. 2020 Apr 26;20:30. doi: 10.1186/s12873-020-00323-0

Table 5.

Telestroke Technology Study Outcomes

Study details	Purpose, Diagnostic accuracy, comparator and clinical scale	Time to conduct telestroke assessment	Acceptability: clinicians and/or patients	Impact on EMS clinician decisions or treatment	Impact on process (time metrics) outcomes	Impact on patient outcomes
TeleBAT LaMonte et al. 2000 [26] Xiao et al. 1997 [27]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: None. Assessed acceptability and usability of TeleBAT Clinical scale: NIHSS	Not reported	Paramedics × 2 and stroke specialists × 2 [26]: Clinicians in favour of TeleBAT (privacy of video transmission, non-interference with regular tasks on ambulances; providing valuable information; & usability) Paramedics × 2 and stroke specialists × 2[27]: System did not intrude into paramedic/patient privacy and was safe. Adequate for clinical examinations: stroke specialists could score most NIHSS items, but difficulty with patients’ leg movement). Easy to learn/operate.	Destination: Not reported Treatment: Not reported	Not reported	Not reported
‘peeq-box’ Bergrath et al. 2012 [28]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: prehospital stroke diagnosis confirmed in hospital in 11 patients (61%, telestroke) vs 30 (67%, standard EMS) – difference non-significant Extrapolated data: Telestroke: False Positive Rate: 7; True Positive Rate: 11 vs standard EMS transport False Positive Rate: 15; True Positive Rate: 30 Non-significant differences between telestroke and standard EMS for other neurological/non-neurological diagnoses Comparator: Standard EMS transport (time metrics) and hospital-confirmed diagnosis Clinical scale: bespoke 14-item stroke history checklist + Glasgow Coma Scale	Not reported	In 15 of 18 missions the telemedicine system functioned faultlessly. Significantly more (median 14) stroke-specific data points were transferred, in written form, from the EMS to the hospital via telestroke (versus median of 5 non-telestroke group).	Destination: Not reported Treatment: No significant impact on thrombolysis rates: 3/10 (30%) telestroke 5/27 (19%) standard EMS	Sample of patients with a suspected pre-hospital diagnosis of stroke Time on Scene: 4 min median increase with Telestroke (median 25 mins) vs standard EMS (median 21 mins). Difference was non-significant Scene to door time: 2.5 min median increase with Telestroke (median 37.5 mins) vs standard EMS (median 35 mins). Difference was non-significant Door-to-scan time: 2 min increase with Telestroke (median 59.5 mins) vs standard EMS (median 57.5 mins. Difference was non- significant	Not reported
Stroke Angel Ziegler et al. 2008 [29]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Extrapolated data: Stroke vs non-stroke False Positive Rate: 27 False Negative Rate: 53 True Positive Rate: 102 True Negative Rate: 44 Sensitivity = 65.81% Specificity = 61.97% Comparator: Hospital-based assessment using the same clinical scales and changes in time metrics before (prior to 2005) and after (2005–2007) introduction of Stroke Angel Clinical scales: Los Angeles Prehospital Stroke Screen, 3-item stroke scale	Not reported	Benefits stated by hospital clinicians were that EMS clinicians are “trained” by direct feedback from the PDA in dealing with the stroke patient. The use of Stroke Angel was evaluated to be consistently positive by EMS clinicians. Hospital clinicians took the early warning seriously and were better prepared for the arrival of patients. Better communication between doctors and EMS clinicians, and improved perception of each other’s tasks and work.	Destination: Not reported Treatment: Local lysis rate (number of lyses / all stroke patients enrolled on the stroke unit) increased from 6.1% (2005) to 11.2% (2007)	Call to scene time: unchanged (10 mins before and after) Time on scene: before (17 mins); after (2007) 23 mins Travel time: before (26 mins) after (2007) 22 mins Call to-door time: before (53 mins); after (2007) 55 mins Door-to-CT time: before (53 mins); after (2007) 30 mins Patients treated with thrombolysis: Door to CT time: before (32 mins); after (2007) 16 mins Door-to-needle time: before 61 mins, after (2007) 38 mins	1.5% of cases with symptomatic intracerebral bleeding (SITS-MOST criteria)
Stroke Angel Rashid et al. 2015 [30]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: Standard EMS transport (time) Clinical scale: ‘Structured checklist’	Not reported	Not reported	Destination: Not reported Treatment: Telestroke (39%), standard EMS (32%). 7% difference statistically significant	Data covered the period 2005–2013: Time on scene: 19 mins (Telestroke), 20 mins (Standard EMS). Not statistically significant Door-to-scan time: 12 mins (Telestroke), 24 mins (Standard EMS). Difference of 12 mins was statistically significant	Not reported
PreSSUB I Espinoza et al. 2016 [31] Certified by Autographe (Wavre, Belgium)	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Teleconsultants identified 12 patients (80%) with potential stroke or TIA, which concorded with in -hospital diagnosis in 10 patients (83%). Telestroke – no missed stroke diagnoses: Extrapolated data: False positives: 2; False negatives: 0; True positives: 10 Comparator: Hospital-based diagnosis Clinical scale: Unassisted Telestroke Scale	Median 9 min (IQR 8–13 min)	NIHSS was considered unsuitable for mobile telemedicine – this led to the development of a novel scale to rapidly assess stroke severity via telemedicine without assistance by a third party – the Unassisted Telestroke Scale. 94% of teleconsultations were established successfully; one major technical issue occurred due to battery malfunction of the in-ambulance device.	Destination: Not reported Treatment: Not reported	Not reported	Not reported
