The Benefits of Telestroke Services at UPMC: Q&A with Rameen Shafiei, MD

When someone is having a stroke, getting care quickly is critical. The faster they receive treatment, the better chance they have of a positive outcome and recovery.

With UPMC telestroke services, people who may have had a stroke can receive a rapid diagnosis and treatment.

Telestroke is a system in which care doctors can contact an on-call UPMC neurologist if someone comes in with stroke symptoms. The neurologist can assess the person via video, view their brain scans, and give them a diagnosis. If a person is having a stroke, they can recommend treatment options — including clot-busting medications or even surgery.

UPMC telestroke is available 24 hours a day, seven days a week. It’s available at hospitals within the UPMC Stroke Institute network, which includes both UPMC and non-UPMC hospitals.

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In this Q&A, Rameen Shafiei, MD, director, UPMC Western Maryland Emergency Department, discusses telestroke services and how they benefit those who use them.

How would you describe to someone what telestroke is?

What makes telestroke unique is it allows us to offer a rapid consult on the floor, in the moment, for acute stroke care.

Normally, we would page our on-call neurologist, who might be on the floor rounding with patients or might be in the sleep lab doing a study, or who might even be in his clinic down the road 10 minutes away, and he has to step away from whatever he’s doing to call us. And usually it’s a phone call, so it’s difficult to assess the patient by word of mouth.

With telestroke, we’ve removed those barriers. We have a physician — a trained neurologist — who is on call, at the computer, ready for these phone calls. That is their only job that day. They’re not distracted with other services or other issues they might be dealing with. And they’re there via video chat, so they can rapidly assess the patient with us, with their own eyes, and use their judgment to help guide our care in the emergency department.

So, really, it’s a game changer.

Can you describe the process of telestroke if a patient comes in that you suspect is having a stroke?

We have two possibilities. A patient can either come to us via ambulance service, or they show up at our front door by private vehicle.

If they come in by ambulance service, our EMS and paramedic crews identify the stroke symptoms and call us ahead of time. So, we actually meet the patient at the door as they’re getting off the ambulance, and we assess them right at the ambulance bay.

We have the telestroke service on the line, and we relay our assessment to them. Then they patch in with the video call and they do their assessment, and we determine if that patient is a candidate for the medication, what we call TNK (tenecteplase).

That medicine has a very finite time window of success. It needs to be given within about three hours from when symptoms start.

A lot of times, patients wait 25 to 30 minutes before coming into the hospital, so our window of opportunity is even shorter. So, time is of the essence with all these patients.

If they come by private vehicle, it’s usually even more last-minute because they had their friend or family pick them up at their house and drive them. So, we have no warning. When they show up in our triage bay, our triage nurses do a very good job of identifying stroke symptoms and bringing that patient immediately back to the main ED, where we assess them and get telestroke services involved right away.

How does the actual call to telestroke services work?

They use an online portal. So, when we assess that patient, there’s a couple key points that we put into that program. We put in the last time they were known well before their symptoms started.

We give what we call an NIH Stroke Scale, which quantifies the symptoms of their stroke. We mention whether or not they’re on any blood thinners. And then we mention whether or not we feel it might be what we call a large vessel occlusion, which is when the patient’s symptoms are profound, involving an entire side of their body, which can be a warning sign that that patient might have a clot in one of the major blood vessels going to their brain, and they may even be a candidate for surgery to reverse their symptoms.

By punching in that information, the neurologist who’s on call with telestroke immediately knows right away, “Is this person a candidate for TNK?” And if they are, they can also see the results of our CT scans that we do in the moment.

And the neurologist on telestroke gets to visually assess the patient themselves?

They do, yes. We have a specialized stroke cart, which remains in our emergency department at all times. When the patient is a candidate for video assessment, we log in to that cart in front of their bed.

The camera and audio are immediately ready, and that neurologist can see the patient, and the patient can see them. So, they can guide the patient through their assessment, and sometimes we’ll help because certain things need to be done with the bedside assistance of a nurse or a physician.

So, usually, we’re all in the room during the video assessment, and it’s like [the telestroke neurologist] is right there with us.

And you mentioned they also can view any scans?

Correct. Being part of the UPMC system allows us to share our data instantly. So, they can log in and see the CT as it’s being done. Many times, they’re telling me the results before my own radiologist has even seen the study, which is fantastic.

As you can tell, it shortens the time interval it takes to make that decision to give the medicine by minutes to hours, and that can be the difference. Sometimes, patients arrive to us with 20 minutes to spare before the clock runs out.

