Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep

Mobile stroke units: Beyond thrombolysis

In the last decade, mobile stroke units (MSUs) have shown the potential to transform prehospital stroke care, marking a paradigm shift in delivering ultra-rapid thrombolysis and streamlining triage processes. These units bring acute stroke care directly to patients, significantly shortening treatment times. This review outlines the rationale for MSU care and discusses the potential applications beyond the original purpose of delivering thrombolysis, including large vessel occlusion detection, intracerebral hemorrhage management, and innovative forms of prehospital research.

Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains

Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.

Barriers to integrating portable Magnetic Resonance Imaging systems in emergency medical service ambulances for stroke care

This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the appropriate hospitals for timely stroke care and potentially reduce door-to-needle time for thrombolytic administration. The study employs a qualitative methodology using a digital twin of the patient handling process developed and demonstrated through semi-structured interviews with 18 participants, including 11 paramedics from an Emergency Medical Services system and seven neurologists from a tertiary stroke care centre. The interview transcripts were thematically analysed to determine the barriers based on the Systems Engineering Initiative for Patient Safety framework. Key barriers include the need for MRI operation skills, procedural complexities in patient handling, space constraints, and the need for training and policy development. Potential solutions are suggested to mitigate these barriers. The findings can facilitate implementing MRI systems in ambulances to expedite stroke treatment.

EvolvRehab-MoveWell telerehabilitation for stroke survivors: study protocol for a feasibility with embedded initial proof-of-concept study

INTRODUCTION

Stroke is a leading cause of disability throughout the world. Unilateral upper limb impairment is common in people who have had a stroke. As a result of impaired upper limb function, people who have had a stroke often employ abnormal 'compensatory' movements. In the short term, these compensatory movements allow the individual to complete tasks, though long-term movement in this manner can lead to limitations. Telerehabilitation offers the provision of rehabilitation services to patients at a remote location using information and communication technologies. 'EvolvRehab' is one such telerehabilitation system, which uses activities to assess and correct compensatory upper body movements, although the feasibility of its use is yet to be determined in National Health Service services. Using EvolvRehab, we aim to assess the feasibility of 6 weeks telerehabilitation in people after a stroke.

METHODS AND ANALYSIS

A multisite feasibility study with embedded design phase. Normally distributed data will be analysed using paired samples t-tests; non-normally distributed data will be analysed using related samples Wilcoxon signed rank tests. Thematic content analysis of interview transcripts will be used to investigate the usability and perceived usefulness of the EvolvRehab kit.

ETHICS AND DISSEMINATION

This study has received ethical approval from Solihull Research Ethics Committee (REC reference: 23/WM/0054). Dissemination will be carried out according to the dissemination plan co-written with stroke survivors, including academic publications and presentations; written reports; articles in publications of stakeholder organisations; presentations to and publications for potential customers.

TRIAL REGISTRATION NUMBER

NCT05875792.

Application of Telemedicine in the Ambulance for Stroke Patients: A Systematic Review

INTRODUCTION

The use of telemedicine for the prehospital management of emergency conditions, especially stroke, is increasing day by day. Few studies have investigated the applications of telemedicine in Emergency Medical Services (EMS). A comprehensive study of the applications of this technology in stroke patients in ambulances can help to build a better understanding. Therefore, this systematic review was conducted to investigate the use of telemedicine in ambulances for stroke patients in 2023.

METHODS

A systematic search was conducted in PubMed, Cochrane, Scopus, ProQuest, Science Direct, and Web of Science from 2013 through March 1, 2023. The authors selected the articles based on keywords and criteria and reviewed them in terms of title, abstract, and full text. Finally, the articles that were related to the study aim were evaluated.

RESULTS

The initial search resulted in the extraction of 2,795 articles. After review of the articles, and applying the inclusion and exclusion criteria, seven articles were selected for the final analysis. Three (42.85%) studies were on the feasibility and intervention types. Also, randomized trials, feasibility, feasibility and prospective-observational, and feasibility and retrospective-interventional studies were each one (14.28%). Six (85.71%) of the studies were conducted in the United States. The National Institutes of Health Stroke Scale (NIHSS) and RP-Xpress were the most commonly used tools for neurological evaluations and teleconsultations.

CONCLUSION

Remote prehospital consultations, triage, and sending patient data before they go to the emergency department can be provided through telemedicine in ambulances. Neurological evaluations via telemedicine are reliable and accurate, and they are almost equal to in-person evaluations by a neurologist.

The early impact of COVID-19 pandemic on mobile stroke unit care delivery: A worldwide survey

OBJECTIVE

To report COVID -19 pandemic impact on mobile stroke units (MSUs) a world-wide survey of MSU programs.

METHODS

Contact information of MSU program was obtained through the Pre-hospital Stroke Treatment Organization. Anonymous electronic questionnaire was developed and sent through the email to one representative of each program on May 15, 2020.

