New Study Shows In-Transit Telemedicine Speeds Ischemic Stroke Treatment

For patients experiencing ischemic stroke—the leading cause of disability in the United States—time to treatment is critically important for avoiding irreversible brain damage. A study by researchers at Overlook Medical Center and Atlantic Health System published by the journal Stroke shows that patients evaluated in ambulances while in-transit to the hospital, could be treated with the brain saving drug alteplase 13 minutes faster once in the emergency department (ED)—referred to as door-to-needle (DTN) time—than patients not evaluated with in-transit telestroke (ITTS).

The first-of-its-kind study assessed 89 presumptive stroke patients in ambulances over 15 months (January 2015 to March 2016). Atlantic Health System paramedics responding to neurological emergencies used an InTouch Xpress device—a portable unit with a high-definition camera, microphone, and screen—allowing video communication with a stroke neurologist who performed a neurological evaluation of the patient while in-transit to the ED. Once the patients arrived at the participating hospital's ED, the neurologist assumed care and, when indicated, administered alteplase, a tissue plasminogen activator that breaks down blood clots to restore blood flow to the brain.

"We are constantly looking for ways to treat stroke patients as quickly as possible, as each passing minute of lost blood supply translates to more brain damage," explains John J. Halperin, MD, lead study investigator and chair of the department of neurosciences at Overlook Medical Center. "Our observations suggest that in-transit telestroke may provide a scalable, inexpensive way to expedite stroke treatment. We are hopeful that the outcome of this study will encourage more hospitals and ambulance corps to adopt telemedicine for stroke."

Study Details
Atlantic Health System, a not-for-profit multihospital system in suburban New Jersey, includes Overlook Medical Center, a Joint Commission–certified Comprehensive Stroke Center, and Chilton Medical Center, a Primary Stroke Center. Overlook provides 24/7 telestroke coverage to six EDs, including Chilton. The current study was piloted at Overlook and Chilton, selected for well-functioning ED telestroke systems (DTN<45 minutes for 85% of patients at both) and an EMS structure facilitating implementation.

New Jersey's EMS is organized in a two-tiered system, comprised of over 500 Basic Life Support (BLS) units and 22 advanced life support (ALS) units. When ALS paramedics are engaged by 911 dispatchers, they join BLS first responders at the scene and then accompany the patient to the ED. Atlantic Health System has two ALS units serving Overlook Medical Center and covering a population of 300,000, and two ALS units serving Chilton Medical Center and covering a population of 160,000.

Each of these four ALS units was provided an InTouch Xpress device, which is clamped onto BLS ambulance stretchers, allowing images to be transmitted by 4G wireless during patient transport. Atlantic Health System paramedics determined patient eligibility, then collaborated with the stroke teleneurologist in performing the neurological evaluation. In the ED, the stroke team, typically with the same stroke neurologist performing in-ambulance assessment, assumed care.

Interventions
From January 2015 through March 2016, all patients managed by these four ALS units, with an abnormal Cincinnati Stroke Scale or otherwise suspected stroke, brought to these two EDs, were assessed with ITTS. We compared DTN and last-known-well to needle (LKWTN) times in this group with all other intravenous alteplase–treated stroke patients brought to these two EDs by EMS. Twenty-five treated walk-in stroke patients were excluded. Analysis was intention to treat; patients with failed ITTS were included in the telestroke group. Prespecified primary outcome measures were the differences in DTN and LKWTN times between these two groups.

Results
Eighty-nine patients with suspected strokes were evaluated by ITTS. There were no misses; all alteplase-treated strokes brought to the Overlook ED by these two ALS units had ITTS. Mean tele-consult duration was 7.3 minutes among the 15 (17%) receiving alteplase and 4.7 minutes among the 74 who did not. Although 39% of tele-consults required reconnection, connectivity was rapidly reestablished in all but two; in all but these two, the tele-neurologist felt the clinical evaluation was satisfactory.

Source: Atlantic Health System