Page 29 - Delaware Medical Journal - July 2017

TELEHEALTH
TABLE 3: General Inclusion Criteria for tPA
Age 18 years or older
Onset of neurological symptoms is less than 3 hours from last seen normal
Clinical suspicion of acute ischemic stroke with measurable neuro- logic deficit
Patient or family member educated to the risks and benefits of tPA
DEVELOPMENT OF A STROKE TELEMEDICINE PROGRAM

of rapid treatment of stroke patients
with tPA along with the development of sophisticated endovascular intervention fostered our realization that improvements in neurologist response-time was of
the utmost importance. Kent General
and Milford hospitals do not have 24/7 in-house neurologist availability, so the neurologists at CNMRI stepped in to develop a full-time telemedicine program for stroke. In spite of the University of Pennsylvania experience, Bayhealth hospital administration was initially reluctant due to concerns regarding the evaluation of patients remotely along
with fears that other specialties would want similar “remote privileges.” With support of the Bayhealth Medical Staff, and early experience has revealed that we could shave 20 to 30 minutes off the “door to needle time” for the administration of tPA, especially for patients that came in after hours.
TELEMEDICINE STROKE PROTOCOL
Upon arrival of a potential stroke patient in the emergency room, the on-call neurologist is contacted immediately
and if not physically available, has the option to institute a telemedicine session. Initially, the neurologist will discuss
the case with the emergency medicine physician and a stat CT scan of the
brain is performed. A CT angiogram
may also be done initially if clinically indicated. After the CT scan is completed, a telemedicine session is set up with
nursing assistance and a history from the patient and family is obtained. A brief physical exam and NIH stroke scale is then completed. If clinically indicated, and there are no contraindications, tPA will then be administered immediately (see Tables 3 and 4 for inclusion and exclusion criteria.) The dose of tPA is 0.9 mg/kg (maximum dose 90 mg) with 10 percent given as an intravenous bolus over one minute and the remainder infused over one hour.
A CT angiogram to rule out large vessel thrombotic disease will be obtained for patients who have an NIH stroke scale of equal or greater than six. If a thrombus is detected, the patient may be transferred
to Christiana Hospital for endovascular intervention.
The Telestroke program at Bayhealth
has become increasingly utilized over
the last several months resulting in more timely evaluation of patients with acute stroke. The program has been successful especially in improving our “door to needle” time for the administration of tPA and markedly improved patient care.
CONTRIBUTING AUTHOR
ROBERTJ.VARIPAPA,MDistheChairmanof the Department of Medicine at Bayhealth Medical Center, Kent Campus in Dover, Del. and CEO and President of CNMRI, PA in Dover and Milford, Del.
TABLE 4: General Exclusion Criteria for tPA
Intracranial hemorrhage
Active bleeding at a non-compressible site
Acute major trauma
Intracranial, intraspinal surgery or serious head trauma within three months
Clinical presentation suggestive of subarachnoid hemorrhage
Arterial puncture at a non-compressible site or lumbar puncture within seven days
Current use of oral anticoagulants
Uncontrolled hypertension
More than 4.5 hours from last known well
Del Med J | July 2017 | Vol. 89 | No. 7
221