Telemedicine in Prehospital Acute Stroke Care

Abstract

Background Mobile stroke units ( MSU s), 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) MSU s 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.

Keywords: emergency medical services; emergency medicine; ischemic stroke; telemedicine; thrombolysis.

Figure 1

Reasons for exclusion of patients are depicted for both studies, TeDir (TeleDiagnostics in Prehospital Emergency Medicine [Tele‐Diagnostik im Rettungsdienst]) and PrioLTE2 (Reliability of Telemedically Guided Prehospital Acute Stroke Care With Prioritized 4G Mobile Network Long‐Term Evolution) separately.

Figure 2

Bland‐Altman plot for the agreement of the neurological examination between the mobile stroke unit (MSU) and remote neurologist as measured in National Institutes of Health Stroke Scale (NIHSS) points. Mean average of the difference between both neurologists is −0.52 (mean average of difference=−0.52; 95% CI, 0.84–0.21), shown as the red horizontal line), the upper and lower limits of agreement are 2.42 and −3.46 (blue horizontal lines). The difference in NIHSS points is depicted on the y axis and the mean average of NIHSS points on the x axis. Some scores were shared by >1 patient. The more simultaneously shared scores, the larger the diameter of the circles; that is, light gray=26 patients, orange=7 patients, gray=6 patients, light blue=5 patients, cyan=4 patients, green=3 patients, red=2 patients.