The American Heart Association and the American Stroke Association have awarded their Gold-Plus Quality Achievement Award to Northwell Health’s Long Island Jewish Hospital in Valley Stream for work in pioneering the use of telemedicine to treat strokes and other cardiovascular disorders.
Telemedicine allows doctors to remotely diagnose a patient with video cameras and telemetry equipment.
In addition, the hospital received the associations’ Stroke Elite Honor Roll Award for meeting quality measures in the use of tissue plasminogen activators, clot-buster medication that is effective in the treatment of some strokes.
According to Dr. Rohan Arora, director of Northwell's stroke program at LIJ Forest Hills, one of the program’s advantages is that it enables the hospital to maximize its small number of stroke specialists. “It’s also a tremendous help for areas that are underserved,” he said.
Northwell’s Telestroke program is part of a wider telemedical effort based in Syosset. In addition to Telestroke, LIJVS has a growing electronic intensive care and telepsychiatry program. “LIJ Valley Stream has a very large telemedical footprint,” Dr. Saurabh Chandra, the electronic ICU program director, said.
“Currently, we have five Tele-stroke doctors, one of whom is on call at all times,” Arora said. “When a patient is coming in, we get alerted. Every minute counts. Each minute that goes by costs 2 million neurons,” he said. “Telestroke saves time. That’s the No. 1 takeaway.”
Telestroke not only improves survival in stroke victims, Arora said, but also helps lessen the long-term effects, including paralysis, and loss of motor abilities or cognitive function.
With some types of stroke, clot-busters are given — tissue plasminogen activators, or tPA — which break up the clots that impede normal brain function. TPA is the only FDA-approved drug for the treatment of clots, Arora said. “It’s really the gold standard for the early treatment of clotting.”
In cases in which tPA cannot be used, a team is on standby, ready to perform surgery. “TPA can be used in only about 30 percent of stroke patients,” Arora said. Patients who cannot take tPA include those with any kind of bleeding, those who are taking blood thinners or those with irregular heartbeats.
“If tPA cannot be used, we thread a small device that looks like a tiny mesh through a blood vessel in the groin,” he said. The process, which is similar to an angiogram, enables the surgical team to capture and remove the clot. The procedure takes about 35 to 40 minutes, he said.
Thirty to 50 percent of stroke patients improve immediately under this combination of tools and have generally improved outcomes.
“Stroke can affect anyone,” Arora said. “That is, nobody is too young. No one is excluded on racial or ethnic grounds.” The main determinants are genetic, dietary and lifestyle factors. “High blood pressure or cholesterol, obesity and, obviously, smoking all greatly increase the risk. We can’t do anything about family, but we have some control over the other areas of our lives,” he said.
“Twenty years ago, our treatment of stroke was mostly reactive,” Arora said. “We knew about the factors that caused strokes, but we didn’t have the ability to remove clots. I just treated an 89-year-old woman. She has an excellent prognosis.” Twenty years ago, she would have likely had lasting impairment or even died, he said.
The main side effects of tPA are bleeding in the brain or, more rarely, in other parts of the body. Some patients may also experience allergic reactions, Arora said.
The first step in Telestroke is a CAT scan, followed by a visual examination, Arora said. Experienced stroke specialists can tell much simply by watching the patient. After the visual exam, doctors use a split screen similar to Skype to compare and contrast visual data with the results of a the scan.
According to Chandra, 130 rooms at eight Northwell hospitals are hard-wired with cameras for telemedical evaluation. The cameras are mobile to provide a variety of views and have extremely high resolution. It’s possible to examine the pupils of the eyes, for example, he said. The e-ICU program incorporates a wider range of specialties and currently has a staff of 20 doctors. “All the critical-care physicians at LIJ Valley Stream are linked to telemedicine systems,” he said.
“Physicians can’t be in every room,” Chandra said. “During their off hours, we monitor everything and make a plan with the bedside provider.” Doctors working in Syosset can get all the information from patients’ rooms, assess their current needs and contact providers on the hospital floor — or even at other sites.
Doctors are considering rolling out telemedicine more widely throughout the Northwell system and are evaluating providing the service outside of Northwell, according to Chandra.
As with Telestroke, the biggest advantage of the e-ICU is the ability to respond rapidly and with optimum care, Chanra said. “The result is a better outcome for most patients and a decrease in the number of readmissions.”
Arora said he became interested in stroke during his medical training in India. “South Asians are four times as likely to suffer from cardiovascular diseases,” he said. While India has high-quality health care, it doesn’t have the same level of emergency care or the same number
of emergency medical technicians as
in the U.S.
Specialists in the Telestroke program undergo a year of intensive training, Arora said.
According to Arora, many people suffer mini-strokes. These attacks often go unnoticed or aren’t taken seriously. Often, they leave no lasting damage, because the body breaks up the clots on its own. Such attacks can indicate a predisposition to stroke, however, and may be a warning sign of bigger events to come, Arora said.
He stressed the importance of having a good primary care physician who is “thoroughly familiar with every aspect of our health.” Family members and friends should also be aware of any health issues, he said. “This is especially important for those of us who live alone.”
Arora reiterated that the most important thing people can do to reduce the risk of stroke or other cardiovascular illness is to stop smoking. “It is the No. 1 risk factor,” he said.