|HONEY BEE SECTION
|Year : 2017 | Volume
| Issue : 1 | Page : 2-4
“Telestroke”: An Indian approach to telemedicine
Department of Neurology, AIIMS, New Delhi, India
|Date of Web Publication||17-Jul-2017|
M V Padma
Department of Neurology, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Smart phone based hub and spoke telestroke model was used (using Whatsapp) with tertiary care hospitals in Himachal Pradesh (with neurologists) as hub and district hospitals (without neurologists) as spokes. Medical officers in district hospitals were trained in the treatment of stroke. Tissue plasminogen activator was made available at all these centers, free of cost through hospital pharmacies. Neurologists at two tertiary care centers were made available for consultation on phone; 26 patients received thrombolysis under the telestroke project at district hospitals without onsite neurologist. Only two patients developed an intracranial bleed following thrombolysis, and both were nonfatal. This is the first telestroke model being reported from India.
Keywords: Stroke, telemedicine, thrombolysis
|How to cite this article:|
Padma M V. “Telestroke”: An Indian approach to telemedicine. J Pract Cardiovasc Sci 2017;3:2-4
| “Telestroke”: An Indian Approach to Telemedicine|| |
Stroke is the second most common cause of death in India. India is witnessing a stroke epidemic! According to the Indian Council of Medical Research statistics, 165,000 strokes occur each year with nearly one stroke every 40 s and one stroke death every 4 min.
| Unmet Needs in Current Stroke Care in India|| |
Many Indian hospitals lack the necessary infrastructure and organization required to triage and treats patients with stroke quickly and efficiently and do not deliver adequate stroke care. The clinical stroke services across the country, especially in public sector hospitals are deficient in many aspects.
| Existing Treatment Gaps in India|| |
- Use of thrombolysis for stroke (a dismal 0.5% of all strokes receive thrombolysis)
- 24/7 availability of stroke physicians
- Interventional radiologist
- Use of stroke care maps and implementation of stroke care pathways
- Presence of a stroke unit
- A stroke team
- Sufficient community awareness programs which are essential key elements necessary to provide optimal stroke care to the community
- Efficient public emergency ambulance system.
At present, these facilities are largely available in high-end corporate sectors in largely metropolitan cities, thereby denying these facilities and medical care to the majority of the Indian population who are geographically and economically inaccessible and underprivileged.
These above limitations can at least partially be met with the addition of “Stroke Program” in the already existent cardiac care units designed and functional in the districts adopted under the NPCDCS.
| Role of Telemedicine/Telestroke|| |
Telemedicine enables a medical consultation to take place when the physician and the patient are in different locations. There is sufficient evidence to suggest that thrombolysis, when given using telestroke consultation, is as safe and effective as when it is given in a stroke center, and there are specific American Heart Association/American Stroke Association statements detailing the evidence for its use and guidelines for implementation. To deliver this treatment in resource-poor settings, we can use innovative approaches such as the use of smartphones.
| Road – Map for Establishing Optimal Stroke Care and Care and Prevention Pathways|| |
Mapping stroke treatment gaps
In different socioeconomic and geographic populations across the country to meaningful categories should be one of the main goals.
This podium should be a mechanism of integrating a team of stroke specialists to build a cohesive training program at the primary, district and tertiary levels of health care delivery systems.
Development of acute stroke care pathways
These acute stroke care pathways should be established in “adopted” geographically distinct areas across the country. Conduct task force meetings to develop and reach consensus/white paper statement/recommendations overcoming the barriers/implementation of standard operating procedures (SOPs) which should be developed in the task force recommendations.
Adoption of telestroke models
Access the current operational models across the country (for example, in Himachal Pradesh in India, as a successful launch of the Telestroke model in resource poor settings) and globally develop “SOPs” for implementation of telemedicine/telestroke facilities for bridging the economically and geographically challenged and underprivileged sections of societies across the country.
Similar task force meetings can be convened for identifying the existing areas of deficiencies in stroke prevention.
The current status of stroke rehabilitation here, caregiver based and community-based rehabilitation, cost effective rehabilitation pathways, integrating the Indian systems such Yoga and Ayurveda.
