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Lee HW, Ko YC, Tang SC, Hsieh MJ, Tsai LK, Chiang WC, Jeng JS, Ma MHM. Prehospital neurologic assessment using mobile phones: Comparison between neurologists and emergency physicians. J Formos Med Assoc 2024:S0929-6646(24)00292-4. [PMID: 38902123 DOI: 10.1016/j.jfma.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/08/2024] [Accepted: 06/17/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Ambulance-based telestroke may be a promising solution to improving stroke care. We assessed the technical feasibility and reliability of prehospital evaluations using commercial mobile phones with fifth-generation wireless communication technology. METHODS Six standardized patients portrayed scripted stroke scenarios during ambulance transport in an urban city and were remotely evaluated by independent raters using tablets (three neurologists and three emergency physicians) in a hospital, assisted by paramedics (trained in National Institute of Health Stroke Scale [NIHSS] assessment) in the ambulance; commercial cellular networks were utilized for videoconferencing transmission. The primary outcomes were mean difference (MD) and correlation of NIHSS scores between the face-to-face and remote assessments. We also examined the Bland-Altman plot for itemized NIHSS components, and Kaplan-Meier curves were used to compare the differences in the duration of the two evaluations between neurologists and emergency physicians. RESULTS We conducted 32 ambulance runs and successfully completed all NIHSS examinations. No significant difference was found between the face-to-face and remote evaluations (MD, 0.782; 95% confidence interval [CI], -0.520-0.395). The correlation of NIHSS scores between the two methods was 0.994 (95% CI, 0.945-1.026), and three items exhibited the highest frequency of runs, with score differences between the two methods. There were no significant differences between neurologists and emergency physicians in the mean evaluation duration and NIHSS scores for the two methods. CONCLUSION Prehospital evaluation using commercial mobile phones with fifth-generation wireless communication technology is feasible and reliable during ambulance transport in urban areas. Emergency physicians and neurologists performed similarly in stroke evaluations.
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Affiliation(s)
- Hong-Wei Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chih Ko
- Section of Emergency Medicine, Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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Sarpourian F, Ahmadi Marzaleh M, Fatemi Aghda SA, Zare Z. Application of Telemedicine in the Ambulance for Stroke Patients: A Systematic Review. Prehosp Disaster Med 2023; 38:774-779. [PMID: 37877359 DOI: 10.1017/s1049023x23006519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The use of telemedicine for the prehospital management of emergency conditions, especially stroke, is increasing day by day. Few studies have investigated the applications of telemedicine in Emergency Medical Services (EMS). A comprehensive study of the applications of this technology in stroke patients in ambulances can help to build a better understanding. Therefore, this systematic review was conducted to investigate the use of telemedicine in ambulances for stroke patients in 2023. METHODS A systematic search was conducted in PubMed, Cochrane, Scopus, ProQuest, Science Direct, and Web of Science from 2013 through March 1, 2023. The authors selected the articles based on keywords and criteria and reviewed them in terms of title, abstract, and full text. Finally, the articles that were related to the study aim were evaluated. RESULTS The initial search resulted in the extraction of 2,795 articles. After review of the articles, and applying the inclusion and exclusion criteria, seven articles were selected for the final analysis. Three (42.85%) studies were on the feasibility and intervention types. Also, randomized trials, feasibility, feasibility and prospective-observational, and feasibility and retrospective-interventional studies were each one (14.28%). Six (85.71%) of the studies were conducted in the United States. The National Institutes of Health Stroke Scale (NIHSS) and RP-Xpress were the most commonly used tools for neurological evaluations and teleconsultations. CONCLUSION Remote prehospital consultations, triage, and sending patient data before they go to the emergency department can be provided through telemedicine in ambulances. Neurological evaluations via telemedicine are reliable and accurate, and they are almost equal to in-person evaluations by a neurologist.
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Affiliation(s)
- Fatemeh Sarpourian
- PhD Candidate of Health Information Management, Student Research Committee, Department of Health Information Technology, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Milad Ahmadi Marzaleh
- Department of Health in Disasters and Emergencies, Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Fatemi Aghda
- PhD Candidate of Medical Informatics, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Zare
- PhD Candidate in Health Care Management, Department of Health Care Management, School of Health Management and Information Sciences, Shiraz University of Medical Science, Shiraz, Iran
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English SW, Chhabra N, Hanus AE, Basharath R, Miller M, Butterfield RJ, Zhang N, Demaerschalk BM. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare 2023:1357633X231204066. [PMID: 37899587 DOI: 10.1177/1357633x231204066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. METHODS This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. RESULTS A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. DISCUSSION Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.
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Affiliation(s)
- Stephen W English
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Nikita Chhabra
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
| | - Abigail E Hanus
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Rida Basharath
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Monet Miller
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Bart M Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
- Center for Digital Health, Mayo Clinic, Rochester, MI, USA
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Fladt J, Ospel JM, Singh N, Saver JL, Fisher M, Goyal M. Optimizing Patient-Centered Stroke Care and Research in the Prehospital Setting. Stroke 2023; 54:2453-2460. [PMID: 37548010 DOI: 10.1161/strokeaha.123.044169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Over the past decades, continuous technological advances and the availability of novel therapies have enabled treatment of more acute medical conditions than ever before. Many of these treatments, such as intravenous thrombolysis and mechanical thrombectomy for acute ischemic stroke, are highly time sensitive. This has raised interest in shifting advanced acute care from hospitals to the prehospital setting. Key objectives of advanced prehospital stroke care may include (1) early targeted treatments in the prehospital setting, for example, intravenous thrombolysis for acute stroke, and (2) advanced prehospital diagnostics such as prehospital large vessel occlusion and intracranial hemorrhage detection, to help inform patient triage and potentially reduce subsequent workload in emergency departments. Major challenges that may hamper a swift transition to more advanced prehospital care are related to conducting clinical trials in the prehospital setting to provide sufficient evidence for emergency interventions, as well as ambulance design, infrastructure, emergency medical service personnel training and workload, and cost barriers. Utilizing new technologies such as telemedicine, mobile stroke units and portable diagnostic devices, customized software applications, and smart storage space management may help surmount these challenges and establish efficient, targeted care strategies that are achievable in the prehospital setting. In this article, we delineate the paradigm of shifting advanced stroke care to the prehospital setting and outline future directions in providing evidence-based, patient-centered prehospital care. While we use acute stroke as an illustrative example, these principles are not limited to stroke patients and can be applied to prehospital triage for any time-critical disease.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland (J.F.)