PreSSUB II Espinoza et al. 2015 [32] Brouns et al. 2016 [33] Certified by Autographe	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: Standard EMS transport (time) and hospital diagnosis Clinical scale: Glasgow Coma Scale, Unassisted Telestroke Scale (UTSS)	Not reported	The proportion of successful in-ambulance telemedicine assessments was 96.2% [33]. Technical and organisational feasibility was established [33].	Destination: Not reported Treatment: Thrombolysis rate (not yet available)	Call-to-CT time [33]: Standard EMS (87.1 min; 95% CI = 68.7–105.6) versus telestroke (50.8 min; 95% CI = 46.3–55.3): Statistically significant mean reduction of 36.4 min (95% CI = 17.5 to 55.3)	No telestroke-related adverse events. Mortality was similar in both groups [33] mRS, Barthel Index, EQ-5D and WHO-Five Well-being Index (not yet available)
InTouch Xpress Belt et al. 2016 [34]	Purpose: Stratify stroke/facilitate diagnosis: -Stroke -Ischemia Diagnostic accuracy:Extrapolated data: Stroke vs non-stroke (telestroke) False Positives: 3 True Positives: 12 Stroke vs non-stroke (Standard EMS transport) False Positives: 17 True Positives: 54 Comparator: Standard EMS transport (time) and hospital diagnosis. Clinical scale: Cincinnati Stroke Scale	With alteplase (n = 15): mean 7.3 mins (95% CI = 4.9–9.8). Without alteplase (n = 74): mean 4.7 mins (95% CI = 3.9–5.4)	Clinicians: 39% of teleconsults required reconnection. Connectivity was rapidly re-established in all but two cases; in all but these two cases, the tele-neurologist felt the clinical evaluation was satisfactory. Acceptance among patients and EMS has been uniformly positive (but no data are presented to support this statement).	Destination: Not assessed Treatment: Not reported	Door to needle time: Telestroke - mean 28 mins Standard EMS – mean 41 mins (decrease of 13 min was statistically significant) Onset to scene time: Telestroke - mean 31.1 mins Standard EMS – mean 50 mins (18.9 min decrease was non-significant) Scene-to-door time: Telestroke - mean 29 mins Standard EMS – mean 34 mins (5 min decrease was non-significant) Onset to needle time: Telestroke - mean 92 mins Standard EMS – mean 122 mins (32 min decrease was significant)	Deaths: 0 (in both groups) Complications: 1 in telestroke group (vs 5 in standard EMS group)
Smartphone with encrypted software Brotons et al. 2016 [35]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: 'High correlations' between telestroke NIHSS and NIHSS on hospital arrival Comparator: Telestroke NIHSS versus arrival at hospital NIHSS (conducted by the same physician) Clinical scales: CPSS, MEND exam	Not reported	Paramedics and physicians: easy to use and extremely valuable in making triage decision.	Destination: Direct transfer to CSC Treatment: Not reported	Not reported	Not reported
HipaaBridge on iPads Barrett et al. 2017 [36]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: None. Assessed acceptability and usability of HipaaBridge Clinical scales: NIHSS	Mean NIHSS assessment time 7.6 mins (range 3 to 9.8 mins)	Neurologists rated 83% of encounters as ‘satisfied/very satisfied’. EMS clinicians - 90% of encounters ‘satisfied/very satisfied’.	Destination: None Treatment: Not reported	Not reported	Not reported
iPad with video capability Shah et al. 2017 [37]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: Standard EMS transport (time) Clinical scales: Cincinnati Stroke Scale and NIH-8	Not reported	Not reported	Destination: Not reported Treatment: Not reported	Door to CT order: Mean decrease 6 mins (95% CI = 3.6–8.5) Door to CT study start: Mean decrease 12 mins (95% CI = 9.4–14.6) Door-to-CT result: Mean decrease 12.6 mins (95% CI = 9.7–15.5) CT order to CT result: Mean decrease 6.9 mins (95% CI = 4.5–9.3)	Not reported
Field-Telestroke Andrefsky et al. 2018 [38]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: Standard EMS transport (time) Clinical scale: None reported	Not reported	Not reported	Destination: None Treatment: Non-significant increase in thrombolysis (10.6–12.7%)	Door-to-scan time: Telestroke (10.7 mins) Standard EMS (34.5 mins) (improvement 23.8 mins) Door-to-needle time: Telestroke (41 mins) Standard EMS (50 mins) (improvement 9 mins)	Not reported
REACHOUT Hackett et al. 2018 [39]	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not reported Comparator: Hospital telestroke (time) Clinical scale: None	Not reported	Not reported	Destination: Not reported Treatment: Not reported	Door-to-needle time: Significant median reduction of 26 min with EMS telestroke (median 39.5 mins) compared with hospital based telestroke (median 65.5 mins)	Not reported
Custom-built system Johansson et al. 2019 [40] CE Marked	Purpose: Stratify stroke/facilitate care Diagnostic accuracy: Not assessed Comparator: Acceptability / usability of the new telestroke system vs current practice Clinical scale: PreHAST and NIHSS	Not reported	4 EMS nurses & 1 remote physician: 2 EMS nurses stated the system was reliable; 3 considered it to be safe. Minor operating interference, physicians’ competence crucial and unclear efficacy emerged from analysis of free text. Remote physician - image quality ‘more than satisfactory’.	Destination: Not assessed Treatment: Not assessed	3 out 4 of EMS nurses did not believe that the system yielded a more uniform assessment or would reduce time-to-treatment	Not reported

Study details

Purpose, Diagnostic accuracy, comparator and clinical scale

Time to conduct telestroke assessment

Acceptability: clinicians and/or patients

Impact on EMS clinician decisions or treatment

Impact on process (time metrics) outcomes

Impact on patient outcomes

TeleBAT

LaMonte et al. 2000 [26]

Xiao et al. 1997 [27]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: None. Assessed acceptability and usability of TeleBAT

Clinical scale: NIHSS

Not reported

Paramedics × 2 and stroke specialists × 2 [26]:

Clinicians in favour of TeleBAT (privacy of video transmission,

non-interference with regular tasks on ambulances; providing valuable information; & usability)

Paramedics × 2 and stroke specialists × 2[27]:

System did not intrude into paramedic/patient privacy and was safe. Adequate for clinical examinations: stroke specialists could score most NIHSS items, but difficulty with patients’ leg movement). Easy to learn/operate.

Destination:

Not reported

Treatment:

Not reported

‘peeq-box’

Bergrath et al. 2012 [28]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: prehospital stroke diagnosis confirmed in hospital in 11 patients (61%, telestroke) vs 30 (67%, standard EMS) – difference non-significant

Extrapolated data:

Telestroke: False Positive Rate: 7; True Positive Rate: 11 vs standard EMS transport False Positive Rate: 15; True Positive Rate: 30

Non-significant differences between telestroke and standard EMS for other neurological/non-neurological diagnoses

Comparator: Standard EMS transport (time metrics) and hospital-confirmed diagnosis

Clinical scale: bespoke 14-item stroke history checklist + Glasgow Coma Scale

Not reported

In 15 of 18 missions the telemedicine system functioned faultlessly.

Significantly more (median 14) stroke-specific data points were transferred, in written form, from the EMS to the hospital via telestroke (versus median of 5 non-telestroke group).

