Ambulance-based assessment of NIH Stroke Scale with telemedicine: A feasibility pilot study

Abstract

Background Ischemic stroke is a time-sensitive disease, with improved outcomes associated with decreased time from onset to treatment. It was hypothesised that ambulance-based assessment of the National Institutes of Health Stroke Scale (NIHSS) using a Health Insurance Portability and Accountability Act (HIPAA)-compliant mobile platform immediately prior to arrival is feasible. Methods This is a proof-of-concept feasibility pilot study in two phases. The first phase consisted of an ambulance-equipped HIPAA-compliant video platform for remote NIHSS assessment of a simulated stroke patient. The second phase consisted of remote NIHSS assessment by a hospital-based neurologist of acute stroke patients en route to our facility. Five ambulances were equipped with a 4G/LTE-enabled tablet preloaded with a secure HIPAA-compliant telemedicine application. Secondary outcomes assessed satisfaction of staff with the remote platform. Results Phase one was successful in the assessment of three out of three simulated patients. Phase two was successful in the assessment of 10 out of 11 (91%) cases. One video attempt was unsuccessful because local LTE was turned off on the device. The video signal was dropped transiently due to weather, which delayed NIHSS assessment in one case. Average NIHSS assessment time was 7.6 minutes (range 3-9.8 minutes). Neurologists rated 83% of encounters as 'satisfied' to 'very satisfied', and the emergency medical service (EMS) rated 90% of encounters as 'satisfied' to 'very satisfied'. The one failed video attempt was associated with 'poor' EMS satisfaction. Conclusion This proof-of-concept pilot demonstrates that remote ambulance-based NIHSS assessment is feasible. This model could reduce door-to-needle times by conducting prehospital data collection.

A scoping review of pre-hospital technology to assist ambulance personnel with patient diagnosis or stratification during the emergency assessment of suspected stroke

“…Technologies employed by included studies [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] were best described using three categories: blood biomarkers [22,23]; pre-hospital imaging [24,25] and mobile telemedicine/telestroke (including transfer of audio and/or visual information or relevant data) [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]. These are summarised in Table 1. Most studies were conducted in the USA [24,26,27,[34][35][36][37][38][39], followed by Germany [28]…”

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association

“…119 More recent studies examined the paradigm again and showed that the transmission of video data reached acceptable levels of quality and reliability. 118,120 However, the most compelling evidence comes from the STEMO (Stroke Emergency Mobile) project in Berlin in which the use of a mobile stroke unit with onboard neurologist but remote teleradiologist has led to more rapid alarm-to-needle times with no increase in the rate of complications and improvement in outcomes estimated at €32 456 per quality-adjusted life-year. 121,122 In the United States, several ongoing pilot studies of mobile stroke units suggest that the model is robust and that a teleneurologist may be able to substitute for an onboard neurologist.…”

“…118 Early attempts at mobile ambulance-based telehealth were hampered by inadequate bandwidth and reliability, but recent advances in telecommunications technology have enabled newer more robust solutions. The TeleBAT intervention from the team at University of Maryland used wireless cellular technology in ambulances to transmit visual and auditory data to a stroke neurologist in real time at very low frame rates and was neither practical nor scalable.…”

Robot-assisted surgical ward rounds: virtually always there

“…While the inspection component of physical examination performed via visual telecommunication devices has been validated,58 – 60 the main limitation of the technology remains the inability of the remote operator to complete full physical examination. We overcame this by a team approach, with an NCHD accompanying the robot and examining where indicated.…”