Telemedicine Stroke Unit Delivers tPA in 'Golden Hour'

Not good enough. I know that negative time is possible. Leaders would settle for nothing less than negative time, in the ambulance.

These people are only thinking of what is currently capable rather than what the best solution is and figure out a way to get there. They are stuck in the past just like your doctor who hasn't read a single research article since medical school. You don't want these people anywhere near you.

Maybe these 17 diagnosis possibilities to find out which one is the best? Or maybe the Qualcomm Xprize for the tricorder?

Hats off to Helmet of Hope - stroke diagnosis in 30 seconds

Microwave Imaging for Brain Stroke Detection and Monitoring using High Performance Computing in 94 seconds 

But the status quo here:

Telemedicine Stroke Unit Delivers tPA in 'Golden Hour' 

• by Salynn Boyles
  Contributing Writer March 08, 2017
• This article is a collaboration between MedPage Today® and:
  

Action Points

• Note that this observational study suggested found that patients in Cleveland treated by a mobile stroke unit had shorter time-to-tPA infusion than those transported in traditional ambulances.
• It remains unclear whether functional outcomes will be improved in this group, and how cost effective the intervention may be.

Suspected stroke patients transported to Cleveland hospitals in the nation's first telemedicine-enabled mobile stroke unit were evaluated and treated nearly twice as fast as those transported in regular ambulances, researchers reported.
Among patients receiving intravenous tissue plasminogen activator (tPA), the time to treatment for those transported in the telemedicine-enabled mobile unit was, on average, 40 minutes shorter.
One-in-four patients receiving tPA were treated within the golden hour of symptom onset, according to Cleveland Clinic neurologist and study researcher Muhammad S. Hussain, MD.
The study, which compared evaluation and treatment times among the first 100 patients transported in the Cleveland Clinic mobile stroke treatment unit (MSTU) to 53 patients brought to hospitals in traditional ambulances, was published March 8 in the journal Neurology.
Significant patient characteristics and stroke severity were similar between the two groups.
Transportation in the telemedicine-enhanced MSTU was associated with significant reductions in:

• median alarm-to CT scan completion times (33 minutes versus 56 minutes, P<0 .0001="" li="">
• median alarm-to-thrombolysis times (55.5 minutes versus 94 minutes, P<0 .0001="" li="">
• median door-to-thrombolysis times (31.5 minutes versus 58 minutes, P=o.oo12),
• and symptom onset-to-thrombolysis times (97 minutes versus 1.22.5 minutes, P=0.0485).

In an interview, Hussain told MedPage Today that the only other mobile stroke units in use when the Cleveland Clinic MSTU went into operation in July of 2014 were in Houston, Texas, and Germany, but those had neurologists on board the mobile stroke units.
The Cleveland MSTU has a nurse, a paramedic, an EMT, and a CT technician on-board connected to a hospital-based vascular neurologist via telemedicine. A neuroradiologist and vascular neurologist also remotely assess images sent from the mobile stroke unit.
Mobile stroke units are now operating in Memphis, Denver, New York City, and Toledo, Ohio, Hussain said, adding that some have physicians on board and others are following the telemedicine model.
"We have shown that we can effectively provide the physician input via video conferencing technology," he said, adding that the model should prove to be significantly less costly than having a neurologist on board.
Among the first 100 patients transported in the Cleveland Clinic MSTU between mid-July and the end of October, 2014, tPA was administered to 16. In a subgroup of patients with probable stroke, the rate of IV tPA administration was 48% (16/33).
More than half (57%) of patients entered the MSTU within four hours of symptom onset.
"Any ischemic stroke patient entering the mobile stroke treatment unit at the four-hour mark could potentially receive thrombolysis as our median door-to-needle time was 31.5 minutes, the fastest one being 13 minutes," the researchers wrote. "Conversely, these patients would almost certainly miss the thrombolysis window if they entered the door of a traditional ambulance at four hours from symptom onset."
In an editorial published with the study, Andrew M. Southerland, MD, of the University of Virginia Health System, Charlottesville, and Ethan S. Brandler, MD, of New York's SUNY Stony Brook Medicine, wrote that despite the early promise of mobile stroke units in stroke care, cost-effectiveness remains a concern.
They noted that in the Cleveland Clinic experience, the MSTU was deployed 317 times to attain 16 tPA treatment cases classified as probable stroke, with just four treatments within the initial hour after symptom onset.
"These included 217 cancellations prior to arrival on site (68% of deployments)," they wrote. "By comparison, in the Prehospital Acute Neurological Stroke [PHANTOM-S] trial in Berlin, Germany, the mobile stroke unit was deployed 2,027 times to achieve 200 tPA treatments, with 349 cancellations prior to arrival (17%)."
The editorial writers noted that this discrepancy may be due to differences in protocol and emergency medical services between the United States and Europe.
They wrote that thus far, the only published analysis of mobile stroke units examining functional outcomes, published in Lancet Neurology in September of 2016, failed to show significance in the primary measure of the proportion of patients with no disability at 3 months compared to conventional medical transport.
Secondary analyses, however, were promising, "and suggested decreased mortality and an increase in the proportion of patients who were able to ambulate independently at three months."
"Hope remains that future trials may demonstrate the ultimate potential of mobile stroke units to improve long-term outcomes for more patients, by treating them more quickly and more effectively. In the meantime, ongoing efforts are needed to streamline medical stroke unit cost and efficiency before achieving road-readiness for widespread health system deployment," Southerland and Brandler wrote.

Funding for this research was provided by Cleveland Clinic and the Milton and Tamar Maltz Family Foundation.
The researchers declared no relevant relationships with industry related to this study.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner