International Journal of Telemedicine and Applications 3 Table 1: Demographic information, diagnoses, and thrombolysis eligibility. Gender (% Female) Age (Mean, Years) NIHSS Score (Mean) Ischemic Stroke (%) Intracerebral Hemorrhage (%) TIA (%) Stroke Mimic (%) CT contraindication to thrombolysis (%) Thrombolysis Administered (proportion of consultations) standard internet connections (BF Technologies, San Diego, CA, USA). Data from ten prospective VN-NP telestroke consulta- tions, supervised by a vascular neurologist, were collected during the interval from November 2008 to November 2009. The study was approved by each of the participating spoke hospital institutional review boards (IRB) and also by Mayo Clinic IRB, with authorization for central oversight. 3. Statistical Analysis This preliminary paper was principally a feasibility study. The study sample size was 10 cases. Analyses included mean and standard deviation of time categories and kappa coeﬃcient for inter rater agreement. 4. Results Table 1 displays basic demographic information, severity of deﬁcit, diagnosis, CT observation, and thrombolysis eligibil- ity of this study cohort. The VN-NP telestroke consultation patients did not diﬀer substantially, in characteristics, from those patients in similar trials [10, 12]. The VN-NP telestroke consultation patients were broadly representative of typical patients seen by emergency stroke teams, for example, similar proportions of ischemic and hemorrhagic stroke, transient ischemic attack, and stroke mimics. Thirty percent of the VN-NP consultation patients were determined to have ischemic stroke and were eligible for thrombolysis, similar to the proportion in other telestroke trials [10, 12]. The inter rater agreement between VN-NP and vascular neurologist (Table 2) was excellent for NIHSS score, diagnosis, head CT interpretation, and overall thrombolysis eligibility. 5. Discussion There are many facets of this small study worthy of discus- sion, including: comparing time intervals between teleme- dicine studies, feasibility, scope of practice of mid level providers, neurovascular specialty training, and future con- siderations. The time intervals of the VN-NP vascular neurologist consultative partnership (Table 3) were similar to those of VN-NP Telemedicine Algorithm (N = 10) 50.0 70.8 11.6 40.0 20.0 10.0 30.0 20.0 30.0 Table 2: VN-NP and Vascular Neurologist Inter rater Agreement. Assessment Kappa (95% CI, if applicable) NIHSS Score Stroke Diagnosis CT contraindication to thrombolysis Thrombolysis eligibility 0.859 (0.734 to 0.984) 1.0 1.0 1.0 previously published traditional vascular neurologist service provision in telestroke trials in the same network (STRokE DOC AZ) [7] and a comparable network in a neighboring state (STRokE DOC) [12]. Compared to physician-only telestroke consultations, the VN-NP algorithm resulted in approximately 10 minutes faster call-to-neurology exam and 10 to 20 minutes faster consent-to-neurology exam intervals, but 20 to 30 minutes slower decision-to-rt-PA interval. The VN-NP appeared to respond quickly to telestroke alert calls from spoke hospitals, progressing swiftly from the emergency alert to starting the consultation. On the other hand, the decision (for tPA eligibility) to tPA administration was relatively long, 45 minutes, in this study. The result represents only three (of 10 total) thrombolysed subjects. The sample was very small. Events needing to occur between VN- NP decision and thrombolysis include: supervising vascu- lar neurologist evaluation, consensus, communication with emergency physician, communication with patient/family, pharmacy order for tPA, drug preparation, and then admin- istration. Occasionally elevated blood pressure required treatment before tPA was administered. Despite the added complexity of two neurology providers assessing each patient and communicating with one another, the overall time inter- vals of call-to-decision and consent-to-rt-PA were similar to intervals reported by STRokE DOC trials [12, 15]. The supervising vascular neurologists required an average 12.0 minutes to assess each shared telestroke case, in contrast to an average requirement of 58.3 to 64.7 minutes per case without VN-NP partnership [12, 15]. Even the cumulative total of VN-NP plus vascular neurologist time requirement (65.2 minutes) was not substantially diﬀerent from the published time required by a solo vascular neurologist (58.3 to 64.7 minutes) [12, 15].