Destination:

Not reported

Treatment:

No significant impact on thrombolysis rates: 3/10 (30%) telestroke

5/27 (19%) standard EMS

Sample of patients with a suspected pre-hospital diagnosis of stroke

Time on Scene:

4 min median increase with Telestroke (median 25 mins) vs standard EMS (median 21 mins). Difference was non-significant

Scene to door time:

2.5 min median increase with Telestroke (median 37.5 mins) vs standard EMS (median 35 mins). Difference was non-significant

Door-to-scan time:

2 min increase with Telestroke (median 59.5 mins) vs standard EMS (median 57.5 mins. Difference was non- significant

Not reported

Stroke Angel

Ziegler et al. 2008 [29]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy:

Extrapolated data:

Stroke vs non-stroke

False Positive Rate: 27 False Negative Rate: 53

True Positive Rate: 102 True Negative Rate: 44

Sensitivity = 65.81%

Specificity = 61.97%

Comparator: Hospital-based assessment using the same clinical scales and changes in time metrics before (prior to 2005) and after (2005–2007) introduction of Stroke Angel

Clinical scales: Los Angeles Prehospital Stroke Screen, 3-item stroke scale

Not reported

Benefits stated by hospital clinicians were that EMS clinicians are “trained” by direct feedback from the PDA in dealing with the stroke patient.

The use of Stroke Angel was evaluated to be consistently positive by EMS clinicians.

Hospital clinicians took the early warning seriously and were better prepared for the arrival of patients. Better communication between doctors and EMS clinicians, and improved perception of each other’s tasks and work.

Destination:

Not reported

Treatment:

Local lysis rate (number of lyses / all stroke patients enrolled on the stroke unit) increased from 6.1% (2005) to 11.2% (2007)

Call to scene time: unchanged (10 mins before and after)

Time on scene: before (17 mins); after (2007) 23 mins

Travel time: before (26 mins) after (2007) 22 mins

Call to-door time: before

(53 mins); after (2007) 55 mins

Door-to-CT time: before (53 mins); after (2007) 30 mins

Patients treated with thrombolysis:

Door to CT time: before (32 mins); after (2007) 16 mins

Door-to-needle time: before 61 mins, after (2007) 38 mins

1.5% of cases with symptomatic intracerebral bleeding (SITS-MOST criteria)

Stroke Angel

Rashid et al. 2015 [30]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: Standard EMS transport (time)

Clinical scale: ‘Structured checklist’

Not reported

Destination:

Not reported

Treatment:

Telestroke (39%), standard EMS (32%). 7% difference statistically significant

Data covered the period 2005–2013:

Time on scene: 19 mins (Telestroke), 20 mins (Standard EMS). Not statistically significant

Door-to-scan time: 12 mins (Telestroke), 24 mins (Standard EMS). Difference of 12 mins was statistically significant

Not reported

PreSSUB I

Espinoza et al. 2016 [31]

Certified by Autographe (Wavre, Belgium)

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Teleconsultants identified 12 patients (80%) with potential stroke or TIA, which concorded with in -hospital diagnosis in 10 patients (83%). Telestroke – no missed stroke diagnoses:

Extrapolated data: False positives: 2; False negatives: 0; True positives: 10

Comparator: Hospital-based diagnosis

Clinical scale: Unassisted Telestroke Scale

Median 9 min (IQR 8–13 min)

NIHSS was considered unsuitable for mobile telemedicine – this led to the development of a novel scale to rapidly assess stroke severity via telemedicine without assistance by a third party – the Unassisted Telestroke Scale.

94% of teleconsultations were established successfully; one major technical issue occurred due to battery malfunction of the in-ambulance device.

Destination:

Not reported

Treatment:

Not reported

PreSSUB II

Espinoza et al. 2015 [32]

Brouns et al. 2016 [33]

Certified by Autographe

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: Standard EMS transport (time) and hospital diagnosis

Clinical scale: Glasgow Coma Scale, Unassisted Telestroke Scale (UTSS)

Not reported

The proportion of successful in-ambulance telemedicine assessments was 96.2% [33].

Technical and organisational feasibility was established [33].

Destination:

Not reported

Treatment:

Thrombolysis rate (not yet available)

Call-to-CT time [33]:

Standard EMS (87.1 min; 95% CI = 68.7–105.6) versus telestroke (50.8 min; 95% CI = 46.3–55.3):

Statistically significant mean reduction of 36.4 min (95% CI = 17.5 to 55.3)

No telestroke-related adverse events. Mortality was similar in both groups [33]

mRS, Barthel Index, EQ-5D and WHO-Five Well-being Index (not yet available)

InTouch Xpress

Belt et al. 2016 [34]

Purpose: Stratify stroke/facilitate diagnosis:

-Stroke

-Ischemia

Diagnostic accuracy:Extrapolated data:

Stroke vs non-stroke (telestroke)

False Positives: 3

True Positives: 12

Stroke vs non-stroke (Standard EMS transport)

False Positives: 17

True Positives: 54

Comparator: Standard EMS transport (time) and hospital diagnosis.