| | - Johanna M Ospel
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
| | - Nishita Singh
- Department of Neurology, University of Manitoba, Winnipeg, Canada (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
| | - Mayank Goyal
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (J.F., J.M.O., M.G.)
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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Zachrison KS, Nielsen VM, de la Ossa NP, Madsen TE, Cash RE, Crowe RP, Odom EC, Jauch EC, Adeoye OM, Richards CT. Prehospital Stroke Care Part 1: Emergency Medical Services and the Stroke Systems of Care. Stroke 2023; 54:1138-1147. [PMID: 36444720 PMCID: PMC11050637 DOI: 10.1161/strokeaha.122.039586] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute stroke care begins before hospital arrival, and several prehospital factors are critical in influencing overall patient care and poststroke outcomes. This topical review provides an overview of the state of the science on prehospital components of stroke systems of care and how emergency medical services systems may interact in the system to support acute stroke care. Topics include layperson recognition of stroke, prehospital transport strategies, networked stroke care, systems for data integration and real-time feedback, and inequities that exist within and among systems.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Natalia Perez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias I Pujol, Badalona, Spain and Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (N.P.d.l.O)
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (K.S.Z., R.E.C.)
| | | | - Erika C Odom
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (E.C.O.)
| | - Edward C Jauch
- Department of Research, University of North Carolina Health Sciences at Mountain Area Health Education Center, Asheville, NC (E.C.J.)
| | - Opeolu M Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (O.M.A.)
| | - Christopher T Richards
- Division of EMS, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH (C.T.R.)
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Jobé C, Carron PN, Métrailler P, Bellagamba JM, Briguet A, Zurcher L, Dami F. Introduction of Telemedicine in a Prehospital Emergency Care Setting: A Pilot Study. Int J Telemed Appl 2023; 2023:1171401. [PMID: 37007985 PMCID: PMC10063356 DOI: 10.1155/2023/1171401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/04/2023] [Accepted: 03/11/2023] [Indexed: 04/04/2023] Open
Abstract
Background Advances in information and communication technology have led to telemedicine applications that could support paramedics in the prehospital field. In an effort to optimise the available resources like prehospital emergency physicians (PHP), the State Health Services of a Swiss state decided to launch a pilot study on the feasibility of using telemedicine in the prehospital emergency setting. Objective The primary objective was to measure the number of missions completed without technical problems with remote PHP support through telemedicine (tele-PHP). The secondary objectives were to evaluate the safety of this protocol and to describe the actions and decisions that clinicians can make by using tele-PHP. Methods This was a prospective observational pilot study on all missions involving the dispatch of ground PHP or tele-PHP. The severity score, dispatch criteria, actions, and decisions made by ground PHP and tele-PHP were collected. Results PHP were dispatched simultaneously with an ambulance on 478 occasions, including 68 (14%) situations that started directly with tele-PHP. Among those situations, three had to be transformed into on-site PHP missions after the on-site evaluation by paramedics. Fifteen missions were cancelled by paramedics once they were on site, and six missions encountered a connection issue. Forty-four PHP missions that were dispatched simultaneously with paramedics were completed by tele-PHP only without any connection problems. Paramedics and PHP estimated that actions or decisions were provided by PHP in 66% of the on-site PHP missions and 34% of the tele-PHP missions. Conclusions This is the first experience of tele-PHP regarding PHP dispatch in Switzerland. Despite the small number of missions carried out, tele-PHP could be used for well-selected situations to reduce the need for a PHP on site.
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Affiliation(s)
- Christophe Jobé
- Emergency Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
| | - Pierre Métrailler
- Helicopter Emergency Medical Services, Air Glacier, Sion, Switzerland
| | | | - Alexandre Briguet
- Emergency Medical Services, Dispatch Centre, State of Valais, Sion, Switzerland
| | - Line Zurcher
- Emergency Medical Services, Dispatch Centre, State of Valais, Sion, Switzerland
| | - Fabrice Dami
- Emergency Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne, Lausanne, Switzerland
- Emergency Medical Services, Dispatch Centre, State of Vaud (Fondation Urgences-Santé), Lausanne, Switzerland
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Qureshi HN, Manalastas M, Ijaz A, Imran A, Liu Y, Al Kalaa MO. Communication Requirements in 5G-Enabled Healthcare Applications: Review and Considerations. Healthcare (Basel) 2022; 10:293. [PMID: 35206907 PMCID: PMC8872156 DOI: 10.3390/healthcare10020293] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
Fifth generation (5G) mobile communication technology can enable novel healthcare applications and augment existing ones. However, 5G-enabled healthcare applications demand diverse technical requirements for radio communication. Knowledge of these requirements is important for developers, network providers, and regulatory authorities in the healthcare sector to facilitate safe and effective healthcare. In this paper, we review, identify, describe, and compare the requirements for communication key performance indicators in relevant healthcare use cases, including remote robotic-assisted surgery, connected ambulance, wearable and implantable devices, and service robotics for assisted living, with a focus on quantitative requirements. We also compare 5G-healthcare requirements with the current state of 5G capabilities. Finally, we identify gaps in the existing literature and highlight considerations for this space.