RESULTS

Of 26 programs queried, 20 responded and completed survey based on the data or personal impression. Eighteen programs were in the regions with pandemic lockdown. Six either suspended or reduced MSU availability at some point. The reasons given for change in availability were as follows: decreased personnel availability (5 programs), risk of exposure (5 programs), and financial concerns (1 program). Staff availability was a concern among 8 programs. MSU activations were reported to be unchanged by 10 programs, but 9 programs experienced decline in activation, 1 program had more activations. Sixteen programs reported change in MSU protocol including introduction of screening questionnaire, PPE, reducing patient contact, and cleaning protocols. Nine reported that the crew was under greater stress. Only 2 respondents felt that the pandemic delayed stroke care on MSU and the remainder did not.

CONCLUSION

Overall Stroke care delivery had no major disruptions despite COVID 19 pandemic posed challenges to MSU Operations.

Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting

Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.

Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018

OBJECTIVE

Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time.

METHODS

This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission.

RESULTS

Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer.

CONCLUSION

Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.

Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study

Background

Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting.

Objective

The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP.

Methods

This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected.

Results

PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions.

Conclusions

This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.

Organizational Factors Determining Access to Reperfusion Therapies in Ischemic Stroke-Systematic Literature Review

BACKGROUND

After onset of acute ischemic stroke (AIS), there is a limited time window for delivering acute reperfusion therapies (ART) aiming to restore normal brain circulation. Despite its unequivocal benefits, the proportion of AIS patients receiving both types of ART, thrombolysis and thrombectomy, remains very low. The organization of a stroke care pathway is one of the main factors that determine timely access to ART. The knowledge on organizational factors influencing access to ART is sparce. Hence, we sought to systematize the existing data on the type and frequency of pre-hospital and in-hospital organizational factors that determine timely access to ART in patients with AIS.

METHODOLOGY

Literature review on the frequency and type of organizational factors that determine access to ART after AIS. Pubmed and Scopus databases were the primary source of data. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

RESULTS

A total of 128 studies were included. The main pre-hospital factors associated with delay or access to ART were medical emergency activation practices, pre-notification routines, ambulance use and existence of local/regional-specific strategies to mitigate the impact of geographic distance between patient locations and Stroke Unit (SU). The most common intra-hospital factors studied were specific location of SU and brain imaging room within the hospital, and the existence and promotion of specific stroke treatment protocols. Most frequent factors associated with increased access ART were periodic public education, promotion of hospital pre-notification and specific pre- and intra-hospital stroke pathways. In specific urban areas, mobile stroke units were found to be valid options to increase timely access to ART.

CONCLUSIONS

Implementation of different organizational factors and strategies can reduce time delays and increase the number of AIS patients receiving ART, with most of them being replicable in any context, and some in only very specific contexts.

Clinical Significance of Prehospital Telecommunication Defined as the Critical Stroke Call Pathway in Acute Ischemic Stroke Requiring Intra-Arterial Recanalization Therapy

BACKGROUND AND PURPOSE

To reduce the door-to-puncture time, which is a prognostic factor for the clinical outcome after intra-arterial recanalization therapy, we established a prehospital telecommunication strategy between neurointerventionalists and emergency medical technicians, namely, the critical stroke call pathway. We retrospectively evaluated the clinical significance of the critical stroke call pathway by comparing the door-to-puncture time and clinical outcome of the critical stroke call pathway with those of the routine stroke pathway.

MATERIALS AND METHODS

From January 2018 to June 2020, one hundred seventy-one patients with anterior circulation occlusion who underwent arterial recanalization therapy via the emergency department were included in this study. Patients were divided into the critical stroke call pathway group (n = 75, 43.9%) and the routine stroke pathway group (n = 96, 56.1%).

RESULTS

The critical stroke call pathway group exhibited a shorter door-to-puncture time than the routine stroke pathway group (median, 87 minutes; interquartile range, 63-107 minutes; P < .001). On multivariable analysis, a good clinical outcome (3-month mRS, 0-2) was independently associated with a shorter door-to-puncture time (adjusted OR, 0.998; adjusted 95% CI, 0.996-1.000; P = .027). In patients with an NIHSS score on admission of ≤11, an excellent clinical outcome (3-month mRS, 0-1) was more frequently achieved in the critical stroke call pathway group than in the routine stroke pathway group (22/33, 66.7%, versus 21/48, 43.8%; P = .042).

CONCLUSIONS

In our study, compared with the routine stroke pathway, the critical stroke call pathway remarkably reduced the door-to-puncture time for arterial recanalization therapy, with better clinical outcomes, especially in patients with a relatively good clinical status.

Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis

Background

The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance.

Methods

Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day.

Results

Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I² = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I² = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I² = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I² = 91%).

Conclusions

In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.

