Telestroke assessment on the move: prehospital streamlining of patient pathways.

T hrombolysis as a treatment for ischemic stroke is only indicated within the first 3 to 4.5 hours after onset of symptoms, and is more efficacious the earlier it is given. Patients must thus seek help, receive a clinical diagnosis, and reach a center of care for imaging and treatment without delay. This is a problem in remote and rural areas, leading to a relative disadvantage for rural dwellers: symptom-to-needle time is nevertheless often too long even for people in major urban centers. In the Scottish Highlands, for example, the total amount of time taken from calling for help, transfer to the nearest diagnostic center, undergoing computed tomography scanning to exclude contraindications to thrombolysis treatment, and then receiving thrombolysis often exceeds the 4.5-hour limit. 3 The ambulance service reports that the more rural the patient's location, the longer their response time is likely to be, reflecting the geography and road network as well as the limited number of vehicles. 4 Even among patients with stroke in the Highlands who make it to hospital within the 4.5-hour thrombolysis window, mean times from onset to thrombolysis range from 130 to 210 minutes at the various hospitals audited, and <8% of patients with stroke actually receive the treatment at all. 5 Scotland has a telestroke program run by the Scottish Center for Telehealth and Telecare, featuring 5 networks around the country. 6 They use videoconferencing from the acute hospital site where local physicians can discuss their patients with specialists many miles away. This service has been running successfully since 2008, and thus the idea of using communications technology in stroke assessment is already in place and being successfully used. However, this service is hospital-based, providing support to smaller institutions rather than in prehospital situations. Initial code stroke systems were set up within hospitals to organize multidisciplinary rapid–response teams and to expedite diagnosis and treatment in stroke, and these proved successful at reducing time to treatment. 7–10 This idea then moved into the prehospital sphere, with paramedics alerting hospitals when they encountered suspected acute stroke, 11 and further studies included expert sign-off before a code stroke was activated , to help reduce false-positive cases. 12 In the past year, initial feasibility studies have appeared building on the work of the TeleBAT system, 13 looking at the use of telemedicine systems in real-time prehospital stroke assessment, 14,15 but these have been based in urban areas, …