Abstract TP246: Emergency Medical Services Survey of a Low-cost, Ambulance-based System for Mobile Neurological Assessment: The iTREAT Study

Introduction: Modern advances in acute stroke care place an added emphasis on accurate prehospital diagnosis and triage. As part of the Improving Treatment with Rapid Evaluation of Acute Stroke via mobile Telemedicine (iTREAT) study, we assessed the EMS provider experience with a novel system for mobile telestroke assessment. Methods: We developed a 12-question survey with input from local participants in an EMS Council serving rural counties in central Virginia. Providers rated the iTREAT system on feasibility for acute stroke triage, potential effectiveness in prehospital neurological assessment, and interactions with prehospital care. All survey responses were voluntary and anonymous. Results: Since initiation of live patient enrollment, we have completed 34 ambulance-based telestroke encounters with the iTREAT system. Among 7 participating agencies, 19 EMS providers have served as tele-presenters during the telestroke assessment, and 17 EMS providers completed the voluntary survey. Of the respondents, 71% were certified EMS providers for over 5 years. Regarding technical feasibility, 69% experienced issues related to maintaining a video connection, 41% with logging in to the videoconferencing application, and 18% powering on the tablet. Of technical challenges, 41% of providers resolved the issue on their own, 18% with guidance from study staff, and 24% could not resolve the issue. Concerning patient care, 23% felt the system interfered, 35% were neutral, and 41% felt there was no interference. The majority of respondents (71%) agreed that the iTREAT system is feasible for acute stroke triage, and an effective tool (59%) for prehospital neurological assessment. In commentary, EMS participants emphasized the system’s utility in rural areas. Conclusion: This survey of the EMS experience with a low-cost, ambulance-based system for prehospital telestroke assessment reveals both technical challenges and clinical promise. Importantly, technical issues are mostly solvable in real time and correctable for further system refinement. As a novel tool for prehospital neurological assessment and acute stroke triage, the initial EMS evaluation supports further investigation of clinical efficacy, particularly in rural and underserved areas.

Download Full-text

Abstract TP250: Defining Technical Quality Standards for Mobile Telestroke Assessment: A Substudy of the Improving Treatment with Rapid Evaluation of Acute Stroke via Mobile Telemedicine (iTREAT) Mobile Telestroke Platform

Stroke ◽

10.1161/str.47.suppl_1.tp250 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Jason M Lippman ◽

Zachary G Sutton ◽

Timothy L McMurry ◽

Brian Gunnell ◽

Jack Cote ◽

...

Keyword(s):

Acute Stroke ◽

High Speed ◽

Low Cost ◽

Video Quality ◽

Stroke Care ◽

Video Data ◽

Acute Stroke Care ◽

Technical Standards ◽

Quality Ratings ◽

Transmission Quality

Introduction: In-ambulance use of remote videoconferencing for prehospital stroke assessment (mobile telestroke) is an emerging innovation in acute stroke care. As a new technology, there is a dearth of technical standards to ensure transmission quality and guide deployment in various EMS settings. Hypothesis: Subjective video quality ratings during in-vehicle mobile telestroke assessment correlate to objective video data transmission metrics. Methods: We performed videoconferencing via a low-cost, utilitarian mobile telestroke platform: tablet endpoint, high-speed 4G LTE modem, external antennae, HIPAA-secure videoconferencing application, and portable bracket mounting. We held test calls along typical ambulance routes recording transmission quality by a stationary and a mobile rater. We used a standardized 6-point scale of video quality: rating ≥ 4 deemed acceptable for mobile telestroke assessment. We recorded jitter, the variance in transmission data reception order, as simultaneously reported by the videoconferencing application. Results: We completed five test runs yielding 64 data ratings. Average jitter for ratings 1 through 6 was 434.9ms (SD = 407), 106.1ms (SD = 110), 41.4ms (SD = 29), 35.3ms (SD = 15), 29.5ms (SD = 6), and 29.0ms (SD = 2) respectively. Analyzing the raw data yielded an R2 of 0.41. As seen in Chart 1, video quality decreased as average jitter increased, but jitter values as low as 30ms were still seen across video transmission of all qualities. Conclusion: These preliminary data suggest modest correlation of transmission variance with subjective quality ratings using a low-cost mobile telestroke platform along rural-based ambulance routes. However, average transmission variance correlated highly (R2 = 0.93) suggesting more data ratings may improve the correlation. Testing of our mobile telestroke platform to assess performance and clinical efficacy as well as incorporate live acute stroke encounters is ongoing.

