Prehospital Utility of Rapid Stroke Evaluation Using In - Ambulance Telemedicine A Pilot Feasibility

Abstract

Treatment with IV tissue-type plasminogen activator is an effective treatment for acute ischemic stroke (AIS) within the first few hours of symptom onset. Earlier treatment is associated with a higher likelihood of better outcomes. This finding has led to national guidelines setting target door to treatment times at 60 minutes for eligible AIS patients. Unfortunately, less than one third of patients treated with IV tissue-type plasminogen activator received the treatment in this recommended 60-minute time window from hospital arrival. Emergency medical technicians (EMT) are the first point of contact for the majority of acute stroke patients in Houston. Their initial assessment and recognition of stroke symptoms play a pivotal role in ensuring that the patient is triaged to the appropriate hospital facility. Studies have shown that with rigorous EMT education, diagnostic accuracy and rapid transport times can be achieved. Prenotification by EMT has also been demonstrated to improve AIS treatment times and increase use of lytics. A potential approach to further reduce treatment times is to use telemedicine in the field and ambulance to assess and rapidly triage acute stroke patients. Telemedicine technology allows 2-way high-quality video conferencing using cellular bandwidth. Enabling a stroke specialist to assess the patient in collaboration with emergency medical service staff during the pick-up and transport could potentially reduce the time spent at hospital arrival to obtain a history and examine the patient. In addition, prehospital identification and registration of the potential thrombolytic candidate, and advance notification to Background and Purpose—Prehospital evaluation using telemedicine may accelerate acute stroke treatment with tissuetype plasminogen activator. We explored the feasibility and reliability of using telemedicine in the field and ambulance to help evaluate acute stroke patients. Methods—Ten unique, scripted stroke scenarios, each conducted 4 times, were portrayed by trained actors retrieved and transported by Houston Fire Department emergency medical technicians to our stroke center. The vascular neurologists performed remote assessments in real time, obtaining clinical data points and National Institutes of Health (NIH) Stroke Scale, using the In-Touch RP-Xpress telemedicine device. Each scripted scenario was recorded for a subsequent evaluation by a second blinded vascular neurologist. Study feasibility was defined by the ability to conduct 80% of the sessions without major technological limitations. Reliability of video interpretation was defined by a 90% concordance between the data derived during the real-time sessions and those from the scripted scenarios. Results—In 34 of 40 (85%) scenarios, the teleconsultation was conducted without major technical complication. The absolute agreement for intraclass correlation was 0.997 (95% confidence interval, 0.992–0.999) for the NIH Stroke Scale obtained during the real-time sessions and 0.993 (95% confidence interval, 0.975–0.999) for the recorded sessions. Interrater agreement using κ-statistics showed that for live-raters, 10 of 15 items on the NIH Stroke Scale showed excellent agreement and 5 of 15 showed moderate agreement. Matching of real-time assessments occurred for 88% (30/34) of NIH Stroke Scale scores by ±2 points and 96% of the clinical information. Conclusions—Mobile telemedicine is reliable and feasible in assessing actors simulating acute stroke in the prehospital setting. (Stroke. 2014;45:2342-2347.)

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@inproceedings{Wu2014PrehospitalUO, title={Prehospital Utility of Rapid Stroke Evaluation Using In - Ambulance Telemedicine A Pilot Feasibility}, author={Ching Wu and Claude B Nguyen and Christy M Ankrom and Julian P Yang and David E Persse and Farhaan Vahidy and James C . Grotta and Sean Isaac Savitz}, year={2014} }