Mobile Stroke Unit Research Articles

Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (S21.001)

Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (S21.001)

Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (I1-3A)

Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (I1-3A)

Early Triage of Acute Ischemic Stroke Patients Using Mobile Stroke Unit Shortens Time to Intra-Arterial Therapy (P4.310)

Early Triage of Acute Ischemic Stroke Patients Using Mobile Stroke Unit Shortens Time to Intra-Arterial Therapy (P4.310)

Establishing the first mobile stroke unit in the United States.

Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States. Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol. The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun. The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described.

Abstract 52: Establishing the First Mobile Stroke Unit in the United States

Background: A Mobile Stroke Unit (MSU) delivers Emergency Department (ED) care in the pre-hospital setting. We describe establishing the first MSU in the U.S. Methods: A full time Medical Director and Project Manager took ownership of the project. A funding plan was developed to build,staff and supply the unit for 3 years. An ambulance company donated a standard ambulance. MSU build-out began after purchase of the CT scanner. A consortium of stakeholders was formed including leaders of the stroke programs and EDs of the city’s 3 Comprehensive Stroke Centers (CSCs) and Houston Emergency Medical Services (EMS). Policies and procedures were developed to obtain both state and city health department licensing and inspection, and an accountability system to maintain the unit to standards. Radiation safety certification was obtained from the state health department. Radiation safety experts inspected the vehicle,obtained rad. measurements and designed safety procedures,confirming minimal risk. Insurance on the vehicle and all equipment was obtained. Staffing was hired,and a secure location to park the MSU with electrical hook-up and an office were located. An EMS education program was carried out and communication pathway developed enabling immediate MSU dispatch within a 5 mile radius following a 911 call, as well as for first-responders to activate the MSU. A study protocol was written to evaluate logistics,cost-effectiveness,telemedicine (TM) vs. on-scene decisions and patient outcomes. A HIPPA-compliant technology grid enabled viewing of CT images by the TM team and receiving hospital radiologist. Results: The MSU effort began in March 2013 and the MSU received Feb 4, 2014. The Houston MSU is a standard 12’ ambulance staffed by a neurologist and registered nurse with stroke expertise, CT tech, and paramedic, with TM connectivity, responding to acute stroke dispatches daily from 8a-6p. All MSU management is standard of care; patient consent is not required except to include patient data. This includes a non-con head CT, point of care labs, blood pressure management and if necessary advanced life support. Conclusion: The Houston MSU treated its first patient on May16,2014, and is carrying out acute stroke treatment within 10-18 minutes of arrival on location.

Implementing a mobile stroke unit program in the United States: why, how, and how much?

There are many ways a mobile stroke unit (MSU) might prove valuable for patients with ischemic and hemorrhagic stroke, such as earlier recognition, more accurate triage, improved management of blood pressure and other critical physiological variables, and eventually earlier implementation of effective therapies. The MSU may be particularly valuable for treatment of patients with acute ischemic stroke with tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, the most evidence-based effective emergency treatment for the most prevalent stroke diagnosis. To review existing data on prehospital stroke treatment, especially relevant to MSU technology, to identify gaps in our understanding of MSU feasibility, especially relevant to applying the MSU strategy in the United States, and to describe the Houston MSU program and clinical trial. Published data from English-language journals in PubMed from 1995 to present reviewing early treatment with tPA and prehospital stroke evaluation and treatment. The MSU may result in an overall shift toward earlier evaluation and treatment with tPA, particularly into the first hour after symptom onset, leading to substantially better outcomes. As a result of improved clinical outcomes owing to earlier treatment, the costs of an MSU program may be offset by a reduction in the costs of long-term stroke care and an increase in quality-adjusted life-years, thereby supporting more widespread use of this technology. To make MSU deployment more practical, the vascular neurologist aboard the MSU must be replaced by a remote vascular neurologist connected to the MSU by telemedicine, reducing manpower requirements and costs. The MSU strategy could dramatically transform the way acute stroke is managed in the United States. A prospective study evaluating the logistics, outcomes, and cost-effectiveness of this approach is needed and under way.