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Affiliation(s)
- Haneya Naeem Qureshi
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA; (M.M.); (Y.L.); (M.O.A.K.)
- AI4Networks Research Center, School of Electrical & Computer Engineering, University of Oklahoma, Tulsa, OK 74135, USA; (A.I.); (A.I.)
| | - Marvin Manalastas
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA; (M.M.); (Y.L.); (M.O.A.K.)
- AI4Networks Research Center, School of Electrical & Computer Engineering, University of Oklahoma, Tulsa, OK 74135, USA; (A.I.); (A.I.)
| | - Aneeqa Ijaz
- AI4Networks Research Center, School of Electrical & Computer Engineering, University of Oklahoma, Tulsa, OK 74135, USA; (A.I.); (A.I.)
| | - Ali Imran
- AI4Networks Research Center, School of Electrical & Computer Engineering, University of Oklahoma, Tulsa, OK 74135, USA; (A.I.); (A.I.)
| | - Yongkang Liu
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA; (M.M.); (Y.L.); (M.O.A.K.)
| | - Mohamad Omar Al Kalaa
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA; (M.M.); (Y.L.); (M.O.A.K.)
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English SW, Barrett KM, Freeman WD, Demaerschalk BM. Telemedicine-enabled ambulances and mobile stroke units for prehospital stroke management. J Telemed Telecare 2021; 28:458-463. [PMID: 34636680 DOI: 10.1177/1357633x211047744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The recognition and management of stroke in the prehospital setting has become increasingly important to improve patient outcomes. Several strategies to advance prehospital stroke care have been developed, including the mobile stroke unit and the telemedicine-enabled ambulance-or "mini-MSU." These strategies both incorporate ambulance-based audio-visual telemedicine evaluation with a vascular neurologist to facilitate faster treatment but differ in several areas including upfront and recurring costs, scalability or growth potential, ability to integrate into existing emergency medical services systems, and interoperability across multiple specialties or conditions. While both the mobile stroke unit and mini-mobile stroke unit model are valid approaches to improve stroke care, the authors aim to compare these models based on costs, scalability, integration, and interoperability in order to guide our prehospital leaders to find the best solutions for their communities.
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Affiliation(s)
| | | | - Willam D Freeman
- Department of Neurology, Neurologic Surgery, and Critical Care, 6915Mayo Clinic, USA
| | - Bart M Demaerschalk
- Department of Neurology and Center for Digital Healthcare, 156400Mayo Clinic College of Medicine and Science, USA
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Menon AK, Adhya S, Kanitkar M. Health technology assessment of telemedicine applications in Northern borders of India. Med J Armed Forces India 2021; 77:452-458. [PMID: 34594075 PMCID: PMC8459044 DOI: 10.1016/j.mjafi.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/18/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Economic evaluations of health technology help to decide which interventions are to be continued and which are to be terminated. In the Armed Forces, the provision of efficient medical services requires meticulous planning for optimal utilization of scarce resources. We report a cost analysis of telemedicine and air transportation of casualties, and attempt to identify the strengths, weaknesses, opportunities and threats of telemedicine services. METHODS The costs incurred in telemedicine were compared with the cost of air evacuation. A qualitative assessment of telemedicine was undertaken through in-depth interviews with the hospital authorities and focused group discussions with medical officers and paramedical staff. RESULTS 34.2% of casualties could successfully be stabilized on-site using available healthcare resources with the peripheral hospitals. 18 casualties were managed at the periphery on-site by teleconsultations each year, averting air-transportation efforts. Estimated cost savings achieved in the initial management of casualty by teleconsultation was Rs. 146,111 per case. The strengths of telemedicine are knowledge updation, faster decision making, improved pre-hospital care and improved confidence in case management. CONCLUSION The reduction in air efforts and remote management of casualties make a substantive case for scaling up telemedicine interventions.
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Affiliation(s)
| | - Saibal Adhya
- Professor, Department of Community Medicine, Armed Forces Medical College, Pune, India
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Eder PA, Laux G, Rashid A, Kniess T, Haeusler KG, Shammas L, Griewing B, Hofmann S, Stangl S, Wiedmann S, Rücker V, Heuschmann PU, Soda H. Stroke Angel: Effect of Telemedical Prenotification on In-Hospital Delays and Systemic Thrombolysis in Acute Stroke Patients. Cerebrovasc Dis 2021; 50:420-428. [PMID: 33774614 DOI: 10.1159/000514563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/02/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Door-to-CT scan time (DCT) and door-to-needle time (DNT) are important process measures in acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis (IVT). We examined the impact of a telemedical prenotification by emergency medical service (EMS) (called the "Stroke Angel" program) on DCT and DNT and IVT rate compared to standard of care. PATIENTS AND METHODS Two prospective observational studies including AIS patients admitted via EMS from 2011 to 2013 (cohort I; n = 496) and from January 1, 2015 to May 31, 2018 (cohort II; n = 349) were conducted. After cohort I, the 4-Item Stroke Scale and a digital thrombolysis protocol were added. Multivariable logistic and linear regression analysis was performed. RESULTS In cohort I, DCT was lower in the intervention group (13 vs. 26 min using standard of care; p < 0.001), but no significant difference in median DNT (35 vs. 39 min; p = 0.24) was observed. In cohort II, a reduction of DCT (8 vs. 15 min; p < 0.001) and DNT (25 vs. 29 min p = 0.003) was observed in the intervention group. Compared to standard of care, the likelihood of DCT ≤10 min or DNT ≤20 min in the intervention group was 2.7 (adjusted odds ratio [aOR] 2.7; 95% CI: 2.1-3.5) and 1.8 (aOR 1.8; 95% CI: 1.1-2.9), respectively. In cohort II, IVT rate was higher (aOR 1.4; 95% CI: 1.1-1.9) in the intervention group. CONCLUSION Although the positive effects of Stroke Angel in AIS provided a rationale for implementation in routine care, larger studies of practice implementation will be needed. Using Stroke Angel in the prehospital management of AIS impacts on important process measures of IVT delivery.