The Mobile Stroke Unit Nurse: An International Exploration of Their Scope of Practice, Education, and Training

ABSTRACT

BACKGROUND: Mobile stroke units (MSUs) are ambulance-based prehospital stroke care services. Through immediate roadside assessment and onboard brain imaging, MSUs provide faster stroke management with improved patient outcomes. Mobile stroke units have enabled the development of expanded scope of practice for stroke nurses; however, there is limited published evidence about these evolving prehospital acute nursing roles. AIMS: The aim of this study was to explore the expanded scope of practice of nurses working on MSUs by identifying MSUs with onboard nurses; describing the roles and responsibilities, training, and experience of MSU nurses, through a search of the literature; and describing 2 international MSU services incorporating nurses from Memphis, Tennessee, and Melbourne, Australia. METHODS: We searched PubMed, CINAHL, and the Joanna Briggs Institute Evidence-Based Practice database using the terms "mobile stroke unit" and "nurse." Existing MSUs were identified through the PRE-hospital Stroke Treatment Organization to determine models that involved nurses. We describe 2 MSUs involving nurses: one in Memphis and one in Melbourne, led by 2 of our authors. RESULTS: Ninety articles were found describing 15 MSUs; however, staffing details were lacking, and it is unknown how many employ nurses. Nine articles described the role of the nurse, but role specifics, training, and expertise were largely undocumented. The MSU in Memphis, the only unit to be staffed exclusively by onboard nurse practitioners, is supported by a neurologist who consults via telephone. The Melbourne MSU plans to trial a nurse-led telemedicine model in the near future. CONCLUSION: We lack information on how many MSUs employ nurses, and the nurses' scope of practice, training, and expertise. Expert stroke nurse practitioners can safely perform many of the tasks undertaken by the onboard neurologist, making a nurse-led telemedicine model an effective and potentially cost-effective model that should be considered for all MSUs.

A Systematic Review of Mobile Stroke Unit Among Acute Stroke Patients: Time Metrics, Adverse Events, Functional Result and Cost-Effectiveness

Background

Mobile stroke unit (MSU) is deployed to shorten the duration of ischemic stroke recognition to thrombolysis treatment, thus reducing disability, mortality after an acute stroke attack, and related economic burden. Therefore, we conducted a comprehensive systematic review of the clinical trial and economic literature focusing on various outcomes of MSU compared with conventional emergency medical services (EMS).

Methods

An electronic search was conducted in four databases (PubMed, OVID Medline, Embase, and the Cochrane Controlled Register of Trials) from 1990 to 2021. In these trials, patients with acute stroke were assigned to receive either MSU or EMS, with clinical and economic outcomes. First, we extracted interested data in the pooled population and conducted a subgroup analysis to examine related heterogeneity. We then implemented a descriptive analysis of economic outcomes. All analyses were performed with R 4.0.1 software.

Results

A total of 22,766 patients from 16 publications were included. In total 7,682 (n = 33.8%) were treated in the MSU and 15,084 (n = 66.2%) in the conventional EMS. Economic analysis were available in four studies, of which two were based on trial data and the others on model simulations. The pooled analysis of time metrics indicated a mean reduction of 32.64 min (95% confidence interval: 23.38–41.89, p &lt; 0.01) and 28.26 minutes (95% CI: 16.11–40.41, p &lt; 0.01) in the time-to-therapy and time-to-CT completion, respectively in the MSU. However, there was no significant difference on stroke-related neurological events (OR = 0.94, 95% CI: 0.70–1.27, p = 0.69) and in-hospital mortality (OR = 1.11, 95% CI: 0.83–1.50, p = 0.48) between the MSU and EMS. The proportion of patients with modified Ranking scale (mRS) of 0–2 at 90 days from onset was higher in the MSU than EMS (p &lt; 0.05). MSU displayed favorable benefit-cost ratios (2.16–6.85) and incremental cost-effectiveness ratio ($31,911 /QALY and $38,731 per DALY) comparing to EMS in multiple economic publications. Total cost data based on 2014 USD showed that the MSU has the highest cost in Australia ($1,410,708) and the lowest cost in the USA ($783,463).

Conclusion

A comprehensive analysis of current research suggests that MUS, compared with conventional EMS, has a better performance in terms of time metrics, safety, long-term medical benefits, and cost-effectiveness.

Mobile Stroke Units: Current Evidence and Impact

PURPOSE OF REVIEW

Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems.

RECENT FINDINGS

MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.

Communication Requirements in 5G-Enabled Healthcare Applications: Review and Considerations

Fifth generation (5G) mobile communication technology can enable novel healthcare applications and augment existing ones. However, 5G-enabled healthcare applications demand diverse technical requirements for radio communication. Knowledge of these requirements is important for developers, network providers, and regulatory authorities in the healthcare sector to facilitate safe and effective healthcare. In this paper, we review, identify, describe, and compare the requirements for communication key performance indicators in relevant healthcare use cases, including remote robotic-assisted surgery, connected ambulance, wearable and implantable devices, and service robotics for assisted living, with a focus on quantitative requirements. We also compare 5G-healthcare requirements with the current state of 5G capabilities. Finally, we identify gaps in the existing literature and highlight considerations for this space.

Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy

BACKGROUND

The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes.

OBJECTIVE

Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes.

RESULTS

Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable.

CONCLUSIONS

Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.

Pilot Paramedic Survey of Benefits, Risks, and Strategies for Pediatric Prehospital Telemedicine

OBJECTIVE

A national survey found prehospital telemedicine had potential clinical applications but lacked provider opinion on its use for pediatric emergency care. We aimed to (1) estimate prehospital telemedicine use, (2) describe perceived benefits and risks of pediatric applications, and (3) identify preferred utilization strategies by paramedics.