Abstract T P200: Feasibility of Telemedicine on a Mobile Stroke Treatment Unit

Background: Mobile stroke treatment unit (MTSU) with on-site treatment team that includes a stroke physician can provide thrombolysis successfully in pre-hospital setting more quickly than traditional treatment in hospital. We report our initial experience of mobile stroke unit with remote physician presence by telemedicine. Methods: We implemented a MSTU at our institution starting July 18 th , 2014. The unit includes a registered nurse, paramedic, emergency medical personnel, CT technologist. Stroke physician evaluated patient via telemedicine (InTouch RP-Lite) and neuroradioloigst remotely assessed images obtained by Ceretom mobile CT. Data were entered in medical records and a prospective registry. The evaluation and treatment in the first 3 weeks of implementation of MSTU was compared to a control group of patients brought to emergency department (ED) via a traditional ambulance in the preceding 2 months. Times were measured from patient arrival entering the “door” of MSTU or emergency department (ED). Results: Twenty three patients were evaluated by MSTU. All patients were evaluated successfully with CT scan, IV placement, neurologic exam and NIH Stroke scale evaluation over telemedicine, and CT interpretation. Duration of telemedicine evaluation was median 21 minutes (IQR: 17-34 minutes). There was a single 44 second interruption of telemedicine connection that did not affect clinical care. The Median NIHS Stroke Scale was 7 (IQR 2 to 11) and was successfully completed in all 23 patients with assistance of a registered nurse by patient side. The time from door to CT scan completion was similar between MSTU and ED (median 21 minutes and 20 minutes, p=0.70). The time from CT completion to radiologist report to stroke physician was similar between MSTU and ED (median 6 minutes and 4.5 minutes, p=0.18). Conclusion: Mobile stroke unit using telemedicine is feasible and as time efficient as traditional ED evaluation.

Abstract 54: Reduction in time to Imaging and intravenous Thrombolysis by in-field Evaluation and Treatment in a Mobile Stroke Treatment Unit

Background: A Mobile stroke treatment unit (MSTU) with on-site treatment team can provide thrombolysis successfully in a pre-hospital setting more quickly than traditional treatment in the hospital. We compared our experience of patients treated with the mobile stroke unit to treatment of patients brought to emergency department via a traditional ambulance Methods: We implemented a MSTU at our institution starting July 18, 2014. The unit includes a registered nurse, paramedic, emergency medical personnel, and CT technologist. A stroke physician evaluated each patient via telemedicine and a neuroradioloigst and stroke physician remotely assessed images obtained by CereTom mobile CT (Neurologica, Danvers, USA). Data were entered in medical records and a prospective registry. The evaluation and treatment in the first 3 weeks of implementation of MSTU was compared to a control group of patients brought to the emergency department via a traditional ambulance in the preceding 3 months. The time of alarm was the dispatch time by the city emergency medical service. Results: 23 patients were treated in the MSTU group and 34 in the control group. There were no significant differences in age or gender between the groups. The median time for alarm-to-MSTU-arrival-at-scene was 13 minutes (Interquartile range 9-17). There was a significant reduction of median alarm-to-CT scan completion times (41 min in MSTU vs 62 min in controls, p<0.0001) and median alarm-to-thrombolysis times (64 min in MSTU vs 104 min in controls, p<0.008). Six patients (26%) received thrombolysis in MSTU group and 5 (14%) in the controls. There were no early complications of thrombolysis in the MSTU group. Conclusion: Compared with traditional ambulance model, ambulance-based thrombolysis resulted in decreased time to imaging and treatment.

Mobile Stroke Unit Hits the Road in Houston

After 1 year of preparation, the nation’s first Mobile Stroke Unit (MSU) delivering acute stroke treatment with tissue plasminogen activator (tPA) in the prehospital setting was launched in mid 2014. The unit is being operated as part of a clinical trial comparing MSU management to standard management to determine how much faster patients can be treated, how much better patients do if treated in the first hour after symptom onset than if treated later, if the physician on board the MSU can be replaced by a remote physician via telemedicine, and the costs and quality-adjusted life years saved by the MSU approach. We are treating on average over two patients per week with intravenous tPA, with more than 30 % treated within the first hour of symptom onset.

Is Prehospital Treatment of Acute Stroke too Expensive An Economic Evaluation Based on the First Trial

Background: Recently, a strategy for treating stroke directly at the emergency site was developed. It was based on the use of an ambulance equipped with a scanner, a point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit). Despite demonstrating a marked reduction in the delay to thrombolysis, this strategy is criticized because of potentially unacceptable costs. Methods: We related the incremental direct costs of prehospital stroke treatment based on data of the first trial on this concept to one year direct cost savings taken from published research results. Key parameters were configuration of emergency medical service personnel, operating distance, and population density. Model parameters were varied to cover 5 different relevant emergency medical service scenarios. Additionally, the effects of operating distance and population density on benefit-cost ratios were analyzed. Results: Benefits of the concept of prehospital stroke treatment outweighed its costs with a benefit-cost ratio of 1.96 in the baseline experimental setting. The benefit-cost ratio markedly increased with the reduction of the staff and with higher population density. Maximum benefit-cost ratios between 2.16 and 6.85 were identified at optimum operating distances in a range between 43.01 and 64.88 km (26.88 and 40.55 miles). Our model implies that in different scenarios the Mobile Stroke Unit strategy is cost-efficient starting from an operating distance of 15.98 km (9.99 miles) or from a population density of 79 inhabitants per km² (202 inhabitants per square mile). Conclusion: This study indicates that based on a one-year benefit-cost analysis that prehospital treatment of acute stroke is highly cost-effective across a wide range of possible scenarios. It is the highest when the staff size of the Mobile Stroke Unit can be reduced, for example, by the use of telemedical support from hospital experts. Although efficiency is positively related to population density, benefit-cost ratios can be greater than 1 even in rural settings.

