A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study.
OBJECTIVE
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.
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).
Sherita N
SN
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
P
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
MM
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
JM
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
TL
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
BL
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
K
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
BS
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
P
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
CY
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
EA
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
C
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
DC
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
WS
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
DG
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
NJ
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
BB
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). as5ef@virginia.edu.
Andrew M
AM
Southerland
D002545:Brain Ischemia / Q000175:diagnosis; D040421:Cell Phone; D034201:Computers, Handheld; D005240:Feasibility Studies; D006801:Humans; D000072141:Neurologists; D010865:Pilot Projects; D012044:Regression Analysis; D015203:Reproducibility of Results; D012424:Rural Population; D012495:San Francisco; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis*; D017216:Telemedicine / Q000191:economics / Q000295:instrumentation; D014187:Transportation of Patients; D014505:Urban Population; D049269:Videoconferencing / Q000191:economics / Q000295:instrumentation; D014768:Virginia