Conference Coverage
A mobile stroke treatment unit using telemedicine is feasible, according to a study that reports on the initial experience with this type of unit in Ohio. In the February issue of JAMA Neurology, lead author Ahmed Itrat, MD, a neurologist at the Cerebrovascular Center at the Cleveland Clinic, and colleagues reported that their mobile stroke treatment unit had a low rate of technical failure and allowed a physician to cover multiple mobile stroke treatment units, thus broadening the geographic coverage and rendering the concept efficient and cost-effective.
Mobile stroke treatment units 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. With this idea in mind, Dr. Itrat and colleagues tested whether telemedicine is reliable and whether remote physician presence is adequate for acute stroke treatment using a mobile stoke treatment unit.
Real-World Data
Dr. Itrat and colleagues conducted a prospective observational study between July 18 and November 1, 2014. Their community-based study assessed telemedicine and the mobile stroke treatment unit in Cleveland. Participants were the first 100 Cleveland residents who had acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the mobile stroke treatment unit after implementation of the telemedicine stroke treatment program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile CT. Data were entered into the medical records and a prospective registry.
The 3.5-month study compared the evaluation and treatment of patients on the mobile stroke treatment unit with the evaluation and treatment of a control group of patients brought to the emergency department by ambulance during the same year. Process times were measured from the time the patient entered the door of the mobile unit or emergency department. Any problems encountered during the stroke evaluation were recorded.
The researchers reported that 99 of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes. One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were six telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Sixteen patients received thrombolysis in the mobile stroke treatment unit. Times from the door to CT completion (13 minutes) and from door to IV thrombolysis (32 minutes) were significantly shorter in the mobile stroke treatment unit group, compared with the control group (18 minutes and 58 minutes, respectively). Times to CT interpretation did not differ significantly between the groups.
"While studies have modeled mobile stroke units to be cost-effective from the societal perspective, our investigation implies further reduction in operational costs of mobile stroke treatment units. Obviating the need for an on-site neurologist and neuroradiologist would allow multiple mobile units to be operated that are geographically distant from the physician," the researchers said.
A Wise Use of Limited Resources?
In an accompanying editorial, Martin Ebinger, MD, and Heinrich J. Audebert, MD, neurologists at Charité—Universitätsmedizin Berlin, state that "the occasionally emotional debate about prehospital thrombolysis usually revolves around the wise use of limited resources." Vascular neurologists, they point out, are a bottleneck for prehospital thrombolysis concepts. They are in short supply, and sending them out into the community seems counterintuitive, hence the appeal of telemedicine. The editorialists posit that "Stroke is a predestined disease for telemedicine because symptoms are audiovisually transmittable, and CT images can easily be accessed remotely. Obviously, replacing a personal encounter with a telemedicine consultation has its limitations. However, in a time-critical scenario such as stroke, the advantages of fast decisions about thrombolysis or thrombectomy may outweigh the shortcomings."
—Glenn S. Williams