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Specialized Stroke Ambulance |
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From medGadget
Specialized Stroke Ambulance Features CereTom Portable CT Scanner to Reduce Time to Treatment
by on Jun 6, 2012 • 3:20 am
NeuroLogica and MEYTEC from Germany
have developed a specialized stroke ambulance, called VIMED STEMO, that
carries a portable CT scanner and a point-of-care laboratory for
nearly-instant diagnosis and initiation of treatment in stroke patients.
It employs MEYTEC’s telemedicine solutions and NeuroLogica’s portable
CT scanner, CereTom.
The VIMED STEMO integrates a fully-functioning pre-clinical stroke
care suite, comparable to those found in specialized stroke hospitals.
The onboard CereTom is a 8-slice CT scanner that allows for multimodal
imaging with CT angiography and CT perfusion in combination with a rapid
scan time. Imaging and other data can be transmitted over encrypted 3G,
4G and satellite connections to emergency rooms or trauma centers.
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Specialized Stroke Ambulance |
In addition to being well-equipped, the ambulance also carries the best medical team you could get delivered to your door when you might be suffering from a stroke, including a paramedic, a stroke physician and a neuroradiologist. All together, this enables hyper-acute stroke care, including thrombolytic treatment as soon as possible, well before arrival at a hospital. No word on how much this all costs per trip.
Of course, the question remains whether this hyperacute care
translates in better patient outcomes, but the companies have already
conducted a randomized trial that provides some clues. They randomized
100 patients to either the stroke ambulance or usual emergency care.
Unsurprisingly, pre-hospital stroke treatment greatly reduced the median
time from alarm to therapy decision (35 versus 76 min) with similar
gains in times from alarm to end of CT, and alarm to end of laboratory
analysis, and to intravenous thrombolysis for eligible ischaemic stroke
patients.
There was no substantial difference in neurological outcome between
the groups, however the current study was not powered to detect such a
difference and follow-up was relatively short. It does show that
pre-hospital stroke diagnosis and treatment is feasible and may reduce
time-to-treatment to a level that was previously unreachable. The VIMED
STEMO is currently embedded in the emergency service system of Berlin.
Flashback: The CereTom Mobile CT Scanner; On the Pitch CT Scanners;
More info: Project STEMO…
Lancet Neurology: Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial…
Related:
Specialized Stroke Ambulance Features CereTom Portable CT Scanner to Reduce Time to Treatment
Stroke ambulances dramatically cut treatment time
| A study found special mobile units cut treatment time for stroke victims from 94 to 56 minutes. These vehicles are being rolled out across the country. Dr. Tara Narula, cardiologist at Northwell Health, joins "CBS This Morning" to explain how these stroke ambulances work.
Mobile Stroke Units for Prehospital Care of Ischemic Stroke by Jeff Mason.
Published online: June 1, 2017.
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Summary
Stroke is a leading cause of death and disability in Canada, and early diagnosis and treatment are essential to improving patient outcomes.
Mobile stroke units are similar to ambulances but are equipped with a portable computed tomography (CT) scanner and specially trained staff for the rapid diagnosis and treatment of ischemic stroke.
Evidence suggests that mobile stroke units reduce the time it takes for people who have suffered a stroke to receive appropriate treatment.
It is still unclear if earlier treatment in a mobile stroke unit improves long-term functional outcomes.
Mobile stroke units are expensive to purchase and operate, but evidence suggests that they may be cost-effective.