Download Full-text

Abstract P278: Improving Stroke Systems of Care in Nebraska

Stroke ◽

10.1161/str.52.suppl_1.p278 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Marco A Gonzalez Castellon ◽

James A BOBENHOUSE ◽

David Franco ◽

Beth L Malina ◽

Mindy Cook ◽

...

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Systems Of Care ◽

Stroke Care ◽

The United States ◽

Advisory Council ◽

Management Tool ◽

Acute Stroke Care ◽

Stroke Systems Of Care ◽

Get With The Guidelines

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

Download Full-text

Utstein recommendation for emergency stroke care

International Journal of Stroke ◽

10.1177/1747493020915135 ◽

2020 ◽

Vol 15 (5) ◽

pp. 555-564 ◽

Cited By ~ 1

Author(s):

AG Rudd ◽

C Bladin ◽

P Carli ◽

DA De Silva ◽

TS Field ◽

...

Keyword(s):

Acute Stroke ◽

Best Practice ◽

Prehospital Care ◽

Public Awareness ◽

Stroke Care ◽

Successful Implementation ◽

Care Needs ◽

Acute Stroke Care ◽

Implementation Program ◽

Prehospital Triage

Background Recent advances in treatment for stroke give new possibilities for optimizing outcomes. To deliver these prehospital care needs to become more efficient. Aim To develop a framework to support improved delivery of prehospital care. The recommendations are aimed at clinicians involved in prehospital and emergency health systems who will often not be stroke specialists but need clear guidance as to how to develop and deliver safe and effective care for acute stroke patients. Methods Building on the successful implementation program from the Global Resuscitation Alliance and the Resuscitation Academy, the Utstein methodology was used to define a generic chain of survival for Emergency Stroke Care by assembling international expertise in Stroke and Emergency Medical Services (EMS). Ten programs were identified for Acute Stroke Care to improve survival and outcomes, with recommendations for implementation of best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through public awareness, optimized prehospital triage and timely diagnostics, and quick and equitable access to acute treatments. Documentation, use of metrics and transparency will help to build a culture of excellence and accountability.

Download Full-text

Optimal patient protocols in regional acute stroke care

Health Care Management Science ◽

10.1007/s10729-020-09524-2 ◽

2021 ◽

Author(s):

B. L. Garcia ◽

R. Bekker ◽

R. D. van der Mei ◽

N. H. Chavannes ◽

N. D. Kruyt

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Interventional Procedure ◽

Treated Patient ◽

Stroke Care ◽

Mixed Integer ◽

Acute Stroke Care ◽

Mixed Integer Linear Program ◽

Patient Allocation ◽

Stroke Centre

AbstractIn acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be given in a stroke centre with specialized facilities. Rapid initiation of either is key to improving the functional outcome (often emphasized by the common phrase in acute stroke care “time=brain”). Delays between the moment the ambulance is called and the initiation of one or both reperfusion treatment(s) should therefore be as short as possible. The speed of the process strongly depends on five factors: patient location, regional patient allocation by emergency medical services (EMS), travel times of EMS, treatment locations, and in-hospital delays. Regional patient allocation by EMS and treatment locations are sub-optimally configured in daily practice. Our aim is to construct a mathematical model for the joint decision of treatment locations and allocation of acute stroke patients in a region, such that the time until treatment is minimized. We describe acute stroke care as a multi-flow two-level hierarchical facility location problem and the model is formulated as a mixed integer linear program. The objective of the model is the minimization of the total time until treatment in a region and it incorporates volume-dependent in-hospital delays. The resulting model is used to gain insight in the performance of practically oriented patient allocation protocols, used by EMS. We observe that the protocol of directly driving to the nearest stroke centre with special facilities (i.e., the mothership protocol) performs closest to optimal, with an average total time delay that is 3.9% above optimal. Driving to the nearest regional stroke centre (i.e., the drip-and-ship protocol) is on average 8.6% worse than optimal. However, drip-and-ship performs better than the mothership protocol in rural areas and when a small fraction of the population (at most 30%) requires the second procedure, assuming sufficient patient volumes per stroke centre. In the experiments, the time until treatment using the optimal model is reduced by at most 18.9 minutes per treated patient. In economical terms, assuming 150 interventional procedures per year, the value of medical intervention in acute stroke can be improved upon up to € 1,800,000 per year.

