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Original Investigation |

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

Ahmed Itrat, MD1; Ather Taqui, MD1; Russell Cerejo, MD1; Farren Briggs, PhD, ScM2; Sung-Min Cho, MD3; Natalie Organek, MD3; Andrew P. Reimer, PhD, RN4,5; Stacey Winners, MSc1; Peter Rasmussen, MD1; Muhammad S. Hussain, MD, FRCP1; Ken Uchino, MD1 ; for the Cleveland Pre-Hospital Acute Stroke Treatment (PHAST) Group
[+] Author Affiliations
1Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio
2Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
3Department of Neurology, Cleveland Clinic, Cleveland, Ohio
4Critical Care Transport Team, Cleveland Clinic, Cleveland, Ohio
5Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
JAMA Neurol. 2016;73(2):162-168. doi:10.1001/jamaneurol.2015.3849.
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Importance  Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence.

Objective  To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU.

Design, Setting, and Participants  Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry.

Main Outcomes and Measures  The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded.

Results  Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups.

Conclusions and Relevance  An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.

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Figure 1.
Mobile Stroke Treatment Unit

A, External view. B, Internal view with a computed tomography imaging system. C, Telemedicine unit at center, with laboratory testing equipment on the counter at the right. D, Team in action.

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Figure 2.
Cleveland Map and Mobile Stroke Treatment Unit (MSTU) Transfers

The dark outline shows the City of Cleveland proper. Dots indicate hospitals capable of triaging patients with stroke.

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Figure 3.
Flowchart Showing Triage and Initial Diagnoses on the Mobile Stroke Treatment Unit for the First 100 Evaluations

IV-tPA indicates intravenous tissue plasminogen activator.

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