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Affiliation(s)
- Patrick Andreas Eder
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany.,Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Gunter Laux
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Asarnusch Rashid
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany
| | - Tobias Kniess
- Department of Neurological Rehabilitation, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | | | - Layal Shammas
- Innovation management, Zentrum für Telemedizin Bad Kissingen, Bad Kissingen, Germany
| | - Bernd Griewing
- Medical Board Division, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | - Susanne Hofmann
- Department of Neurology, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
| | - Stephanie Stangl
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Silke Wiedmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Hassan Soda
- Department of Neurology, Campus Rhön Klinikum AG, Bad Neustadt/Saale, Germany
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12
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Wu Y, Chen F, Song H, Feng W, Sun J, Liu R, Li D, Liu Y. Use of a Smartphone Platform to Help With Emergency Management of Acute Ischemic Stroke: Observational Study. JMIR Mhealth Uhealth 2021; 9:e25488. [PMID: 33560236 PMCID: PMC7902188 DOI: 10.2196/25488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/06/2020] [Accepted: 01/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To improve the outcomes of acute ischemic stroke (AIS), timely thrombolytic therapy is crucial. Series strategies were recommended to reduce door-to-needle (DTN) time for AIS. Mobile technologies are feasible and have been used in stroke management for various purposes. However, the use of smartphone platforms that integrate series strategies through the entire first aid process to improve emergency management of AIS remains to be verified. OBJECTIVE This study aims to describe the utility and application of a smartphone platform in the emergency management of AIS and report the DTN time for patients with AIS during its 2-year application period. Our results are relevant to digital health management. METHODS A smartphone platform named "Green" was developed to incorporate the field assessment, hospital recommendation, prehospital notification, real-time communication, clinical records creation, key time-stamping, and quality control to streamline and standardize overall AIS emergency management processes. The emergency medical system (EMS) and all the emergency departments in Beijing have used this platform since 2018. From January 1, 2018, to December 31, 2019, 8457 patients diagnosed with AIS received intravenous tissue-type plasminogen activator therapy. The median DTN time and the proportions of patients with DTN times of ≤60 minutes and ≤45 minutes were reported. RESULTS During the 2-year application period of this platform, the median DTN time was 45 minutes, and the proportions of patients with DTN times of ≤60 minutes and ≤45 minutes were 74.6% and 50.5%, respectively. The median DTN time was significantly reduced from 50 minutes in 2018 to 42 minutes in 2019 (P<.001). The proportions of patients with DTN times of ≤60 minutes and ≤45 minutes increased from 66.1% and 40.7%, respectively, in 2018 to 80.7% and 57.3%, respectively, in 2019 (both P<.001). Sustained improvement in DTN time was seen during all the observed months. The improvement occurred across all facilities, and the variations among hospitals also decreased. The median DTN time for patients transferred by ambulances (43 minutes) was significantly shorter than those who reached hospitals by themselves (47 minutes; P<.001). CONCLUSIONS Sustained reductions in DTN time reflected the improvement in AIS emergency management processes. The use of a smartphone platform integrating recommended strategies throughout all first aid stages is a practical way to help the emergency management of AIS.
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Affiliation(s)
- Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Peking, China
| | - Fei Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, China
| | - Jinping Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruisen Liu
- Beijing Municipal Health Commission, Beijing, China
| | - Dongmei Li
- BEIJING ANMED Medical Technology Co Ltd, Beijing, China
| | - Ying Liu
- Beijing Municipal Health Commission, Beijing, China
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13
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Rudd AG, Bladin C, Carli P, De Silva DA, Field TS, Jauch EC, Kudenchuk P, Kurz MW, Lærdal T, Ong M, Panagos P, Ranta A, Rutan C, Sayre MR, Schonau L, Shin SD, Waters D, Lippert F. Utstein recommendation for emergency stroke care. Int J Stroke 2020; 15:555-564. [PMID: 32223543 PMCID: PMC7672780 DOI: 10.1177/1747493020915135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Recent advances in treatment for stroke give new possibilities for optimizing
outcomes. To deliver these prehospital care needs to become more
efficient. Aim To develop a framework to support improved delivery of prehospital care. The
recommendations are aimed at clinicians involved in prehospital and
emergency health systems who will often not be stroke specialists but need
clear guidance as to how to develop and deliver safe and effective care for
acute stroke patients. Methods Building on the successful implementation program from the Global
Resuscitation Alliance and the Resuscitation Academy, the Utstein
methodology was used to define a generic chain of survival for Emergency
Stroke Care by assembling international expertise in Stroke and Emergency
Medical Services (EMS). Ten programs were identified for Acute Stroke Care
to improve survival and outcomes, with recommendations for implementation of
best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through
public awareness, optimized prehospital triage and timely diagnostics, and
quick and equitable access to acute treatments. Documentation, use of
metrics and transparency will help to build a culture of excellence and
accountability.
