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The evaluation and treatment of acute ischemic stroke in the emergency department is a time critical event whose success requires the evaluation of the symptomatic patient by a stroke neurologist at the bedside. Certain treatment modalities (TPA/Activase) must be initiated within three hours of the onset of symptoms. Most hospitals do not have a stroke neurologist in house 24/7 and therefore must rely on an on – call system where the physician is part of a call roster of specialists whose responsibilities include the treatment of acute stroke in the emergency department.

The administration of thrombolytics, in the appropriate clinical setting, for the treatment of acute ischemic strokes is now the standard of care in the emergency department. The failure to treat ischemic stroke with thrombolytics has now become a growing medical liability concern for physicians. If you work in a hospital or emergency department, you must provide all of your patients the capability to receive thrombolytic stroke treatment. Here is the dilemma. What do you do if you are a hospital that either does not have stroke neurologists or neurologists willing to commit to a time critical intervention process? The treatment must be provided or your patients will suffer and you expose yourself to medical liability.

At the Dr. P. Phillips Hospital Emergency Department (ED), we feel that tele-medicine has provided us with a solution. Utilizing the capabilities of tele-medicine, we can now provide immediate bedside stroke care by a fellowship trained stroke neurologist. The tele-neuro service is composed of a panel of stroke neurologists who provide remote consult services to our ED through the use of high-resolution cameras and broadband. The patient and patient's family are engaged with the neurologist through interactive real time cameras and monitors. The patient and neurologist speak and communicate with each other through the monitor. The neurologists are all members of our medical staff and therefore have access to all of the patient's clinical information. This information includes all laboratory and radiologic imaging as well as past medical history. All previous medical records and allergies are accessible to the tele-neurologist.

Upon arrival to the ED, all patients with symptoms suspicious for acute stroke are identified as "stroke alert" and immediately evaluated and stabilized by the acute stroke team. All lab work and radiological imaging is obtained stat, and after review by the ED physician, a decision is made as to whether or not this patient is a potential thrombolytic candidate based on defined Stroke Association criteria. If the patient is a potential candidate or if a neurology opinion is needed, consent is then obtained from the patient or family for tele-med services.

Once communications are established, the tele-neurologist interviews the patient and family. All lab and radiology findings such as CT are available for the neurologist to review. Currently, the system has no capabilities for a complete physical examination; however, the major components of a neurological examination are observational. The patient is asked to perform certain motor skills and with the assistance of a bedside nurse, the neurologist is able to determine the specific stroke syndrome. Throughout the entire session, the patient and neurologist, as well as the bedside staff, are visible to each other.

The tele-neurologist now has all of the information necessary to render an opinion as to whether or not thrombolytic therapy is indicated for this patient. The neurologist is able to speak directly to the patient and family in order to explain treatment options as well as answer any questions that they might have. Moreover, if thrombolytic therapy is indicated, the tele-neurologist is able to obtain informed witnessed consent for treatment. Specific orders as well as consult are faxed back to the ED and the appropriate treatment is initiated.

Our experience with tele-neuro in the treatment of acute stroke has been extremely positive. Patients and families are impressed with our ability to access stroke specialists in real-time and are not upset or intimidated by the remote access. Emergency physicians enjoy having the reassurance of immediate specialty back up for this high risk/high reward intervention. Moreover, tele-neuro has allowed the emergency physicians to feel that their medical liability exposure is now greatly reduced. Patient outcomes have been very satisfactory. We have experienced minimal thrombolytic complications because of the ability to access immediate specialty back-up. Most importantly, because of this immediate specialty access, we have substantially increased the amount of thrombolytic therapy that we provide, therefore, greatly impacting the health of the community that we serve.


Jeffrey Backer, MD, is the Chief Medical Officer at Dr. P. Phillips Hospital and the Medical Director of the Dr. P. Phillips Hospital Emergency Department. Board certified in emergency medicine, Dr. Backer is a Fellow in the American College of Emergency Physicians. He completed his medical training at George Washington University School of Medicine and residency at the University of Miami. Dr. Backer has been with Dr. P. Phillips Hospital since its opening in 1985 as Sand Lake Hospital.

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