In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case–control study

PurposeStroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment.MethodsObservational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients.ResultsThe in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0–2 at discharge was similar in both groups when adjusting for NIHSS score and age.ConclusionThe same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care

Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil:TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial

OBJECTIVE: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. METHODS: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. CONCLUSION: According to the trial’s best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results. ClinicalTrials.gov registration: NCT0392050