And this service is available throughout the UPMC network?

Yes, and I believe they’re integrating more and more facilities as they’ve found the benefit of this service.

I think traditionally, when people think about telehealth services, they think of rural medicine with minimal access. And that’s not the case with stroke. We have neurologists at our hospital who live in this town. But when it comes to stroke, you quite literally sometimes have only minutes to spare, and our neurologists are very busy.

The consultant service is extremely busy with other care that’s needed in the hospital. So, by allowing strokes to go specifically to this one service, it frees them up from that burden and allows our patients the best likelihood of rapid care.

The saying is that “time is brain” when it comes to stroke. How important is the rapid care that telestroke provides?

Very important — because every moment that goes by is more neurons lost to the injury. In an ideal scenario, we would go back in time and keep the injury from ever happening. Unfortunately, we don’t have that power yet, so all we really can do is try to stop any further damage as quick as we can.

Obviously, the faster we are at that, the more brain that is saved, the more neurons that will receive blood flow again and be able to heal from the stroke. But the longer it takes us — even if it’s only an extra 20 minutes or a half-hour — that’s more area of the brain that will succumb to permanent injury.

The goal of administering this medication within three hours helps improve their morbidity and mortality from their stroke upwards of 30% to 60% in some cases. If you miss that three-hour window, you essentially are powerless to do much else, unless they have one of those vessel occlusions that maybe they could be a surgical candidate.

A lot of stroke patients are not surgical candidates, so if they don’t get to us within those three hours and we don’t intervene, we’re essentially stuck with giving them aspirin and Plavix and starting rehab. Which, as you can imagine, won’t do much to reverse the damage. It’s just trying to help that patient learn to walk again, learn to speak again, or whatever other deficits they’ve suffered. So, that first three-hour window is so crucial.

You’ve mentioned the medication TNK. Is it a blood thinner?

It’s a little bit different than a traditional blood thinner. It actually breaks down clots that have already formed. We call it a fibrinolytic; it actually actively works against the enzymes that are trying to stabilize a clot that’s already in the body.

So, when we administer it, it very rapidly starts to initiate the cascade that allows the body to dissolve that clot. … In stroke care, it is the mainstay in treatment because once administered, it rapidly works to dissolve any clots that are present in the body.

As you can imagine, that does introduce a variable where patients could potentially start bleeding. The good news is TNK has shown less likelihood of spontaneous hemorrhaging, especially in patients who are not having a stroke.

The risk of a spontaneous bleed or a random bleed from the medicine is much smaller with TNK than some of the other versions that are out there. But it is a very active blood-clot-busting drug.

What are the benefits of telestroke to those who use it?

The biggest benefit is the rapid onset of care. You’re at the bedside with a neurologist within five minutes of arrival, which is almost unheard of for any specialty consultant service.

The other benefit, really, is you’re getting expert care. You’re getting treated by a physician who’s seeing this every day.

They’re seeing hundreds of cases every month and can work through the nuances of certain presentations. Because not all stroke symptoms are cut and dry, and not all patients who present with stroke symptoms are having a stroke.

And so, when you have someone who is not only trained in stroke care but is interacting with stroke patients every single day at such a large volume, they become experts at what they’re doing and what they’re assessing. That benefit to our patients is priceless.

What should people in the community know about telestroke?

We rolled out our program in early February, and we’ve been doing our best to advertise to the community.

The feedback I’ve been getting from patients who have had to go through the system, or from family members who have been involved with their loved ones, has been nothing but good feedback as to how quickly we’ve been able to intervene. The rapport of the physicians who are on the telestroke hotline have all been fantastic — very good bedside manner, very good speaking on the phone with my colleagues and with our families.

What I’m trying to hammer home when I talk to families and to my friends in the community is we’re bringing a service into our area that we’ve never had before. And this is a huge benefit to them and their loved ones.

If you or a loved one is showing warning signs of stroke, don’t wait to get care. Call 911 or visit the emergency department right away.

For more information on UPMC telestroke services, visit our website.

About UPMC

Headquartered in Pittsburgh, UPMC is a world-renowned health care provider and insurer. We operate 40 hospitals and 800 doctors’ offices and outpatient centers, with locations throughout Pennsylvania, Maryland, New York, West Virginia, and internationally. We employ 4,900 physicians, and we are leaders in clinical care, groundbreaking research, and treatment breakthroughs. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside as one of the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. We are dedicated to providing Life Changing Medicine to our communities.