METHODS

We administered a 14-question survey to a convenience sample of 25 Massachusetts paramedics attending a regional course in 2018. Volunteer participants were offered a gift card. We compared respondents to a state database for sample representativeness. We present descriptive statistics and summarize qualitative responses.

RESULTS

Twenty-five paramedics completed the survey (100% response); 23 (96%) were male, 21 (84%) 40 years or older, and 23 (92%) in urban practice. Respondents were older and more experienced than the average Massachusetts paramedic. Few had used prehospital telemedicine for patients younger than 12 years (8%; 95% confidence interval, 10-26%). Potential benefits included paramedic training (80%), real-time critical care support (68%), risk mitigation (68%), patient documentation (72%), decision support for hospital team activation (68%), and scene visualization (76%). Time delays from telemedicine equipment use (76%) and physician consultation (64%), broadband reliability (52%), and cost (56%) were potential risks. Respondents preferred video strategies for scene visualization, physician-assisted assessment and care. More respondents felt pediatric telemedicine applications would benefit rural/suburban settings than urban ones.

CONCLUSIONS

Paramedics reported prehospital telemedicine is underutilized for children but identified potential benefits including provider telesupport, training, situational awareness, and documentation. Concerns included transportation delays, cost, and broadband availability. Video was preferred for limited pediatric exposure settings. These results inform which telemedicine applications and strategies paramedics favor for children.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine

INTRODUCTION

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM.

METHODS

Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important."

RESULTS

Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety).

CONCLUSION

The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Association of Financial Factors and Telemedicine Adoption for Heart Attack and Stroke Care Among Rural and Urban Hospitals: A Longitudinal Study

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial

Importance

Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem.

Objective

To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment.

Design, Setting, and Participants

In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients.

Interventions

Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities).

Main Outcomes and Measures

The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others).

Results

A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different.

Conclusions and Relevance

Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients.

Trial Registration

ClinicalTrials.gov identifier: NCT02465346.

Impact of mobile stroke units

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study

BACKGROUND

Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe.

METHODS

A nonrandomized, prospective, controlled intervention study.

INCLUSION CRITERIA

age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality.

RESULTS

We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71-155) minutes versus 118 (90-176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44-65) minutes versus 74 (63-95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11-5.03]). There were no other significant differences in outcomes.

CONCLUSIONS

Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.

A Comparison of Time to Treatment between an Emergency Department Focused Stroke Protocol and Mobile Stroke Units

BACKGROUND

San Francisco (California USA) is a relatively compact city with a population of 884,000 and nine stroke centers within a 47 square mile area. Emergency Medical Services (EMS) transport distances and times are short and there are currently no Mobile Stroke Units (MSUs).

METHODS

This study evaluated EMS activation to computed tomography (CT [EMS-CT]) and EMS activation to thrombolysis (EMS-TPA) times for acute stroke in the first two years after implementation of an emergency department (ED) focused, direct EMS-to-CT protocol entitled "Mission Protocol" (MP) at a safety net hospital in San Francisco and compared performance to published reports from MSUs. The EMS times were abstracted from ambulance records. Geometric means were calculated for MP data and pooled means were similarly calculated from published MSU data.

RESULTS

From July 2017 through June 2019, a total of 423 patients with suspected stroke were evaluated under the MP, and 166 of these patients were either ultimately diagnosed with ischemic stroke or were treated as a stroke but later diagnosed as a stroke mimic. The EMS and treatment time data were available for 134 of these patients with 61 patients (45.5%) receiving thrombolysis, with mean EMS-CT and EMS-TPA times of 41 minutes (95% CI, 39-43) and 63 minutes (95% CI, 57-70), respectively. The pooled estimates for MSUs suggested a mean EMS-CT time of 35 minutes (95% CI, 27-45) and a mean EMS-TPA time of 48 minutes (95% CI, 39-60). The MSUs achieved faster EMS-CT and EMS-TPA times (P <.0001 for each).

CONCLUSIONS

In a moderate-sized, urban setting with high population density, MP was able to achieve EMS activation to treatment times for stroke thrombolysis that were approximately 15 minutes slower than the published performance of MSUs.

Role of Telemedicine in Prehospital Stroke Care

PURPOSE OF REVIEW

To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions.

RECENT FINDINGS

A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.

Stroke Care in the United Kingdom During the COVID-19 Pandemic

Supplemental Digital Content is available in the text.

The coronavirus disease 2019 (COVID-19) pandemic has potentially caused indirect harm to patients with other conditions via reduced access to health care services. We aimed to describe the impact of the initial wave of the pandemic on admissions, care quality, and outcomes in patients with acute stroke in the United Kingdom.

Pre-Hospital Diagnosis in Mobile Stroke Unit

OBJECTIVES

Mobile stroke unit (MSU) has been shown to rapidly provide pre-hospital thrombolysis in acute ischemic stroke (AIS). MSU encounters neurological disorders other than AIS that require emergent treatment.

METHODS/MATERIALS

We obtained pre-hospital diagnosis and treatment data from the prospectively collected dataset on 221 consecutive MSU encounters. Based on initial clinical evaluation and neuroimaging obtained on MSU, the diagnosis of AIS (definite, probable, and possible AIS, transient ischemic attack), intracranial hemorrhage, and likely stroke mimics was made.