Clinical scale: Cincinnati Stroke Scale

With alteplase (n = 15): mean 7.3 mins (95% CI = 4.9–9.8).

Without alteplase (n = 74): mean 4.7 mins (95% CI = 3.9–5.4)

Clinicians: 39% of teleconsults required reconnection. Connectivity was rapidly re-established in all but two cases; in all but these two cases, the tele-neurologist felt the clinical evaluation was satisfactory.

Acceptance among patients and EMS has been uniformly positive (but no data are presented to support this statement).

Destination:

Not assessed

Treatment:

Not reported

Door to needle time:

Telestroke - mean 28 mins

Standard EMS – mean 41 mins (decrease of 13 min was statistically significant)

Onset to scene time:

Telestroke - mean 31.1 mins

Standard EMS – mean 50 mins (18.9 min decrease was non-significant)

Scene-to-door time:

Telestroke - mean 29 mins

Standard EMS – mean 34 mins (5 min decrease was non-significant)

Onset to needle time:

Telestroke - mean 92 mins

Standard EMS – mean 122 mins (32 min decrease was significant)

Deaths: 0 (in both groups)

Complications: 1 in telestroke group (vs 5 in standard EMS group)

Smartphone with encrypted software

Brotons et al. 2016 [35]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: 'High correlations' between telestroke NIHSS and NIHSS on hospital arrival

Comparator: Telestroke NIHSS versus arrival at hospital NIHSS (conducted by the same physician)

Clinical scales: CPSS, MEND exam

Not reported

Paramedics and physicians: easy to use and extremely valuable in making triage decision.

Destination:

Direct transfer to CSC

Treatment:

Not reported

HipaaBridge on iPads

Barrett et al. 2017 [36]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: None. Assessed acceptability and usability of HipaaBridge

Clinical scales: NIHSS

Mean NIHSS assessment time 7.6 mins (range 3 to 9.8 mins)

Neurologists rated 83% of encounters as ‘satisfied/very satisfied’.

EMS clinicians - 90% of encounters ‘satisfied/very satisfied’.

Destination:

None

Treatment:

Not reported

iPad with video capability

Shah et al. 2017 [37]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: Standard EMS transport (time)

Clinical scales: Cincinnati Stroke Scale and NIH-8

Not reported

Destination:

Not reported

Treatment:

Not reported

Door to CT order: Mean decrease 6 mins (95% CI = 3.6–8.5)

Door to CT study start:

Mean decrease 12 mins (95% CI = 9.4–14.6)

Door-to-CT result: Mean decrease 12.6 mins (95% CI = 9.7–15.5)

CT order to CT result: Mean decrease 6.9 mins (95% CI = 4.5–9.3)

Not reported

Field-Telestroke

Andrefsky et al. 2018 [38]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: Standard EMS transport (time)

Clinical scale: None reported

Not reported

Destination:

None

Treatment:

Non-significant increase in thrombolysis (10.6–12.7%)

Door-to-scan time:

Telestroke (10.7 mins)

Standard EMS (34.5 mins)

(improvement 23.8 mins)

Door-to-needle time:

Telestroke (41 mins)

Standard EMS (50 mins)

(improvement 9 mins)

Not reported

REACHOUT

Hackett et al. 2018 [39]

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not reported

Comparator: Hospital telestroke (time)

Clinical scale: None

Not reported

Destination:

Not reported

Treatment:

Not reported

Door-to-needle time:

Significant median reduction of 26 min with EMS telestroke (median 39.5 mins) compared with hospital based telestroke (median 65.5 mins)

Not reported

Custom-built system

Johansson et al. 2019 [40]

CE Marked

Purpose: Stratify stroke/facilitate care

Diagnostic accuracy: Not assessed

Comparator: Acceptability / usability of the new telestroke system vs current practice

Clinical scale: PreHAST and NIHSS

Not reported

4 EMS nurses & 1 remote physician: 2 EMS nurses stated the system was reliable; 3 considered it to be safe.

Minor operating interference, physicians’ competence crucial and unclear efficacy emerged from analysis of free text.

Remote physician - image quality ‘more than satisfactory’.

Destination:

Not assessed

Treatment:

Not assessed

3 out 4 of EMS nurses did not believe that the system yielded a more uniform assessment or would reduce time-to-treatment

Not reported