Thrombolysis Within 1 Hour of Symptom Onset in a Mobile Stroke Unit

German investigators previously reported results from a project in which a “stroke emergency mobile unit” (STEMO) was deployed (NEJM JW Emerg Med Apr 22 2014). The STEMO is an ambulance that is equipped with a computed tomography scanner and staffed by a neurologist. In this substudy, …

First response: race against time.

Mobile stroke units can save lives by treating people before any damage starts to take hold.

Technology foresight for medical device development through hybrid simulation: The ProHTA Project

“Prospective Health Technology Assessment” (ProHTA) aims to develop a platform targeting health care manufacturers and decision makers that facilitates the assessment of innovative health technologies prior to their launch. The simulation has been run for the first case study of Mobile Stroke Units (MSUs). In the highly time sensitive setting of acute stroke, MSUs are an innovative approach as they aim to reduce ‘time-to-thrombolysis’.The ProHTA approach focuses on interdisciplinary work related to forecasting with hybrid simulation consisting of system dynamics models for macro-simulation and agent-based models for micro-simulation.Results of the simulation show that MSUs save up to 49min of time between ambulance call and therapy decision. Whereas without MSUs, only 0.2% of patients fall in the group with the most favourable time interval between 0 and 90min, up to 16.6% of patients treated in MSUs fall into this group of early onset times to thrombolysis. As a flexible and primarily quantitative decision-making tool for foresight, ProHTA adds value to existing methodologies for pre-assessing health technology at a very early stage of technology research and development. With its emphasis on strategic planning, ProHTA helps to improve the efficiency of health care delivery in different settings using hybrid simulation techniques.

Advances in Critical Care/Emergency Medicine 2013

Of the many publications in this field, the ones discussed hereunder seem to be most relevant for clinical practice. Intravenous thrombolysis with tissue plasminogen activator (tPA) is the only therapy proven to improve outcome in ischemic stroke. Studies of intravenous thrombolysis show that response to therapy is time-dependent; the sooner the patients receive tPA, the better the chance of good outcome.1 The required brain imaging before tPA administration delays the initiation of therapy because it necessitates patient transport. In the Pre-Hospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) pilot study, Weber et al2 attempt to speed up stroke treatment by administering tPA before hospital arrival. When patients with presumed stroke contacted the emergency medical system, a stroke emergency mobile unit equipped with a CT scanner was dispatched. Brain imaging was performed at the scene, enabling tPA administration in the stroke emergency mobile unit. For patients in stroke emergency mobile unit, the median time between emergency call and initiation of tPA was 58 minutes (5–63); this time was 92 minutes (79–112) in a group of historic controls. The PHANTOM-S study was a nonrandomized study performed in urban Germany. A randomized controlled study performed in a more rural region of Germany showed a similar relative decrease in the time to tPA treatment among patients treated in a CT-equipped mobile stroke unit compared with those treated in the emergency room.3 These studies show that CT-equipped mobile stroke units decrease the time to tPA …

PHP217 - The Framework for Health Economic Modeling and Multi-Criteria Decision Analysis (MCDA) on the Example of the Mobile Stroke Unit (MSU)

PHP217 - The Framework for Health Economic Modeling and Multi-Criteria Decision Analysis (MCDA) on the Example of the Mobile Stroke Unit (MSU)

“Mobile Stroke Unit” for stroke treatment at the emergency site

“Mobile Stroke Unit” for stroke treatment at the emergency site

The chain of care enabling tPA treatment in acute ischemic stroke: a comprehensive review of organisational models

Protracted and partial implementation of treatment with intravenous tissue plasminogen activator (tPA) within 4.5 h after acute stroke onset results in potentially eligible patients not receiving optimal treatment. The goal of this study was to review the performance of various organisational models of acute stroke care delivery, and subsequent attempts to improve implementation of tPA treatment. Publications comprehensively reporting on organisational models to improve implementation of i.v. tPA treatment of acute ischemic stroke patients were selected. The efficacy of organisational models was assessed using process outcome measures: thrombolysis rates, time-dependent operational endpoints (time delays), functional outcomes: safety (rate of symptomatic intracranial hemorrhage, mortality rates) and clinical outcome at 90 days (modified Rankin Scale). Fifty-eight published studies assessing organisational models were identified. Four dominant models of acute stroke care delivery were discerned, i.e., primary and comprehensive stroke centres, telemedicine, and the mobile stroke unit. Performance reported for these models suggest a large variation in administration of thrombolytic therapy (0.7-30 %). Time delays and functional outcomes found varied considerably, just like safety and mortality (0.0-11.5 %, and 3.4-31.9 %, respectively). These findings suggest that improving organisational models for tPA treatment may improve acute stroke care. However, implementation may be hampered by regional variation in acute stroke care capacity, expertise, and a fragmented approach towards organising stroke care.