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Affiliation(s)
- A G Rudd
- NHS England and King's College, London, England
| | - C Bladin
- Eastern Health Monash University, Melbourne, Australia
| | - P Carli
- Emergency Medical Services, Paris, France
| | - D A De Silva
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - T S Field
- University of British Columbia, Vancouver, Canada
| | - E C Jauch
- Mission Health System, Asheville, USA
| | - P Kudenchuk
- University of Washington School of Medicine, Seattle, WA, USA
| | - M W Kurz
- Stavanger University Hospital, Stavanger, Norway
| | - T Lærdal
- The Laerdal Foundation, Stavanger, Norway
| | - Meh Ong
- Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - P Panagos
- Washington University School of Medicine, St. Louis, MO, USA
| | - A Ranta
- University of Otago, Dunedin, New Zealand
| | - C Rutan
- American Heart Association, Dallas, TX, USA
| | | | - L Schonau
- Danish Resuscitation Council, Copenhagen, Denmark
| | - S D Shin
- Seoul National University College of Medicine, Seoul, South Korea
| | - D Waters
- Ambulance New Zealand, Wellington, New Zealand
| | - F Lippert
- Copenhagen Emergency Medical Services, Copenhagen, Denmark
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14
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The role of fifth-generation mobile technology in prehospital emergency care: An opportunity to support paramedics. HEALTH POLICY AND TECHNOLOGY 2020. [DOI: 10.1016/j.hlpt.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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15
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Culmer N, Smith T, Stager C, Meyer H, Quick S, Grimm K. Evaluation of the triple aim of medicine in prehospital telemedicine: A systematic literature review. J Telemed Telecare 2019; 26:571-580. [PMID: 31238783 DOI: 10.1177/1357633x19853461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES With telemedicine becoming more widely implemented in emergency situations, understanding the quality and content of current findings that explore prehospital telemedicine is vital to establish best practices and guide future research. This systematic review examines the clinical importance of telemedicine in patient-provider ambulance-based settings with a focus on multifunctional systems for general prehospital emergency populations. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology we found 1564 abstracts, which were blind-reviewed by independent reviewers. Relevant articles were reviewed, classified, and analyzed according to research methods and technology type, as well as quality, cost, and satisfaction. The studies were also reviewed for validated evidence-based practice. RESULTS Those studies that looked at cost, quality, and satisfaction with care generally shared favorable results. Setup notwithstanding, cost was comparable or less than controls. Care quality was also found to be in line with or slightly preferable to face-to-face care with some advantages in response time and quality. Patients and providers were satisfied with the systems. Common obstacles included limited bandwidth and small sample sizes. CONCLUSIONS Although feasibility remains salient, research regarding the impact of ambulance-based telemedicine on patients and healthcare providers is encouraging, but nascent. As a whole, this body of literature does not yet adequately speak to the most important concerns of medicine: quality, cost, and satisfaction. More research is needed in each of these areas. However, those studies that do address these matters share hopeful results. Future research should test these mechanisms in prehospital settings with greater rigor.
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Affiliation(s)
- Nathan Culmer
- The College of Community Health Sciences, The University of Alabama, US
| | - Todd Smith
- The College of Community Health Sciences, The University of Alabama, US
| | - Catanya Stager
- The College of Community Health Sciences, The University of Alabama, US
| | - Hannah Meyer
- The College of Community Health Sciences, The University of Alabama, US
| | - Sarah Quick
- The College of Community Health Sciences, The University of Alabama, US
| | - Katherine Grimm
- The College of Community Health Sciences, The University of Alabama, US
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16
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Martinez-Gutierrez JC, Chandra RV, Hirsch JA, Leslie-Mazwi T. Technological innovation for prehospital stroke triage: ripe for disruption. J Neurointerv Surg 2019; 11:1085-1090. [DOI: 10.1136/neurintsurg-2019-014902] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022]
Abstract
BackgroundWith the benefit of mechanical thrombectomy firmly established, the focus has shifted to improved delivery of care. Reducing time from symptom onset to reperfusion is a primary goal. Technology promises tremendous opportunities in the prehospital space to achieve this goal.MethodsThis review explores existing, fledgling, and potential future technologies for application in the prehospital space.ResultsThe opportunity for technology to improve stroke care resides in the detection, evaluation, triage, and transport of patients to an appropriate healthcare facility. Most prehospital technology remains in the early stages of design and implementation.ConclusionThe major challenges to tackle for future improvement in prehospital stroke care are that of public awareness, emergency medical service detection, and triage, and improved systems of stroke care. Thoughtfully applied technology will transform all these areas.
