4G versus 3G-enabled telemedicine in prehospital acute stroke care

Abstract

Background

Time to reperfusion treatment is closely related to outcome in ischemic stroke. Prehospital stroke work-up in CT-equipped mobile stroke units is effective in reducing time to thrombolytic treatment. Current evidence predominantly comes from mobile stroke units staffed with neurologists but telemedicine-guided management may be acceptable for providing neurological expertise in ambulances. With unsatisfactory experiences in third-generation (3G)-based approaches, fourth-generation (4G) networks may provide adequate audio-visual quality but systematic comparisons of technological parameters and decision-making are lacking.

Methods

Trained actors presented stroke symptoms and paramedics assisted the remotely guided extended National Institutes of Health Stroke Scale (eNIHSS) assessment on the mobile stroke unit in Berlin, Germany. We compared technical parameters of 4G and 3G connections, assessed audio-visual quality of examination, and analyzed reliability of neurological assessment and treatment decisions made by the remote neurologist versus the mobile stroke unit neurologist.

Results

4G and 3G connections were evaluated in 40 scenarios each. Connectivity was not available in 17% of 4G- and 15% of 3G-attempts with 6% simultaneous unavailability of both networks. The remote examiners graded audio and video quality in 4G better than in 3G with slightly shorter assessment duration in 4G (mean: 9 (SD:5) vs. mean 11 (SD:3) min, p = 0.10). Reliability of the eNIHSS sum scores was high with intraclass correlation coefficients of 0.99 (95% CI: 0.987–1.00) for 4G and 0.98 (95% CI: 0.96–0.99) for 3G. None of the remote treatment decisions differed from onsite decisions.

Conclusions

4G mobile communications provided higher quality of video-examination and allowed reliable remote assessment of stroke symptoms but coverage was still incomplete in both networks.

Keywords

Stroke telemedicine thrombolysis prehospital emergency medical services

Get full access to this article

View all access options for this article.

References

Emberson

Lees

Lyden

, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384: 1929–1935.

Ebinger

Winter

Wendt

, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014; 311: 1622–1631.

Walter

Kostopoulos

Haass

, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol 2012; 11: 397–404.

Audebert

Saver

Starkman

Lees

Endres

. Prehospital stroke care: new prospects for treatment and clinical research. Neurology 2013; 81: 501–508.

Liman

Winter

Waldschmidt

, et al. Telestroke ambulances in prehospital stroke management: concept and pilot feasibility study. Stroke 2012; 43: 2086–2090.

Bergrath

Reich

Rossaint

, et al. Feasibility of prehospital teleconsultation in acute stroke—a pilot study in clinical routine. PLoS One 2012; 7: e36796.

Bergrath

Reich

Rossaint

, et al. Feasibility of prehospital teleconsultation in acute stroke—a pilot study in clinical routine. PLoS One 2012; 7: e36796.

Ebinger

Rozanski

Waldschmidt

, et al. Phantom-s: the prehospital acute neurological therapy and optimization of medical care in stroke patients—study. Int J Stroke 2012; 7: 348–353.

Koch

Kunz

Ebinger

, et al. Influence of distance to scene on time to thrombolysis in a specialized stroke ambulance. Stroke 2016; 47: 2136–2140.

10.

Wendt

Tutuncu

Fiebach

Scheitz

Audebert

Nolte

. Preclusion of ischemic stroke patients from intravenous tissue plasminogen activator treatment for mild symptoms should not be based on low national institutes of health stroke scale scores. J Stroke Cerebrovasc Dis 2013; 22: 550–553.

11.

Van Hooff

Cambron

Van Dyck

, et al. Prehospital unassisted assessment of stroke severity using telemedicine: a feasibility study. Stroke 2013; 44: 2907–2909.

12.

Bowry

Parker

Rajan

, et al. Benefits of stroke treatment using a mobile stroke unit compared with standard management: the BEST-MSU study run-in phase. Stroke 2015; 46: 3370–3374.

13.

Itrat

Taqui

Cerejo

, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol 2016; 73: 162–168.

14.

Parker

Jagolino

, et al. Telemedicine can replace the neurologist on a mobile stroke unit. Stroke 2017; 48: 493–496.

15.

Ramadan

Denny

Vahidy

, et al. Agreement among stroke faculty and fellows in treating ischemic stroke patients with tissue-type plasminogen activator and thrombectomy. Stroke 2017; 48: 222–224.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.21 MB