Photo: iStock
Photo: iStock.com/sihuo0860371
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Background
Stroke is a condition caused when blood vessels in the brain become blocked or rupture, preventing oxygen and nutrient-rich blood from reaching brain cells.1,2 Signs and symptoms of stroke appear suddenly and may include numbness or loss of strength in the face, arm, or leg; difficulty seeing or speaking; impaired comprehension; confusion; headache; and dizziness or loss of balance.3
Ischemic stroke, the most common type of stroke, occurs when a blood clot disrupts blood flow to the brain.1 Other types of stroke are caused by bleeding within the brain (intracranial hemorrhage) or when a blood vessel at the base of the brain bursts and causes bleeding into the lining of the brain (atraumatic subarachnoid hemorrhage).1
The longer the brain goes without oxygen and other nutrients, the more likely a stroke will lead to permanent damage to the brain.2 When people have an ischemic stroke, restoring blood flow as quickly as possible is key. This treatment strategy, called “time is brain,” uses medications that break up blood clots (thrombolytic drugs, such as tissue plasminogen activator [t-PA] or recombinant tissue plasminogen activator) or mechanical means of retrieving and removing the blood clot (endovascular therapy).4,5
Stroke costs Canadians an estimated C$3.6 billion annually in health care costs and lost productivity.1 Although hospitalization rates for stroke have declined since the 1990s, with an increasingly aging population, this decline is expected to flatten, and the number of Canadians who suffer a stroke is expected to increase in the future.1,3
People treated in-hospital after a stroke also have increasingly complex medical conditions, and most have at least one pre-existing chronic health condition.3
Improvements in stroke care mean that more Canadians have access to comprehensive stroke centres, are treated in dedicated stroke units staffed by multidisciplinary stroke teams, have access to telestroke services (audio and video connections to stroke specialists), and have faster access to appropriate treatments, such as medications to break up blood clots in the brain.3
Mobile stroke units are being investigated as a way to provide earlier care to people who may have suffered a stroke.
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The Technology
A mobile stroke unit is a modified ambulance or custom-built vehicle, resembling a large ambulance, that contains a small CT scanner to provide on-site imaging of patients with suspected stroke.6–14 Other features of mobile stroke units vary from region to region and include telestroke equipment, point-of-care laboratories, thrombolytic drugs, and standard emergency response equipment, as in a regular ambulance.6–14
Mobile stroke units also differ from regular ambulances in the way they are staffed. In addition to a paramedic or an emergency medical technician, mobile stroke units may be staffed by neurologists, nurses, radiology or CT technicians, or other health professionals.6–14 In vehicles in which telestroke equipment is available, the mobile stroke unit is also connected to specialists, such as radiologists and neurologists, in the hospital.15,16
Adapted with permission from Wolters Kluwer: Health Physics, 2016; 110(5):S73–S80
Adapted with permission from Wolters Kluwer: Health Physics, 2016; 110(5):S73–S80.53
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Who Might Benefit?
Approximately 62,000 Canadians experience a stroke each year, and approximately 14,000 die after having a stroke1,2,17 Another 741,800 Canadians are living with the effects of stroke.1,2,17 However, these numbers are likely underestimates because they do not include people who died outside the health care system or from a silent stroke.18
Although stroke occurs most often in people older than 70 years, stroke rates in people in their 50s and 60s are increasing, and rates in younger people (between the ages of 24 and 64) are expected to double by 2030.3 One-third to two-thirds of all people who survive a stroke need some form of rehabilitation.18 Early treatment with thrombolytic drugs reduces both the mortality and the morbidity of stroke, and more patients who receive early treatment are discharged home (rather than to a nursing home).19
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Availability
Canada’s first mobile stroke unit began operating in January 2017, as part of a three-year pilot project out of the University of Alberta Hospital in Edmonton.11
Elsewhere in the world, mobile stroke units are in use or are being evaluated for use in Germany (where the model originated), the UK, France, Belgium, Switzerland, Finland, Norway, Qatar, Thailand, Australia, Argentina, and in several US cities.6–10,12–14,20
Regulation of Mobile Stroke Units in Canada
In Canada, some components of a mobile stroke unit (e.g., the CT scanner) are regulated by Health Canada, but the mobile stroke unit vehicle is not, as it is designed for the transportation of this medical equipment (Gary Scott Holub, Media Spokesperson, Health Canada, Ottawa, ON: personal communication, 2017 Feb 9). How the equipment in a mobile stroke unit is regulated depends on the component; for example, CT scanners are considered a Class III medical device by Health Canada. This designation means that CT scanners are considered a moderate risk and require scientific evaluation to confirm that they comply with regulations. CT scanners are therefore regulated by Medical Devices Regulations, but they must also comply with the Food and Drugs Act and the Radiation Emitting Devices Act (Gary Scott Holub: personal communication, 2017 Feb). Small CT scanners, like the one being used in Edmonton’s mobile stroke unit,11 are licensed for use in Canada (Gary Scott Holub: personal communication, 2017 Feb).
