Stroke Rounds: Telemedicine Shortens Door-to-Needle Time

Big f*cking whoopee.
The BHAG should be in the ambulance, getting rid of the scan and the neurologist. This is definitely doable. 
Test out these 17 diagnosis possibilities to find out which one is the best?  Or maybe the Qualcomm Xprize for the tricorder?    But don't worry, NONE of these will be tested, you'll be screwed just as you normally are.
http://www.medpagetoday.com/Cardiology/Strokes/55065?

Nearly half-hour saved in innovative program, (So? Was that fast enough to stop the neuronal cascade of death? That would be the a main definition of success.)

A mobile stroke treatment unit (MSTU) operated by Cleveland Clinic which uses telemedicine to connect emergency team members to a hospital-based vascular neurologist, reduced time to tPA treatment by more than 25 minutes in an analysis of the first 100 patients transported.
Ninety-nine of the 100 transports were successful with just one connection failure occurring due to crew error, and door to CT completion times were also shortened, researcher Ken Uchino, MD, and colleagues wrote in the journal JAMA Neurology, published online Dec. 7.

Cleveland Clinic is the first medical center in the country to incorporate telemedicine into MSTU transport in an effort to reduce stroke assessment and treatment times and eliminate the need for a neurologist on board the ambulance. The initiative is being conducted in partnership with the city of Cleveland, the Cleveland Emergency Medicine Service, and other area participating hospitals.
More than 400 patients have been transported by the telemedicine-assisted MSTUs since the program began operations in July 2014.
"With this approach the neurologist could potentially be in another city or even another state," Uchino told MedPage Today. "We have shown that mobile stroke evaluation and treatment is feasible."
Uchino explained that the MSTUs, which are staffed with a registered nurse, paramedic, emergency medical technician (EMT), and a CT technologist, are dispatched when 911 operators suspect possible stroke.
CT is performed on board the MSTU and a neuroradiologist remotely assesses the images obtained by CT. The ambulance is also equipped with its own lab to measure prothrombin time, blood glucose, electrolyte levels, hemoglobin levels, platelet, and leukocyte counts.

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During the initial phase of the program from July 18 to Nov. 1, 2014, the MSTU was deployed 317 times; dispatches were cancelled in 217 of these cases before hospital arrival.
The remaining 100 patients (31.5%) underwent urgent evaluation in the MSTU. A diagnosis of probable ischemic stroke was made in 33 patients, and 26 of these patient (78.8%) were transferred to one of three comprehensive stroke centers, while seven received treatment at a stroke-certified hospital.
The telemedicine assessment was successfully completed in 99 of the 100 attempts, with the failure occurring when the power supply to the telemedicine station on the MSTU was not switched on and video could not be initiated. This patient was transported to the nearest emergency department where stroke evaluation was performed.
Ninety-three telemedicine assessments were conducted without transmission disruptions and the median door to video log-in time was 11 minutes (interquartile range, 7-17 minutes). The median video log-in duration was 20 minutes (IQR 14-27 minutes).
Video disconnections occurred in six instances, with five occurring due to poor wireless reception and one due to the use of a tablet computer by the neurologist which was not compatible with the devices on the MSTU. No video disconnections lasted longer than 60 seconds and they were not determined to have adversely affected clinical care.

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Ninety-nine of the 100 patients had CT performed in the MSTU and 16 received IV tPA in the MSTU. One additional patient was a candidate for MSTU-delivered IV tPA, but could not be evaluated because of video failure. This patient received IV-tPA after hospital arrival.
When the 100 MSTU patients were compared with 56 patients matched for age and stroke severity who were evaluated at hospital emergency departments, median door to CT completion time, door to international normalized ratio result time, and time to IV tPA administration were found to be shorter in the MSTU group:

• Time from door to CT completion was 13 minutes in the MSTU group (IQR 9-21 minutes) and 18 minutes in the ED group (IQR 12-26 minutes)
• Time from door to IV thrombolysis was 32 minutes in the MSTU group (IQR 24-47 minutes) and 58 minutes in the ED group (IQR 53-68 minutes)
• Time to CT interpretation did not differ significantly between the two groups

Uchino noted that earlier attempts at using telemedicine to evaluate and treat stroke patients before hospital arrival have been hampered by technological issues that limited connectivity.
"Improvements in wireless network communication in just the last few years have made this less of an issue," he told MedPage Today.
In an editorial published with the study, Martin Ebinger, MD, and Heinrich Audebert, MD, of Charite-Universitatsmedizin, Berlin, Germany, wrote that stroke is an obvious candidate for telemedicine because symptoms "are audiovisually transmittable and computed tomographic images can be easily accessed remotely."

"Obviously, replacing a personal encounter with a telemedicine consultation has its limitations," they wrote. "However, in a time-critical scenario such as stroke, the advantages of fast decisions about thrombolysis or thrombectomy may outweigh the shortcomings. Most patients with stroke faced with the two options of no neurologist(the goal should be no neurologist because we have objectively determined which way to go) or an expert telemedicine consultation would clearly prefer the latter."