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17
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Collaboration risk management in IT-enabled asymmetric partnerships: Evidence from telestroke networks. INFORMATION AND ORGANIZATION 2018. [DOI: 10.1016/j.infoandorg.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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19
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Chapman Smith SN, Brown PC, Waits KH, Wong JS, Bhatti MS, Toqeer Q, Ricks JV, Stockner ML, Habtamu T, Seelam J, Britt RC, Giovia JM, Blankson BK, Bennam P, Gormley MA, Lu J, Ornato JP. Development and Evaluation of a User-Centered Mobile Telestroke Platform. Telemed J E Health 2018; 25:638-648. [PMID: 30207927 DOI: 10.1089/tmj.2018.0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background: Reperfusion is the most effective acute treatment for ischemic stroke within a narrow therapeutic time window. Ambulance-based telestroke is a novel way to improve stroke diagnosis and timeliness of treatment. This study aims to (1) assess the usability of our ambulance-based telestroke platform and (2) identify strengths and limitations of the system from the user's perspective. Materials and Methods: An ambulance was equipped with a mobile telemedicine system to perform remote stroke assessments. Scripted scenarios were performed by actors during transport and evaluated by physicians using the National Institutes of Health Stroke Scale (NIHSS). Scores obtained during transport were compared with original scripted NIHSS scores. Participants completed the System Usability Scale (SUS), NASA Task Load Index (NASA TLX), audio/video quality scale, and a modified Acceptability of Technology survey to assess perceptions and usability. In addition, interviews were conducted to evaluate user's experience. Descriptive analysis was used for all surveys. Weighted kappa statistics was used to compare the agreement in NIHSS scores. Results: Ninety-one percent (59/65) of mobile scenarios were completed. Median completion time was 9 min (range 4-17 min). There was moderate inter-rater agreement (weighted kappa = 0.46 [95% confidence interval 0.33-0.60, p = 0.0018]) among mobile and original scripted scenarios. The mean SUS score was 68.8 (standard deviation = 15.9). There was variability between usability score and formative feedback among all end-users in the areas of usability issues (i.e., audibility and equipment stability) and safety. Conclusion: Before implementation of a mobile prehospital telestroke program, the use of combined clinical simulation and Plan-Do-Study-Act methodology can improve the quality and optimization of the telemedicine system.
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Affiliation(s)
- Sherita N Chapman Smith
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia.,2 Department of Neurology, University of Virginia Health System, Charlottesville, Virginia
| | - Pamela C Brown
- 3 Department of Nursing, Simmons College, Boston, Massachusetts
| | - Kaitlynne H Waits
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Jason S Wong
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Muhammad S Bhatti
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Qaiser Toqeer
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Jamie V Ricks
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Michelle L Stockner
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Tsion Habtamu
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | | | - Rashon C Britt
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Jacob M Giovia
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Baaba K Blankson
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Poanna Bennam
- 1 Department of Neurology, Virginia Commonwealth University, Richmond, Virginia
| | - Mirinda A Gormley
- 4 Department of Public Health, Virginia Commonwealth University, Richmond, Virginia
| | - Juan Lu
- 5 Department of Family Medicine and Population Health, and Virginia Commonwealth University, Richmond, Virginia
| | - Joseph P Ornato
- 6 Department of Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia
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20
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Abstract
PURPOSE OF REVIEW Acute ischemic stroke (AIS) care is rapidly evolving. This review discusses current diagnostic, therapeutic, and process models that can expedite stroke treatment to achieve best outcomes. RECENT FINDINGS Use of stent retrievers after selection via advanced imaging is safe and effective, and is an important option for AIS patients with large vessel occlusion (LVO). Significant time delays occur before and during patient transfers, and upon comprehensive stroke center (CSC) arrival, and have deleterious effects on functional outcome. Removing obstacles, enhancing inter-facility communication, and creating acute stroke management processes and protocols are paramount strategies to enhance network efficiency. Inter-departmental CSC collaboration can significantly reduce door-to-treatment times. Streamlined stroke systems of care may result in higher treatment rates and better functional outcomes for AIS patients, simultaneously conserving healthcare dollars. Stroke systems of care should be structured regionally to minimize time to treatment. A proactive approach must be employed; a management plan incorporating stroke team prenotification and parallel processes between departments can save valuable time, maximize brain salvage, and reduce disability from stroke.
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22
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Hov MR, Zakariassen E, Lindner T, Nome T, Bache KG, Røislien J, Gleditsch J, Solyga V, Russell D, Lund CG. Interpretation of Brain CT Scans in the Field by Critical Care Physicians in a Mobile Stroke Unit. J Neuroimaging 2017; 28:106-111. [PMID: 28766306 PMCID: PMC5811888 DOI: 10.1111/jon.12458] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/23/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute stroke, thromboembolism or spontaneous hemorrhage abruptly reduces blood flow to a part of the brain. To limit necrosis, rapid radiological identification of the pathological mechanism must be conducted to allow the initiation of targeted treatment. The aim of the Norwegian Acute Stroke Prehospital Project is to determine if anesthesiologists, trained in prehospital critical care, may accurately assess cerebral computed tomography (CT) scans in a mobile stroke unit (MSU). METHODS In this pilot study, 13 anesthesiologists assessed unselected acute stroke patients with a cerebral CT scan in an MSU. The scans were simultaneously available by teleradiology at the receiving hospital and the on‐call radiologist. CT scan interpretation was focused on the radiological diagnosis of acute stroke and contraindications for thrombolysis. The aim of this study was to find inter‐rater agreement between the pre‐ and in‐hospital radiological assessments. A neuroradiologist evaluated all CT scans retrospectively. Statistical analysis of inter‐rater agreement was analyzed with Cohen's kappa. RESULTS Fifty‐one cerebral CT scans from the MSU were included. Inter‐rater agreement between prehospital anesthesiologists and the in‐hospital on‐call radiologists was excellent in finding radiological selection for thrombolysis (kappa .87). Prehospital CT scans were conducted in median 10 minutes (7 and 14 minutes) in the MSU, and median 39 minutes (31 and 48 minutes) before arrival at the receiving hospital. CONCLUSION This pilot study shows that anesthesiologists trained in prehospital critical care may effectively assess cerebral CT scans in an MSU, and determine if there are radiological contraindications for thrombolysis.