RESULTS

From July 2014 to April 2015, 221 patients were treated on MSU. 78 (35%) patients had initial clinical diagnosis of definite/probable AIS or TIA, 69 (31%) were diagnosed as possible AIS or TIA, 15 (7%) had intracranial hemorrhage while 59 patients (27%) were diagnosed as likely stroke mimics. Stroke mimics encountered included 13 (6%) metabolic encephalopathy, 11 (5%) seizures, 9 (4%) migraines, 3 (1%) substance abuse, 2 (1%) CNS tumor, 3 (1%) infectious etiology and 3 (1%) hypoglycemia. Fifty-four (24%) patients received non-thrombolytic treatments on MSU CONCLUSION: About one third of MSU encounters were not AIS initially, including intracranial hemorrhage and stroke mimics. MSU can be utilized to provide pre-hospital treatments in emergent neurological conditions other than AIS.

Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

Digital health during COVID-19: lessons from operationalising new models of care in ophthalmology

The COVID-19 pandemic has resulted in massive disruptions within health care, both directly as a result of the infectious disease outbreak, and indirectly because of public health measures to mitigate against transmission. This disruption has caused rapid dynamic fluctuations in demand, capacity, and even contextual aspects of health care. Therefore, the traditional face-to-face patient-physician care model has had to be re-examined in many countries, with digital technology and new models of care being rapidly deployed to meet the various challenges of the pandemic. This Viewpoint highlights new models in ophthalmology that have adapted to incorporate digital health solutions such as telehealth, artificial intelligence decision support for triaging and clinical care, and home monitoring. These models can be operationalised for different clinical applications based on the technology, clinical need, demand from patients, and manpower availability, ranging from out-of-hospital models including the hub-and-spoke pre-hospital model, to front-line models such as the inflow funnel model and monitoring models such as the so-called lighthouse model for provider-led monitoring. Lessons learnt from operationalising these models for ophthalmology in the context of COVID-19 are discussed, along with their relevance for other specialty domains.

Mobile Stroke Units: Current and Future Impact on Stroke Care

Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.

The Implementation of an Emergency Medicine Telehealth System During a Pandemic

Background

In March of 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19)—a disease caused by a novel coronavirus—a pandemic, and it continued to spread rapidly in the community. Our institution implemented an emergency medicine telehealth system that sought to expedite care of stable patients, decrease provider exposure to COVID-19, decrease overall usage rate of personal protective equipment, and provide a platform so that infected or quarantined physicians could continue to work. This effort was among the first to use telehealth to practice emergency medicine in the setting of a pandemic in the United States.

Discussion

Outside the main emergency departments at each of 2 sites of our academic institution, disaster tents were erected with patient care equipment and medications, as well as technology to allow for telehealth visits. The triage system was modified to appropriately select low-risk patients with symptoms suggestive of COVID-19 who could be seen in these disaster tents. Despite some issues that needed to be addressed, such as provider discomfort, limited medication availability, and connectivity problems, the model was successful overall.

Conclusions

Other emergency departments might find this proof of concept article useful. Telehealth will likely be used more broadly in the future, including emergency care. It is imperative that the health care system continues to adapt to respond appropriately to challenges such as pandemics.

Probability assessment of intracerebral hemorrhage in prehospital emergency patients

BACKGROUND

Routing of patients with intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) to the most appropriate hospital is challenging for emergency medical services particularly when specific treatment options are only provided by specialized hospitals and determination of the exact diagnosis is difficult. We aimed to develop a prehospital score - called prehospital-intracerebral hemorrhage score (ph-ICH score) - to assist in discriminating between both conditions.

METHODS

The ph-ICH score was developed with data from patients treated aboard a mobile stroke unit in Berlin, Germany, between 2011 and 2013 (derivation cohort) and in 2018 (validation cohort). Diagnosis of ICH or AIS was established using clinical data and neuroradiological cerebral imaging. Diagnostic accuracy was measured with significance testing, Cohen's d and receiver-operating-characteristics.

RESULTS

We analyzed 416 patients (32 ICH, 224 AIS, 41 transient ischemic attack, 119 stroke mimic) in the derivation cohort and 285 patients (33 ICH and 252 AIS) in the validation cohort. Systolic blood pressure, level of consciousness and severity of neurological deficits (i. e. certain items of the National Institutes of Health Stroke Scale) were used to calculate the ph-ICH score that showed higher values in the ICH compared to the AIS group (derivation cohort: 1.8 ± 1.2 vs. 1.0 ± 0.9 points; validation cohort: 1.8 ± 0.9 vs. 0.8 ± 0.7 points; d = 0.9 and 1.4, both p < 0.01). Receiver-operating-characteristics showed fair and good accuracy with an area under the curve of 0.71 for the derivation and 0.81 for the validation cohort.

CONCLUSIONS

The ph-ICH score can assist medical personnel in the field to assess the likelihood of ICH and AIS in emergency patients.

Innovations in Prehospital Stroke Management Utilizing Mobile Stroke Units

Using a representative case, this article discusses prehospital innovations for patients with acute large vessel occlusion ischemic stroke, including mobile stroke unit care supported by advanced field imaging.

