Video streaming from ambulance can be life-changing for acute stroke patients

When someone suffers a stroke, time and choice of treatment are critical factors. The outcome largely depends on how quickly the person receives the right care. If the ambulance staff can consult a stroke specialist via video streaming inside the ambulance, before departure, lives can be saved and permanent brain damage prevented. This is shown in a study led by Chalmers University of Technology, in Sweden, which involved all of the key professional groups required when someone suffers an acute stroke.

"Using video streaming and consultation in the ambulance, stroke patients can quickly and remotely be assessed by a neurologist and driven directly to the hospital that can provide them with the best care. The biggest difference can be felt by the people who live furthest away from a specialist hospital. So, in addition to better care outcomes, this means more equal care for each stroke patient," says Stefan Candefjord, who is a researcher in digital health at the Department of Electrical Engineering at Chalmers and first author of a new scientific study within the project VIPHS (Video Support in the PreHospital Stroke Chain). 

The right decision can save one and a half hours

A stroke is mostly caused by a clot in the blood vessels of the brain. In the case of clots in smaller blood vessels, clot-dissolving drugs, known as thrombolytics, are normally given at a nearby emergency hospital. However, in the case of clots in the larger vessels of the brain, significantly better results are achieved if the blood clot can be removed through a surgical procedure - thrombectomy. This involves entering a blood vessel that leads into the brain and mechanically pulling out the clot with the help of a catheter. Since this is quite a complicated procedure, it can only be performed at specialist hospitals like university hospitals, such as Sahlgrenska University Hospital in Gothenburg, Sweden. Regardless of the treatment needed, a CT (computed tomography) image examination of the brain is initially done at hospital to assess the situation and the type of stroke. If the patient has been transported to a nearby emergency hospital, further transport is then usually required to be able to offer thrombectomy - if this is deemed to be the optimal treatment.

 "A decision in the ambulance to transport a patient directly to Sahlgrenska University Hospital is estimated to save one and a half hours in processing time for patients who live outside Greater Gothenburg. This can be a life-changing timesaving for those who need a thrombectomy, as an hour's delay is estimated to halve the effect of the treatment. Every year, a significant number of people could have a completely different life if they had a thrombectomy faster," says Bengt Arne Sjöqvist, Professor Emeritus of digital health at the Department of Electrical Engineering at Chalmers, and co-author of the scientific article.

The researchers behind the study point out that it is important to identify as early as possible, and with high precision, which patients need which care. With the video streaming support, it is possible to enhance an existing care process for selected patients, which is currently based on telephone calls between ambulance personnel and specialist doctors. 

"With video cameras in the ambulances, we can make today's stroke care even better for more patients. The same neurological assessment that the doctor does in a hospital can now be done at a much earlier stage in the ambulance. This process is a team effort that involves many people from different parts of the care chain, where everyone is important to reduce the number of minutes it takes to treat the stroke patient," says Mikael Jerndal, neurologist and chief physician at the stroke unit at Sahlgrenska University Hospital in Gothenburg.

Realistic full-scale simulations

To test and evaluate how a video-assisted decision support system can work in practice, realistic full-scale simulations were conducted. Four ambulance teams received alerts about people with stroke symptoms of varying severity. The patients were played by neurologists and the ambulances were equipped with three cameras that were connected to stroke specialists at Sahlgrenska University Hospital in Gothenburg.

The first camera focused on the patient’s face, so that an assessment of facial expressions, as well as head and eye movements could be made. The second camera was angled towards the side of the patient, to give a general overview and assess the ability to lift and hold up their arms. Finally, a third camera showed the patient's legs, to make a similar assessment as for the arms.

Continued work to introduce technology as normal routine

After the simulation study, a clinical pilot study was carried out with three ambulances and actual stroke patients, in a region outside of Gothenburg – Södra Älvsborg. The pilot study was successful, and the results and experiences where transferred to Region Västra Götaland , the responsible healthcare stakeholder, as part of its investment and promotion of increased healthcare digitalisation.

"With the primarily responsible stakeholder as project lead, the intention was to manage a critical phase in utilisation as well as regional adaptation, deployment and future form of operation, a work that is still ongoing.  Of course, we hope that the positive results from our work will soon be shared by patients, and then also in other places. Disseminating and sharing our results and experiences, as well as helping everyone who wants to test and implement, is important to us," says Bengt Arne Sjöqvist.

All images and footage from realistic full-scale simulations can be downloaded via this link.

More about the research 

The study “Video support for prehospital stroke consultation: implications for system design and clinical implementation from prehospital simulations” is published in BMC Medical Informatics and Decision Making.

The article is written by Stefan Candefjord, Magnus Andersson Hagiwara, Bengt Arne Sjöqvist, Jan-Erik Karlsson, Annika Nordanstig, Lars Rosengren and Hanna Maurin Söderholm.

The study has been carried out within the framework of the project Video Support in the Prehospital Stroke Chain, ViPHS, which was started in 2015/2016 on the initiative of Bengt Arne Sjöqvist (concept, technology, system and process design) from Chalmers and Lars Rosengren (concept, medicine and care process) from Sahlgrenska Academy at the University of Gothenburg and Sahlgrenska University Hospital. 

The work with ViPHS has been carried out within the framework of the long-term regional interdisciplinary collaboration on prehospital care that has been ongoing in and around Gothenburg, Sweden, for more than ten years. This includes all parties involved in the study, and the ambition of the collaboration is to cover the entire perspective from research to utilisation in healthcare. In addition to ViPHS, other possible tools are also being studied to increase the precision of early decisions in stroke. These are still in their early stages, but include, for example, AI methods.

At the time of writing the scientific article, the authors were active at Chalmers University of Technology, the University of Borås, Sahlgrenska University Hospital, the Sahlgrenska Academy at the University of Gothenburg and the PICTA Prehospital Innovation Arena at Lindholmen Science Park.

The research has received support from the Innovation Fund VGR, Region Västra Götaland and Vinnova. 

More about stroke:

Stroke is a collective name for diseases caused by a blood clot (infarction) or a haemorrhage in the brain. About 85 percent of the cases are infarctions. Every year, about 6 million people are affected in the world, and in Sweden, according to the National Quality Register for Stroke Care, there are about 25,000 people. In Sweden, just over 20 percent die within 28 days, about 30 percent end up in a lifelong position of dependency and the rest have manageable after-effects or become unaffected. The outcome largely depends on how quickly the person receives the right care. The social cost of stroke is estimated at just over SEK 18 billion annually in Sweden – excluding efforts from, for example, relatives.

Sources: riksstroke.org, neurologiisverige.se