In addition to national standards and regulations, mobile stroke units may also be subject to provincial policies on the design, construction, and operation of emergency vehicles.21–24
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How Much Does It Cost?
The costs of operating a mobile stroke unit include the initial investment in the vehicle and equipment and the ongoing operating, maintenance, and staffing costs.8,25–27 In Edmonton, the reported cost of the stroke ambulance is more than C$1 million.11 In Germany, the vehicle and equipment costs have been reported to be €405,000 and €955,666.26,27 The vehicle and equipment for the Houston unit cost US$600,000.25
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Current Practice
Prevention strategies, such as quitting smoking, losing weight, eating a healthier diet, and engaging in more exercise, can reduce the risk of having a stroke.1–3 The early detection and management of conditions that can lead to stroke, such as atrial fibrillation (irregular heartbeat), high blood pressure, and diabetes, also help reduce the risk of stroke.1 However, not all strokes can be prevented, and when a stroke occurs, Canadian guidelines recommend the following approaches to prehospital care, thrombolysis, and other management considerations.4,5
“Canada’s first mobile stroke unit began operating in January 2017, as part of a three-year pilot project out of the University of Alberta Hospital in Edmonton.”
Prehospital and Early Care
The 2015 Canadian Stroke Best Practice Recommendations note that the use of paramedics to transport people with suspected stroke to hospital is important to patient safety and to patients being appropriately routed to specialized stroke centres, if needed, as quickly as possible.4 The recommendations for prehospital care and management include:
using emergency medical services (EMS) dispatch processes designed to recognize the signs of probable stroke
using out-of-hospital screening tools to assess patients on arrival at the scene
limiting the amount of time spent at the scene to 20 minutes or less
measuring the patient’s blood glucose level
directly transferring patients with suspected stroke eligible for thrombolysis to an appropriate centre in less than 3.5 hours from symptom onset, with a target door-to-needle time in the emergency department of 30 minutes and no more than 60 minutes.4
After discussing EMS handover to the emergency department, the recommendations emphasize the importance of rapidly assessing patients with suspected stroke and beginning treatment as soon as possible.4 Initial in-hospital care should include immediate clinical examination to confirm stroke, rule out conditions that resemble stroke, and determine if the patient is eligible for thrombolysis (including ordering blood work).4 Neuroimaging with noncontrast CT must be done for any patient with suspected stroke.4
The 2015 Canadian Association of Emergency Physicians’ Position Statement on Acute Ischemic Stroke also recommends prehospital protocols, which include the transportation of patients to facilities designed to receive stroke patients, if such facilities are available.5 Stroke protocols should be in place to evaluate, image, and treat people with stroke as soon as possible, and telemedicine should be available in places where access to specialized care is limited.5 In the EMS stage of care, stroke calls should be given the highest transportation priority, the time symptoms began should be determined, blood glucose should be measured, and standardized tools should be used on-site to ensure immediate transportation to an appropriate health care facility, if necessary.5
Thrombolysis
The 2015 Canadian Stroke Best Practice Recommendations for managing acute ischemic stroke state that thrombolysis using t-PA is the standard of care and that screening by a stroke physician (on-site or by telestroke) should take place as soon as possible.4 Initial imaging should be evaluated using the Alberta Stroke Program Early CT Score, and if a patient is eligible, t-PA should be provided within 4.5 hours of the time symptoms began and as soon as possible after arrival at a hospital.4 If there is uncertainty about whether a patient is eligible to receive t-PA or if imaging results are unclear, specialists should be consulted as soon as possible.4
The Canadian Association of Emergency Physicians’ 2015 position statement strongly recommends providing recombinant tissue plasminogen activator to patients with acute ischemic stroke within three hours of the time symptoms began, provided the patients’ imaging results rule out any contraindications.5 The statement also strongly recommends a door-to-needle time of less than 60 minutes in eligible patients.5
Other Management Recommendations
A significant change in the 2015 Canadian Stroke Best Practice Recommendations is new guidance about endovascular therapy (mechanical clot retrieval) in people with acute ischemic stroke.4 The decision to provide endovascular therapy should be coordinated in a system that includes EMS; rapid imaging; in-hospital arrangements between the emergency department, the radiology department, and a stroke team; expertise performing the procedure; and access to a stroke unit for ongoing patient management.4 Patients may be eligible for endovascular therapy within six to 12 hours of when symptoms began and should ideally begin treatment within 60 minutes of CT imaging.4