Effectiveness of interventions to improve rates of intravenous thrombolysis using behaviour change wheel functions: a systematic review and meta-analysis

BACKGROUND

Despite being one of the few evidence-based treatments for acute ischemic stroke, intravenous thrombolysis has low implementation rates-mainly due to a narrow therapeutic window and the health system changes required to deliver it within the recommended time. This systematic review and meta-analyses explores the differential effectiveness of intervention strategies aimed at improving the rates of intravenous thrombolysis based on the number and type of behaviour change wheel functions employed.

METHOD

The following databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL and SCOPUS. Multiple authors independently completed study selection and extraction of data. The review included studies that investigated the effects of intervention strategies aimed at improving the rates of intravenous thrombolysis and/or onset-to-needle, onset-to-door and door-to-needle time for thrombolysis in patients with acute ischemic stroke. Interventions were coded according to the behaviour change wheel nomenclature. Study quality was assessed using the QualSyst scoring system for quantitative research methodologies. Random effects meta-analyses were used to examine effectiveness of interventions based on the behaviour change wheel model in improving rates of thrombolysis, while meta-regression was used to examine the association between the number of behaviour change wheel intervention strategies and intervention effectiveness.

RESULTS

Results from 77 studies were included. Five behaviour change wheel interventions, 'Education', 'Persuasion', 'Training', 'Environmental restructuring' and 'Enablement', were found to be employed among the included studies. Effects were similar across all intervention approaches regardless of type or number of behaviour change wheel-based strategies employed. High heterogeneity (I2 > 75%) was observed for all the pooled analyses. Publication bias was also identified.

CONCLUSION

There was no evidence for preferring one type of behaviour change intervention strategy, nor for including multiple strategies in improving thrombolysis rates. However, the study results should be interpreted with caution, as they display high heterogeneity and publication bias.

Stroke systems of care in high-income countries: what is optimal?

Stroke is a complex, time-sensitive, medical emergency that requires well functioning systems of care to optimise treatment and improve patient outcomes. Education and training campaigns are needed to improve both the recognition of stroke among the general public and the response of emergency medical services. Specialised stroke ambulances (mobile stroke units) have been piloted in many cities to speed up the diagnosis, triage, and emergency treatment of people with acute stroke symptoms. Hospital-based interdisciplinary stroke units remain the central feature of a modern stroke service. Many have now developed a role in the very early phase (hyperacute units) plus outreach for patients who return home (early supported discharge services). Different levels (comprehensive and primary) of stroke centre and telemedicine networks have been developed to coordinate the various service components with specialist investigations and interventions including rehabilitation. Major challenges include the harmonisation of resources for stroke across the whole patient journey (including the rapid, accurate triage of patients who require highly specialised treatment in comprehensive stroke centres) and the development of technology to improve communication across different parts of a service.

Patients' Perception of Telemedicine in a Large Urban Inner-City Emergency Department: A Cross-Sectional Survey

Introduction

Telemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients’ perception of telemedicine in an urban ED.

Methods

A survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients’ perspective.

Results

A total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p<0.0001), and had frequent video chat in the past (p=0.0142).

Conclusion

With widespread access to smartphones with internet connectivity and pressing demands for healthcare services, telemedicine may provide a potential solution to low acuity medical care needs.

Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Automatic Grading of Stroke Symptoms for Rapid Assessment Using Optimized Machine Learning and 4-Limb Kinematics: Clinical Validation Study

Background

Subtle abnormal motor signs are indications of serious neurological diseases. Although neurological deficits require fast initiation of treatment in a restricted time, it is difficult for nonspecialists to detect and objectively assess the symptoms. In the clinical environment, diagnoses and decisions are based on clinical grading methods, including the National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council (MRC) score, which have been used to measure motor weakness. Objective grading in various environments is necessitated for consistent agreement among patients, caregivers, paramedics, and medical staff to facilitate rapid diagnoses and dispatches to appropriate medical centers.

Objective

In this study, we aimed to develop an autonomous grading system for stroke patients. We investigated the feasibility of our new system to assess motor weakness and grade NIHSS and MRC scores of 4 limbs, similar to the clinical examinations performed by medical staff.

Methods

We implemented an automatic grading system composed of a measuring unit with wearable sensors and a grading unit with optimized machine learning. Inertial sensors were attached to measure subtle weaknesses caused by paralysis of upper and lower limbs. We collected 60 instances of data with kinematic features of motor disorders from neurological examination and demographic information of stroke patients with NIHSS 0 or 1 and MRC 7, 8, or 9 grades in a stroke unit. Training data with 240 instances were generated using a synthetic minority oversampling technique to complement the imbalanced number of data between classes and low number of training data. We trained 2 representative machine learning algorithms, an ensemble and a support vector machine (SVM), to implement auto-NIHSS and auto-MRC grading. The optimized algorithms performed a 5-fold cross-validation and were searched by Bayes optimization in 30 trials. The trained model was tested with the 60 original hold-out instances for performance evaluation in accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve (AUC).