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Affiliation(s)
- Maren Ranhoff Hov
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Zakariassen
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, Uni Research Health, Bergen, Norway
| | - Thomas Lindner
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,The Regional Centre for Emergency Medical Research and Development, Stavanger, Norway
| | - Terje Nome
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Kristi G Bache
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Jo Røislien
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
| | | | - Volker Solyga
- Department of Neurology, Østfold Hospital, Kalnes, Norway
| | - David Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christian G Lund
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | -
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway
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23
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Winburn AS, Brixey JJ, Langabeer J, Champagne-Langabeer T. A systematic review of prehospital telehealth utilization. J Telemed Telecare 2017; 24:473-481. [PMID: 29278996 DOI: 10.1177/1357633x17713140] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective There has been moderate evidence of telehealth utilization in the field of emergency medicine, but less is known about telehealth in prehospital emergency medical services (EMS). The objective of this study is to explore the extent, focus, and utilization of telehealth for prehospital emergency care through the analysis of published research. Methods The authors conducted a systematic literature review by extracting data from multiple research databases (including MEDLINE/PubMed, CINAHL Complete, and Google Scholar) published since 2000. We used consistent key search terms to identify clinical interventions and feasibility studies involving telehealth and EMS, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results We identified 68 articles focused specifically on telehealth interventions in prehospital care. The majority (54%) of the studies involved stroke and acute cardiovascular care, while only 7% of these (4) focused on telehealth for primary care. The two most common delivery methods were real-time video-conferencing capabilities (38%) and store and forward (25%); and this variation was based upon the clinical focus. There has been a significant and positive trend towards greater telehealth utilization. European telehealth programs were most common (51% of the studies), while 38% were from the United States. Discussion and Conclusions Despite positive trends, telehealth utilization in prehospital emergency care is fairly limited given the sheer number of EMS agencies worldwide. The results of this study suggest there are significant opportunities for wider diffusion in prehospital care. Future work should examine barriers and incentives for telehealth adoption in EMS.
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Andrew BY, Stack CM, Yang JP, Dodds JA. mStroke: "Mobile Stroke"-Improving Acute Stroke Care with Smartphone Technology. J Stroke Cerebrovasc Dis 2017; 26:1449-1456. [PMID: 28434773 DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/15/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of method and time of system activation on clinical metrics in cases utilizing the Stop Stroke (Pulsara, Inc.) mobile acute stroke care coordination application. METHODS A retrospective cohort analysis of stroke codes at 12 medical centers using Stop Stroke from March 2013 to May 2016 was performed. Comparison of metrics (door-to-needle time [DTN] and door-to-CT time [DTC], and rate of DTN ≤ 60 minutes [goal DTN]) was performed between subgroups based on method (emergency medical service [EMS] versus emergency department [ED]) and time of activation. Effects were adjusted for confounders (age, sex, National Institutes of Health Stroke Scale [NIHSS] score) using multiple linear and logistic regression. RESULTS The final dataset included 2589 cases. Cases activated by EMS were more severe (median NIHSS score 8 versus 4, P < .0001) and more likely to receive recombinant tissue plasminogen activator (20% versus 12%, P < .0001) than those with ED activation. After adjustment, cases with EMS activation had shorter DTC (6.1 minutes shorter, 95% CI [-10.3, -2]) and DTN (12.8 minutes shorter, 95% CI [-21, -4.6]) and were more likely to meet goal DTN (OR 1.83, 95% CI [1.1, 3]). Cases between 1200 and 1800 had longer DTC (7.7 minutes longer, 95% CI [2.4, 13]) and DTN (21.1 minutes longer, 95% CI [9.3, 33]), and reduced rate of goal DTN (OR .3, 95% CI [.15, .61]) compared to those between 0000 and 0600. CONCLUSIONS Incorporating real-time prehospital data obtained via smartphone technology provides unique insight into acute stroke codes. Activation of mobile electronic stroke coordination in the field appears to promote a more expedited and successful care process.
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Affiliation(s)
- Benjamin Y Andrew
- Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina
| | - Colleen M Stack
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Julian P Yang
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Jodi A Dodds
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina.
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25
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Rogers H, Madathil KC, Agnisarman S, Narasimha S, Ashok A, Nair A, Welch BM, McElligott JT. A Systematic Review of the Implementation Challenges of Telemedicine Systems in Ambulances. Telemed J E Health 2017; 23:707-717. [PMID: 28294704 DOI: 10.1089/tmj.2016.0248] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Telemedicine systems are gaining attention nationwide as a means for providing care in remote areas and allowing a small number of providers to impact a large geographic region. We systematically reviewed the literature to identify the efficacy and implementation challenges of telemedicine systems in ambulances. METHODS A search for published studies on Web of Science and PubMed was completed. Studies were selected if they included at least a pilot study and they focused on feasibility or implementation of telemedicine systems in ambulances. RESULTS A total of 864 articles were used for title and abstract screening. Full text screening was completed for 102 articles, with 23 being selected for final review. Sixty-one percent of the studies included in the review focused on general emergency care, while 26% focused on stroke care and 13% focused on myocardial infarction care. The reviewed studies found that telemedicine is feasible and effective in decreasing treatment times, report a high diagnosis accuracy rate, show higher rates of positive task completion than in regular ambulances, and demonstrate that stroke evaluation is completed with comparable accuracy to the standard way of delivering care. CONCLUSIONS Although this review identified life-saving benefits of telemedicine, it also showed the paucity of the scientifically sound research in its implementation, prompting further studies. Further research is needed to analyze the capabilities and challenges involved in implementing telemedicine in ambulances, especially studies focusing on human-system integration and human factors' considerations in the implementation of telemedicine systems in ambulances, the development of advanced Internet connectivity paradigms, additional applications for triaging, and the implications of ambulance location.
