Prehospital Utility of Rapid Stroke Evaluation Using In-Ambulance Telemedicine

Abstract

Background and Purpose : Pre-hospital evaluation using telemedicine (TM) may accelerate acute stroke treatment with tissue plasminogen activator (t-PA). We explored the feasibility and reliability of using TM in the field and ambulance to help evaluate acute stroke patients. Methods : Ten unique, scripted stroke scenarios, each conducted four times, were portrayed by trained actors retrieved and transported by Houston Fire Department emergency medical technicians (EMT) to our stroke center. The vascular neurologists (VN) performed remote assessments in real-time, obtaining clinical data points and NIH Stroke-Scale (NIHSS) using the In-Touch RP-Xpress TM device. Each scripted scenario was recorded for a subsequent evaluation by a second blinded VN. 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 the scripted scenarios. Results In 34/40 (85%) scenarios, the teleconsultation was conducted without major technical complication. The absolute agreement for intra-class-correlation (ICC) was 0.997 (95% CI: 0.992-0.999) for the NIHSS obtained during the real-time sessions and 0.993 (95% CI: 0.975-0.999) for the recorded sessions. Inter-rater agreement using κ-statistics showed that for live-raters, 10/15 items on the NIHSS showed excellent agreement, and 5/15 showed moderate agreement. Matching of real-time assessments occurred for 88% (30/34) of NIHSS scores by ±2 points, and 96% of the clinical information. Conclusions Mobile TM is reliable and feasible in assessing actors simulating acute stroke in the pre-hospital setting.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study

“…[9][10][11] In the United States, investigators in Houston, TX, reported successful feasibility and reliability of telemedicine in a mobile stroke unit using the RPXpress portable telemedicine system from InTouch Technologies, Inc. (Santa Barbara, CA). 12 Similar to our study, they utilized patient actors performing simulated stroke scenarios during ambulance transport and were able to demonstrate excellent intraclass correlation (0.997, 0.97-0.998) for the NIHSS score between real-time and scripted scenarios. Ambulance connectivity was achieved through a Verizon 4G LTE mobile hotspot allowing successful teleconsultation in 34 of 40 scenarios (85%) without major technical interruption.…”

“…[8][9][10] More recent studies incorporating modern cellular connectivity have shown greater reliability but involve costly telemedicine endpoints and a limited geographic scope primarily confined to urban areas. 11,12 The objective of our study, Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine (iTREAT), is to demonstrate the reliability and technical feasibility of bidirectional, ambulance-based videoconferencing using a low cost, portable mobile telestroke system. Utilizing fourthgeneration (4G) long-term evolution (LTE) commercial broadband, we developed a tabletbased platform for emergency medical services (EMS) transport and assessed feasibility using simulated stroke scenarios.…”

Telestroke Assessment on the Move

“…The Omni-Hub system is also able to connect to satellite networks in the event of cellular networks being totally unavailable. 15 reported a success rate of 85% without technical complications when performing National Institutes of Health Stroke Scale assessments. This study, performed in rural areas of the Scottish Highlands and including not only the National Institutes of Health Stroke Scale assessment but also the Recognition of Stroke in the Emergency Room Score, Modified Rankin Scale and thrombolysis exclusion criteria, achieved a determination of eligibility for thrombolysis in an average of 11 minutes, which could save considerable time by bypassing these initial checks on arrival at hospital.…”

A call for formal telemedicine training during stroke fellowship

“…In AIS simulation scenarios, mobile telemedicine has been shown to be both feasible and reliable, with good interrater reliability. 31,32 Moreover, one pilot study on mobile telestroke found that the NIHSS correlation increased over the course of the study period. 32 This finding supports a role for training physicians to evaluate patients via mobile telestroke.…”