Results

The proposed system can grade NIHSS scores with an accuracy of 83.3% and an AUC of 0.912 using an optimized ensemble algorithm, and it can grade with an accuracy of 80.0% and an AUC of 0.860 using an optimized SVM algorithm. The auto-MRC grading achieved an accuracy of 76.7% and a mean AUC of 0.870 in SVM classification and an accuracy of 78.3% and a mean AUC of 0.877 in ensemble classification.

Conclusions

The automatic grading system quantifies proximal weakness in real time and assesses symptoms through automatic grading. The pilot outcomes demonstrated the feasibility of remote monitoring of motor weakness caused by stroke. The system can facilitate consistent grading with instant assessment and expedite dispatches to appropriate hospitals and treatment initiation by sharing auto-MRC and auto-NIHSS scores between prehospital and hospital responses as an objective observation.

Mobile Stroke Unit in the UK Healthcare System: Avoidance of Unnecessary Accident and Emergency Admissions

BACKGROUND

Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay.

OBJECTIVE

The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions.

METHODS

Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&amp;E) department, rate of admission directly to target ward, and stroke management metrics were assessed.

RESULTS

In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&amp;E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40-60).

CONCLUSION

This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&amp;E departments.

Telemedicine in Prehospital Acute Stroke Care

Background

Mobile stroke units (MSUs), equipped with an integrated computed tomography scanner, can shorten time to thrombolytic treatment and may improve outcome in patients with acute ischemic stroke. Original (German) MSUs are staffed by neurologists trained as emergency physicians, but patient assessment and treatment decisions by a remote neurologist may offer an alternative to neurologists aboard MSU.

Methods and Results

Remote neurologists examined and assessed emergency patients treated aboard the MSU in Berlin, Germany. Audiovisual quality was rated by the remote neurologist from 1 (excellent) to 6 (insufficient), and duration of video examinations was assessed. We analyzed interrater reliability of diagnoses, scores on the National Institutes of Health Stroke Scale and treatment decisions (intravenous thrombolysis) between the MSU neurologist and the remote neurologist. We included 90 of 103 emergency assessments (13 patients were excluded because of either failed connection, technical problems, clinical worsening during teleconsultation, or missing data in documentation) in this study. The remote neurologist rated audiovisual quality with a median grade for audio quality of 3 (satisfactory) and for video quality of 2 (good). Mean time for completion of teleconsultations was about 19±5 minutes. The interrater reliabilities between the onboard and remote neurologist were high for diagnoses (Cohen's κ=0.86), National Institutes of Health Stroke Scale sum scores (intraclass correlation coefficient, 0.87) and treatment decisions (16 treatment decisions agreed versus 2 disagreed; Cohen's κ=0.93).

Conclusions

Remote assessment and treatment decisions of emergency patients are technically feasible with satisfactory audiovisual quality. Agreement on diagnoses, neurological examinations, and treatment decisions between onboard and remote neurologists was high.

See Editorial by Derry et al

Mobile stroke unit versus standard medical care in the management of patients with acute stroke: A systematic review and meta-analysis

INTRODUCTION

Mobile stroke units have recently been introduced in the care of patients suspected of having an acute stroke, leading to shortening in the time to thrombolytics. We aimed to compare the clinical effectiveness in terms of functional outcome and survival among patients treated in mobile stroke unit and/or conventional care.

METHODS

A systematic search of electronic databases, comparing the clinical outcomes among patients with acute stroke in the same study was conducted from 1990 to 2019. Pooled and subgroup analysis were performed using the random- and fixed-effect model based upon the I² heterogeneity.

RESULTS

A total of 21,297 patients from 11 publications (seven randomized controlled trials and four non-randomized controlled trials including prospective cohort studies) were retrieved. This included 6065 (n = 28.4%) of the patients treated in the mobile stroke unit and 71.6% (n = 15,232) of the patients managed in the conventional care. The mean age at clinical presentation (70.1 ± 14.5 vs. 71.05 ± 15.8) and National Institute Health Stroke Scale (9.8 ± 1.7 vs. 8.4 ± 1.5) was comparable (p > 0.05) in patients treated with mobile stroke unit and conventional care, respectively. The mean time-to-treatment window was significantly shorter among the patients treated in mobile stroke unit compared to conventional care (62.0 min vs. 75.0 min; p = 0.03, respectively). The pooled analysis of clinical outcome at day 7 indicated that patients treated in mobile stroke unit had 1.46-folds higher likelihood of better clinical outcome (modified Rankin scale 0-2) than those in the hospital (odds ratio: 1.46, 95% confidence interval: 1.306-2.03, p = 0.02). However, there was no significant difference in terms of mortality (odds ratio: 0.98, 95% confidence interval: 0.81-1.18, p = 0.80), stroke-related neurological deficits (odds ratio: 1.37, 95% confidence interval: 0.81-2.32, p = 0.24), and other serious adverse events (odds ratio: 0.69, 95% confidence interval: 0.39-1.20, p = 0.19) among patients treated in mobile stroke unit versus conventional care.

CONCLUSION

Our results corroborate that patients treated in mobile stroke unit lead to short-term recovery following acute stroke without influencing the mortality rate. Further prospective studies are needed to validate our results.