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Affiliation(s)
- Hunter Rogers
- 1 Department of Industrial Engineering, Clemson University , Clemson, South Carolina
| | - Kapil Chalil Madathil
- 1 Department of Industrial Engineering, Clemson University , Clemson, South Carolina.,2 Department of Civil Engineering, Clemson University , Clemson, South Carolina.,3 Department of Public Health Sciences, Medical University of South Carolina , Charleston, South Carolina
| | - Sruthy Agnisarman
- 2 Department of Civil Engineering, Clemson University , Clemson, South Carolina
| | - Shraddhaa Narasimha
- 1 Department of Industrial Engineering, Clemson University , Clemson, South Carolina
| | - Aparna Ashok
- 4 School of Dental Medicine, Southern Illinois University at Edwardsville , Alton, Illinois
| | - Aswathi Nair
- 2 Department of Civil Engineering, Clemson University , Clemson, South Carolina
| | - Brandon M Welch
- 3 Department of Public Health Sciences, Medical University of South Carolina , Charleston, South Carolina
| | - James T McElligott
- 5 South Carolina Telehealth Alliance, Medical University of South Carolina , Charleston, South Carolina
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Schwamm LH, Chumbler N, Brown E, Fonarow GC, Berube D, Nystrom K, Suter R, Zavala M, Polsky D, Radhakrishnan K, Lacktman N, Horton K, Malcarney MB, Halamka J, Tiner AC. Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association. Circulation 2017; 135:e24-e44. [DOI: 10.1161/cir.0000000000000475] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.
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27
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Langabeer JR, Champagne-Langabeer T, Alqusairi D, Kim J, Jackson A, Persse D, Gonzalez M. Cost-benefit analysis of telehealth in pre-hospital care. J Telemed Telecare 2016; 23:747-751. [PMID: 27913657 DOI: 10.1177/1357633x16680541] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model.
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Affiliation(s)
- James R Langabeer
- 1 School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
| | | | - Diaa Alqusairi
- 1 School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA.,2 Houston Fire Department Emergency Medical Services, Houston, TX, USA
| | - Junghyun Kim
- 1 School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
| | - Adria Jackson
- 3 City of Houston Health Department, Houston, TX, USA
| | - David Persse
- 2 Houston Fire Department Emergency Medical Services, Houston, TX, USA
| | - Michael Gonzalez
- 2 Houston Fire Department Emergency Medical Services, Houston, TX, USA
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Belt GH, Felberg RA, Rubin J, Halperin JJ. In-Transit Telemedicine Speeds Ischemic Stroke Treatment. Stroke 2016; 47:2413-5. [DOI: 10.1161/strokeaha.116.014270] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/08/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Time to treatment is critically important in ischemic stroke. We compared the efficacy and cost of teleneurology evaluation during patient transport with that of mobile stroke transport units.
Methods—
Using cellular-connected telemedicine devices, we assessed 89 presumptive stroke patients in ambulances in transit. Paramedics assisted remote teleneurologists in obtaining a simplified history and examination, then coordinating care with the receiving emergency department. We prospectively assessed door-to-needle and last-known-well-to-needle times for all intravenous alteplase–treated stroke patients brought to our emergency departments by emergency medical services’ transport, comparing those with and without in-transit telestroke.
Results—
From January 2015 through March 2016, 111 stroke patients received intravenous alteplase at study emergency departments. Mean door to needle was 13 minutes less with in-transit telestroke (28 versus 41;
P
=0.02). Although limitations in cellular communication degraded transmission quality, this did not prevent the completion of satisfactory patient evaluations.
Conclusions—
Improvement in time to treat seems comparable with in-transit telestroke and mobile stroke transport units. The low cost/unit makes this approach scalable, potentially providing rapid management of more patients.
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Affiliation(s)
- Gary H. Belt
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - Robert A. Felberg
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - Jane Rubin
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
| | - John J. Halperin
- From the Department of Neurosciences, Overlook Medical Center, Summit, NJ
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Chapman Smith SN, Govindarajan P, Padrick MM, Lippman JM, McMurry TL, Resler BL, Keenan K, Gunnell BS, Mehndiratta P, Chee CY, Cahill EA, Dietiker C, Cattell-Gordon DC, Smith WS, Perina DG, Solenski NJ, Worrall BB, Southerland AM. A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study. Neurology 2016; 87:19-26. [PMID: 27281534 DOI: 10.1212/wnl.0000000000002799] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/08/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. METHODS We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). RESULTS We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. CONCLUSIONS Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.
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Affiliation(s)
- Sherita N Chapman Smith
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Prasanthi Govindarajan
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Matthew M Padrick
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Jason M Lippman
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Timothy L McMurry
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Brian L Resler
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Kevin Keenan
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Brian S Gunnell
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Prachi Mehndiratta
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Christina Y Chee
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Elizabeth A Cahill
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Cameron Dietiker
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - David C Cattell-Gordon
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Wade S Smith
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Debra G Perina
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Nina J Solenski
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Bradford B Worrall
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current)
| | - Andrew M Southerland
- From the Departments of Neurology (S.N.C.S., M.M.P., J.M.L., P.M., C.Y.C., N.J.S., B.B.W., A.M.S.), Public Health Sciences (T.L.M., B.B.W., A.M.S.), and Emergency Medicine (D.G.P.), and Center for Telehealth (B.S.G., D.C.C.-G.), University of Virginia Health System, Charlottesville; Department of Neurology (S.N.C.S., P.M.), Virginia Commonwealth University Health System, Richmond, VA (current); Departments of Emergency Medicine (P.G., B.L.R.) and Neurology (K.K., E.A.C., C.D., W.S.S.), University of California, San Francisco Medical Center; and Department of Emergency Medicine (P.G.), Stanford University Medical Center, Palo Alto, CA (current).
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