Mobile stroke unit for diagnosis-based triage of persons with suspected stroke

In this feasibility study, we tested whether prehospital diagnostic stroke workup enables rational decision-making regarding treatment and the target hospital in persons with suspected stroke. A mobile stroke unit that delivers imaging (including multimodal brain imaging with CT angiography and CT perfusion), point-of-care-laboratory analysis, and neurologic expertise directly at the emergency site was analyzed for its use in prehospital diagnosis-based triage of suspected stroke patients. We present 4 complementary cases with suspected stroke who underwent prehospital diagnostic workup that enabled direct diagnosis-based treatment decisions and reliable triage regarding the most appropriate medical facility for that individual, e.g., a primary hospital vs specialized centers of a tertiary hospital. This preliminary report demonstrates the feasibility of prehospital diagnostic stroke workup for immediate etiology-specific decision-making regarding the necessary time-sensitive stroke treatment and the most appropriate target hospital.

Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial

Only 2-5% of patients who have a stroke receive thrombolytic treatment, mainly because of delay in reaching the hospital. We aimed to assess the efficacy of a new approach of diagnosis and treatment starting at the emergency site, rather than after hospital arrival, in reducing delay in stroke therapy. We did a randomised single-centre controlled trial to compare the time from alarm (emergency call) to therapy decision between mobile stroke unit (MSU) and hospital intervention. For inclusion in our study patients needed to be aged 18-80 years and have one or more stroke symptoms that started within the previous 2·5 h. In accordance with our week-wise randomisation plan, patients received either prehospital stroke treatment in a specialised ambulance (equipped with a CT scanner, point-of-care laboratory, and telemedicine connection) or optimised conventional hospital-based stroke treatment (control group) with a 7 day follow-up. Allocation was not masked from patients and investigators. Our primary endpoint was time from alarm to therapy decision, which was analysed with the Mann-Whitney U test. Our secondary endpoints included times from alarm to end of CT and to end of laboratory analysis, number of patients receiving intravenous thrombolysis, time from alarm to intravenous thrombolysis, and neurological outcome. We also assessed safety endpoints. This study is registered with ClinicalTrials.gov, number NCT00153036. We stopped the trial after our planned interim analysis at 100 of 200 planned patients (53 in the prehospital stroke treatment group, 47 in the control group), because we had met our prespecified criteria for study termination. Prehospital stroke treatment reduced the median time from alarm to therapy decision substantially: 35 min (IQR 31-39) versus 76 min (63-94), p<0·0001; median difference 41 min (95% CI 36-48 min). We also detected similar gains regarding times from alarm to end of CT, and alarm to end of laboratory analysis, and to intravenous thrombolysis for eligible ischaemic stroke patients, although there was no substantial difference in number of patients who received intravenous thrombolysis or in neurological outcome. Safety endpoints seemed similar across the groups. For patients with suspected stroke, treatment by the MSU substantially reduced median time from alarm to therapy decision. The MSU strategy offers a potential solution to the medical problem of the arrival of most stroke patients at the hospital too late for treatment. Ministry of Health of the Saarland, Germany, the Werner-Jackstädt Foundation, the Else-Kröner-Fresenius Foundation, and the Rettungsstiftung Saar.

Bringing the Hospital to the Patient: First Treatment of Stroke Patients at the Emergency Site

BackgroundEarly treatment with rt-PA is critical for favorable outcome of acute stroke. However, only a very small proportion of stroke patients receive this treatment, as most arrive at hospital too late to be eligible for rt-PA therapy.Methods and FindingsWe developed a “Mobile Stroke Unit”, consisting of an ambulance equipped with computed tomography, a point-of-care laboratory system for complete stroke laboratory work-up, and telemedicine capabilities for contact with hospital experts, to achieve delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital. In a departure from current practice, stroke patients could be differentially treated according to their ischemic or hemorrhagic etiology even in the prehospital phase of stroke management. Immediate diagnosis of cerebral ischemia and exclusion of thrombolysis contraindications enabled us to perform prehospital rt-PA thrombolysis as bridging to later intra-arterial recanalization in one patient. In a complementary patient with cerebral hemorrhage, prehospital diagnosis allowed immediate initiation of hemorrhage-specific blood pressure management and telemedicine consultation regarding surgery. Call-to-therapy-decision times were 35 minutes.ConclusionThis preliminary study proves the feasibility of guideline-adherent, etiology-specific and causal treatment of acute stroke directly at the emergency site.