Prehospital Triage of Acute Stroke Patients During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has broad implications on stroke patient triage. Emergency medical services providers have to ensure timely transfer of patients while minimizing the risk of infectious exposure for themselves, their co-workers, and other patients. This statement paper provides a conceptual framework for acute stroke patient triage and transfer during the COVID-19 pandemic and similar healthcare emergencies in the future.

Factors delaying intravenous thrombolytic therapy in acute ischaemic stroke: a systematic review of the literature

BACKGROUND/AIMS

This review examined factors that delay thrombolysis and what management strategies are currently employed to minimise this delay, with the aim of suggesting future directions to overcome bottlenecks in treatment delivery.

METHODS

A systematic review was performed according to PRISMA guidelines. The search strategy included a combination of synonyms and controlled vocabularies from Medical Subject Headings (MeSH) and EmTree covering brain ischemia, cerebrovascular accident, fibrinolytic therapy and Alteplase. The search was conducted using Medline (OVID), Embase (OVID), PubMed and Cochrane Library databases using truncations and Boolean operators. The literature search excluded review articles, trial protocols, opinion pieces and case reports. Inclusion criteria were: (1) The article directly related to thrombolysis in ischaemic stroke, and (2) The article examined at least one factor contributing to delay in thrombolytic therapy.

RESULTS

One hundred and fifty-two studies were included. Pre-hospital factors resulted in the greatest delay to thrombolysis administration. In-hospital factors relating to assessment, imaging and thrombolysis administration also contributed. Long onset-to-needle times were more common in those with atypical, or less severe, symptoms, the elderly, patients from lower socioeconomic backgrounds, and those living alone. Various strategies currently exist to reduce delays. Processes which have achieved the greatest improvements in time to thrombolysis are those which integrate out-of-hospital and in-hospital processes, such as the Helsinki model.

CONCLUSION

Further integrated processes are required to maximise patient benefit from thrombolysis. Expansion of community education to incorporate less common symptoms and provision of alert pagers for patients may provide further reduction in thrombolysis times.

Cost-Consequence Analysis of Mobile Stroke Units vs. Standard Prehospital Care and Transport

Background: Mobile stroke units (MSUs) are the latest approach to improving time-sensitive stroke care delivery. Currently, there are no published studies looking at the expanded value of the MSU to diagnose and transport patients to the closest most appropriate facility. The purpose of this paper is to perform a cost consequence analysis of standard transport (ST) vs. MSU.

Methods and Results: A cost consequence analysis was undertaken within a decision framework to compare the incremental cost of care for patients with confirmed stroke that were served by the MSU vs. their simulated care had they been served by standard emergency medical services between July 2014 and October 2015. At baseline values, the incremental cost between MSU and ST was $70,613 ($856,482 vs. $785,869) for 355 patient transports. The MSU avoided 76 secondary interhospital transfers and 76 emergency department (ED) encounters. Sensitivity analysis identified six variables that had measurable impact on the model's variability and a threshold value at which MSU becomes the optimal strategy: number of stroke patients (>391), probability of requiring transfer to a comprehensive stroke center (CSC, >0.52), annual cost of MSU operations (<$696,053), cost of air transfer (>$8,841), probability initial receiving hospital is a CSC (<0.32), and probability of ischemic stroke with ST (<0.76).

Conclusions: MSUs can avert significant costs in the administration of stroke care once optimal thresholds are achieved. A comprehensive cost-effectiveness analysis is required to determine not just the operational value of an MSU but also its clinical value to patients and the society.

Mobile Stroke Units: Bringing Treatment to the Patient

PURPOSE OF REVIEW

Mobile stroke units (MSUs) have revolutionized emergency stroke care by delivering pre-hospital thrombolysis faster than conventional ambulance transport and in-hospital treatment. This review discusses the history of MSUs technological development, current operations and research, cost-effectiveness, and future directions.

RECENT FINDINGS

Multiple prospective and retrospective studies have shown that MSUs deliver acute ischemic stroke treatment with intravenous recombinant tissue plasminogen activator (IV r-tPA) approximately 30 min faster than conventional care. The 90-day modified Rankin Scores for patients who received IV r-tPA on the MSU compared to conventional care were not statistically different in the PHANTOM-S study. Two German studies suggest that the MSU model is cost-effective by reducing disability and improving adjusted quality-life years post-stroke. The ongoing BEST-MSU trial will be the first multicenter, randomized controlled study that will shed light on MSUs' impact on long-term neurologic outcomes and cost-effectiveness. MSUs are effective in reducing treatment times in acute ischemic stroke without increasing adverse events. MSUs could potentially improve treatment times in large vessel occlusion and intracranial hemorrhage. Further studies are needed to assess functional outcomes and cost-effectiveness. Clinical trials are ongoing internationally.

Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry

Background Mobile stroke units (MSUs) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi-institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm). Our exposure was MSU care, and our primary outcome was dispatch-to-thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch-to-thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P=0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0-mile radius (4.8 versus 2.7, P=0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch-to-thrombolysis time of 29.7 minutes (95% CI, 6.9-52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.