Feasibility of prehospital teleconsultation in acute stroke--a pilot study in clinical routine

Abstract

Background: Inter-hospital teleconsultation improves stroke care. To transfer this concept into the emergency medical service (EMS), the feasibility and effects of prehospital teleconsultation were investigated.

Methodology/principal findings: Teleconsultation enabling audio communication, real-time video streaming, vital data and still picture transmission was conducted between an ambulance and a teleconsultation center. Pre-notification of the hospital was carried out with a 14-item stroke history checklist via e-mail-to-fax. Beside technical assessments possible influences on prehospital and initial in-hospital time intervals, prehospital diagnostic accuracy and the transfer of stroke specific data were investigated by comparing telemedically assisted prehospital care (telemedicine group) with local regular EMS care (control group). All prehospital stroke patients over a 5-month period were included during weekdays (7.30 a.m.-4.00 p.m.). In 3 of 18 missions partial dropouts of the system occurred; neurological co-evaluation via video transmission was conducted in 12 cases. The stroke checklist was transmitted in 14 cases (78%). Telemedicine group (n = 18) vs. control group (n = 47): Prehospital time intervals were comparable, but in both groups the door to brain imaging times were longer than recommended (median 59.5 vs. 57.5 min, p = 0.6447). The prehospital stroke diagnosis was confirmed in 61% vs. 67%, p = 0.8451. Medians of 14 (IQR 9) vs. 5 (IQR 2) stroke specific items were transferred in written form to the in-hospital setting, p<0.0001. In 3 of 10 vs. 5 of 27 patients with cerebral ischemia thrombolytics were administered, p = 0.655.

Conclusions: Teleconsultation was feasible but technical performance and reliability have to be improved. The approach led to better stroke specific information; however, a superiority over regular EMS care was not found and in-hospital time intervals were unacceptably long in both groups. The feasibility of prehospital tele-stroke consultation has future potential to improve emergency care especially when no highly trained personnel are on-scene.

Trial registration: International Standard Randomised Controlled Trial Number Register (ISRCTN) ISRCTN83270177.

Figure 1. Trial flow.

ALS, Advanced Life Support; EMS, Emergency Medical Service. * if telemedical and standard ambulance had the same distance to emergency location: primary dispatch of telemedical ambulance, regardless of the type of emergency † technical and organizational assessments.

Figure 2. Interior of the telemedically equipped ambulance.

Picture A. Trailing scene with a volunteer in the role of a patient and paramedics from the fire department. The video camera is behind a glass cover (Picture B and indicated by the red arrow). The camera position in the ceiling allows zooming to the patient’s face and looking at all body regions from the teleconsultation center. Picture A provided by Peter Winandy, Aachen, Germany.

Figure 3. Telemedical workstation.

Three monitors display the following information: Vital data (numerical values and curves), transmitted 12-lead-ECGs, transmitted still pictures, video transmission from the ambulance, software to fill out stroke checklist, position of the ambulance via global positioning system, internet access. One touchscreen monitor enabled audio system control and monitoring of data transmission.

Figure 4. Stroke history checklist used.

Translated version, original version in German. The checklist was completed electronically in the teleconsultation center and sent via e-mail to fax to the emergency department and handed over to the neurologist. EMS, Emergency Medical Service; PMH, past medical history.