At prespecified time intervals and with a priori assumptions of achievable, due audit measures of performance must be undertaken from the different task force groups who have been entrusted with responsibilities of achieving the targets and goals.
| Methodology/Operational Manuel|| |
States initiated at various levels:
- Himachal Pradesh: Successful program running since April 2014
- Uttar Pradesh: Initiated and operational at district level. Thrombolysis done at district hospitals
- Odisha: Planning
- West Bengal: Planning
- Punjab and Haryana: Initiated and training started, thrombolysis and acute stroke care pathways established at district level and Government Medical Colleges in Punjab
- Kerala: Planning
- Rajasthan: Initiated and training completed
- Telangana: Initiated and training to be started
- Tamil Nadu: Planning
- Jammu and Kashmir: Planning.
Resource person and mentor: Dr. Padma Srivastava MD, DM, FAMS, F.N.A. Sc, Professor, Head Unit II Neurology, AIIMS, New Delhi, Past President, Indian Stroke Association, Scientific Co-Chair, World Stroke Congress.
| Synopsis of Himachal Pradesh Telestroke Program|| |
In March 2014 under the guidance of Prof. Padma Srivastava, from All India Institute of Medical Sciences, New Delhi, and on the initiative of Secretary Health, Himachal Pradesh a telestroke project was envisaged. All the government hospitals with computed tomography (CT)-scan facility were roped in. Out of 18 such hospitals, nine were attached to each of the two tertiary care centers. Workshops were conducted at various district hospitals. Medical officers in these hospitals (M.B.B.S. graduates and internal medicine postgraduates) were trained in recognizing stroke through these workshops. They were taught reading plain CT-scan head to rule out hemorrhage even without the help of radiologist, and written protocols for thrombolysis in ischemic stroke with explicit inclusion and exclusion criteria were provided. Blood sugar and electrocardiography (ECG) were only other investigations to be done apart from CT-head before thrombolysis. Tissue plasminogen activator (TPA) was made available at all these centers and provided free of cost through hospital pharmacies. All the four neurologists were made available on phone 24 × 7, and whenever any ischemic stroke came in window period, they were to be contacted. It was decided to use social networking sites like “Whatsapp for transmitting CT-scan images to neurologists for consultation.” These hospitals were then designated as primary stroke centers. Without any extra infrastructure requirement or any new manpower the project was finally launched in May-June 2014 amid much skepticism about its success.
Within 1 month the first ever patient of acute ischemic stroke was successfully thrombolysed at a district hospital without on–site presence of a neurologist. A 75-year-old male who had presented within 40 min of right hemiparesis with a power of 1/5 in the right upper limb and 3/5 in lower limb was given TPA after exclusion of hemorrhage with door to needle time of 40 min. At discharge, he had power of 3/5 in upper limb and 5/5 in the lower limb. This first case proved the feasibility of telestroke project, and then there was no looking back. Till date, total 150 patients had received thrombolysis under telestroke project at primary stroke centers. All this has been achieved without any extra infrastructure and manpower. All the patients were thrombolysed by stroke physicians with no in–house neurologists.
| An Illustrative Case|| |
A 42-year-male presented at district hospital Kullu (about 220 km from IGMC, Shimla, a journey of about 7 h by road) with a history of weakness of right side of the body of 1 h duration at 16.00 h. At presentation, he had a right facial weakness with 0/5 power in the right UL and 2/5 in right LL. There was no speech or sensory involvement. National Institutes of Health Stroke Scale (NIHSS) score was 10. His blood pressure was 136/84 mmHg and blood sugar 87 mg/dl. ECG was normal. His noncontrast CT head done at 16:24 h and the neurologist at IGMC, Shimla was contacted on the phone. The CT-head images were sent via Whatsapp at 16:44 h. It showed hypodensity in the left occipital region suggestive more of a sequel of chronic infarct than fresh lesion. The site of lesion also did not clinically correlate with the neurological deficit. The opinion of neuroradiologist at IGMC was also taken by showing him Whatsapp images, and he too was of the same opinion. The neurologist finally advised to go ahead with thrombolysis at 17:05 h and patient was thrombolysed with 50 mg of TPA. 24 h later he had 2/5 power in upper limb and 4/5 in LL with NIHSS of 6. At 1 month follow-up, he had modified ranking score of two with mild facial weakness [Figure 1], [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Month-wise patients' thrombolysis centers at primary stroke centers.|
Click here to view
Editors' note: There are a number of examples where doctors and even patients have shared ECGs after chest pain to get a second opinion and a myocardial infarction has been diagnosed from the Whatsapp image. Similarly a video transmitted by Whatsapp Video is often easier than other means of transmitting video imagings and much less resource heavy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sharma S, Padma MV, Bhardwaj A, Sharma A, Sawal N, Thakur S. Telestroke in resource-poor developing country model. Neurol India 2016;64:934-40.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]