Download Full-text

Stroke Care in Pakistan

Cerebrovascular Diseases Extra ◽

10.1159/000519554 ◽

2021 ◽

pp. 118-121

Author(s):

Anjum Farooq ◽

Narayanaswamy Venketasubramanian ◽

Mohammad Wasay

Keyword(s):

Acute Stroke ◽

Plasminogen Activator ◽

Rural Areas ◽

Recombinant Tissue Plasminogen Activator ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Units ◽

Stroke Outcomes ◽

Tissue Plasminogen ◽

Urban And Rural Areas

Increasing incidence of stroke and lack of infrastructure in both urban and rural areas needs immediate attention in Pakistan. There is a high proportion of young stroke with poor stroke outcomes. Acute stroke care is scarce in Pakistan due to the small number of neurologists (1 neurologist per 1 million population), few stroke units, and limited availability of alteplase (recombinant tissue plasminogen activator) in the country.

Download Full-text

Prehospital EMS Triage for Acute Stroke Care

Seminars in Neurology ◽

10.1055/s-0040-1722725 ◽

2021 ◽

Vol 41 (01) ◽

pp. 005-008

Author(s):

Ali Reza Noorian

Keyword(s):

Acute Stroke ◽

New Technologies ◽

Systems Of Care ◽

Prehospital Care ◽

Stroke Care ◽

Acute Stroke Care ◽

Stroke Units ◽

Levels Of Care ◽

Stroke Systems Of Care ◽

Efficient Care

AbstractAcute stroke has had major advances over the last two decades due to the introduction of pharmacologic and endovascular revascularization, which can improve functional outcome. Stroke systems of care have been developed to provide faster, more efficient care for stroke patients. A major part of these care pathways is prehospital care, when patients are triaged to appropriate levels of care. It is essential that prehospital scales are used accurately and effectively by emergency medical services to assist them with the triage process. New technologies including mobile stroke units, telemedicine, and wearable technology have been introduced as options for optimization of this emergent process.

Download Full-text

Abstract TP236: Geographical Disparity of Acute Stroke Care Capabilities in Japan From a Nationwide Database: J-ASPECT Study

Stroke ◽

10.1161/str.48.suppl_1.tp236 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Koichi Arimura ◽

Kunihiro Nishimura ◽

Akiko Kada ◽

Satoru Kamitani ◽

Kuniaki Ogasawara ◽

...

Keyword(s):

Hospital Mortality ◽

Acute Stroke ◽

Rural Areas ◽

Patient Characteristics ◽

Stroke Care ◽

International Classification Of Diseases ◽

Stroke Severity ◽

Acute Stroke Care ◽

Nationwide Database ◽

Geographical Disparity

Objective: We previously demonstrated comprehensive stroke care (CSC) capabilities of the hospitals affect in-hospital mortality of patients with acute stroke. With the advent of unprecedented aging society, proper implementation of stroke centers requires understanding of geographical disparity of patient characteristics as well as stroke care capabilities. The aim of this study was to elucidate such geographical disparity regarding acute stroke care in Japan using a nationwide database. Materials and methods: We analyzed the data obtained from the Japanese Diagnosis Procedure Combination-based Payment System in 445 institutions between 2010 and 2012. Patients hospitalized emergently for ischemic stroke(IS), non-traumatic intracerebral hemorrhage(ICH) and non-traumatic subarachnoid hemorrhage(SAH) were identified using International Classification of Diseases-10 diagnosis codes. We classified the location of the hospitals into 4 areas, “Metropolitan Employment Area-Central (MEA-C)”, “ Metropolitan Employment Area-Outlying (MEA-O)”, “Micropolitan Employment Area-Central (McEA-C)”, and “ Micropolitan Employment Area-Outlying (McEA-O)”. We investigated patient characteristics, medical backgrounds, interventions and outcomes for each area. Results: Data obtained from a total of 214,910 patients with acute strokes (136,753 IS, 60,379 ICH and 17,778 SAH) were analyzed. As for patient characteristics, elderly patients and those with hypertension were more common in McEA-C and McEA-O, and stroke severity was more severe in McEA-C in all stroke types. As for hospital characteristics, proportion of admission by ambulance and CSC capabilities of the hospitals were smaller in all stroke types. Moreover, emergent interventions such as intravenous rt-PA infusion were performed at a lesser extent and in-hospital mortality was higher in McEA-C and McEA-O, and severe disability with mRS 3-6 was more often noted in McEA-C in all stroke types. Conclusion: We demonstrated geographical disparity of acute stroke care in Japan from a nationwide database. For proper implementation of stroke centers, centralization of acute stroke care capabilities should be considered in the rural areas to improve outcomes of acute stroke.

Download Full-text