Acute Telestroke Implementation to optimise Treatment rates, incorporating video-conferencing & virtual reality education

This hybrid implementation-effectiveness study applies a paramedic workflow intervention and virtual reality training intervention seeking to upskill paramedics in stroke assessment and transport decision-making and assess the effectiveness of a neurologist-supported video call in pre-hospital workflow. PARAMEDIC WORKFLOW INTERVENTION VIA NEUROLOGIST VIDEO CALL Stroke patients will be identified and assessed by paramedics per existing pathways based on the time since last seen well, stroke assessment score (based on Hunter-8) and previous function (by modified Rankin Score). If assessment scores are within pre-determined cut-off ranges, this will trigger a video-call for video assessment support by the stroke neurologist on-call. The video call will seek to a) confirm if the patient is a candidate for transport by-pass directly to the comprehensive stroke centre and b) the likelihood that patient will be a candidate for endovascular clot retrieval. It is anticipated that the video call will take approximately 5-minutes per patient, depending on case complexity and any aspects requiring clarification / discussion. Data will be collected regarding every patient in the 90-minute drive-time radius from the comprehensive stroke centre in which local ambulance services identified stroke-like symptoms and performed the Hunter-8. Compliance with the video-call protocol will be documented based on hospital records of all stroke transport cases, via existing process in hospital stroke records. Under conditions where video-conferencing is not available (e.g. equipment malfunction, insufficient WiFi signal, neurologist unavailable), paramedics will complete assessment and transport according to the existing business-as-usual protocols. EDUCATION / TRAINING INTERVENTION VIA VIRTUAL REALITY TRAINING Novel, tailored, interactive virtual reality-based training will be implemented to support paramedic up-skilling in stroke assessment and transport decision-making. Paramedics will complete a single virtual reality training session delivered on-site at training facilities, in station and/or via workshops (1 x ~30-minute session + debriefing). Virtual reality training sessions will be completed individually or in small groups (e.g. up to 8 paramedics and one facilitator). Training will be delivered by senior paramedic staff and supported by research team members. During each session, paramedics will use the virtual reality headset and controller to navigate through the training module. In the training module, paramedics complete a virtual stroke case from a first-person perspective, with workflow proceeding from the initial 000 call, patient assessment, transport and handover. During training, paramedics make active decisions and receive feedback on their responses in the virtual reality headset. Paramedics will then apply the workflow algorithm for all stroke patients encountered following completion of training, supported by process documentation (e.g. laminated transport algorithm forms). Training data will be assessed via data audits, surveys and interviews. All paramedic staff involved in acute stroke assessment and management and/or paramedic training at local ambulance sites will be invited by the research team to complete semi-structured qualitative interviews to assess existing enablers and barriers and document outcomes of implementation. Data will be collected continuously, with staggered implementation of the intervention across the training population (VR training & video-enabled neurologist workflow) over the intervention period. Training roll-out will occur within real-world local ambulance processes and informed by staff availability to complete VR training sessions (e.g. on-demand workshops, in-station training, training centre deployment).