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The Evidence
We found two randomized controlled trials of mobile stroke unit models in Germany (cities of Saarland and Berlin) reported in the literature.6,7 We also found additional observational studies, case studies, and cost studies from Europe and the US.26–40
In 2012, researchers in Saarland compared the treatment of 100 adult patients living in a mixed rural-urban setting with at least one symptom of stroke that began no more than 2.5 hours before calling EMS.6 Patients were randomized in week-long blocks to either mobile stroke unit care (n = 53) or conventional, but optimized care with point-of-care laboratory testing (n = 47).6 Mobile stroke unit care included a CT scan, point-of-care laboratory testing, thrombolytic treatment when indicated, and transportation to a stroke centre.6
The 2014 Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S), like the Saarland trial, randomized patients in week-long blocks to mobile stroke unit care (n = 310) or conventional stroke care (n = 220). The PHANTOM-S trial looked at adult patients in urban Berlin.7
Time to Treatment
Much of the research about mobile stroke units evaluates the time it takes for a patient to receive treatment. However, the outcome measured varies from study to study. For example, the primary end point of the Saarland trial6 was the time from when dispatchers activated the stroke alarm to the time a treatment decision was made (reported as the “alarm-to-treatment time”); the primary end point of the PHANTOM-S trial7 was the time from alarm to the time t-PA was administered (also reported as the “alarm-to-treatment time”).
The Saarland trial found that patients treated in the mobile stroke unit had a shorter median alarm-to-treatment decision time (35 minutes) than patients who received conventional treatment (median alarm-to-treatment decision time of 76 minutes).6 Similarly, the PHANTOM-S trial found a reduction in the average alarm-to-t-PA administration time in mobile stroke unit patients (64.1 minutes) compared with patients who received conventional care (76.3 minutes).7
Functional Outcomes
The way prehospital care in a mobile stroke unit affects the ability of people to perform the activities of their daily lives after a stroke was also assessed.6,28 Researchers in Berlin used data collected from patients (n = 932) who had experienced acute ischemic stroke before, during, and after the PHANTOM-S study to compare the proportion of patients living without disability (modified Rankin score of 0 to 1) three months after being treated with prehospital intravenous thrombolysis in a mobile stroke unit (n = 427) with patients who received standard hospital care (n = 505).28 No difference was found between the two groups.
The proportion of patients living without severe disability or able to walk without assistance (modified Rankin score of 0 to 3) was also assessed in the two groups, and the difference was found to be statistically significant. In the mobile stroke unit group, 83% of patients (n = 253) were living without severe disability or were able to walk on their own three months after treatment, compared with 74% (n = 260) of those in the conventional care group; however, the study was not designed to detect differences in this outcome.28
Functional ability (modified Rankin score of less than 2) at one and seven days after mobile stroke unit treatment or conventional treatment was also a secondary end point in the 2012 Saarland trial.6 No difference was found between the two groups.6
Further research to assess the impact of mobile stroke unit care on functional outcomes is being conducted as part of the Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit study, an observational study in Houston,29 and the Berlin Prehospital or Usual Delivery of Acute Stroke Care trial, a randomized controlled trial in Berlin.30
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Triage
The use of mobile stroke units to refer patients to appropriate treatment facilities has been studied in Germany and the US.31–34 Using data from the PHANTOM-S trial7 and its pilot study,41 researchers in Berlin evaluated how care in a mobile stroke unit affected the transport of patients with cerebrovascular disease to appropriate health care facilities.31 When compared with standard prehospital treatment, patients with cerebrovascular disease or ischemic stroke treated in the mobile stroke unit were more likely to be transported to a facility with a stroke unit, and those with intracranial hemorrhage were more likely to be transported to a hospital with a neurosurgery department.31
Investigators in Cleveland, using data from five mobile stroke unit patients and historical controls, found that treatment in a mobile stroke unit may reduce the time it takes for a patient in need of clot retrieval to be brought to an appropriate care facility and receive treatment.33 A case report in Cleveland also concluded that a CT angiography performed in a mobile stroke unit may be a helpful tool to triage patients eligible for mechanical clot retrieval.34
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Safety
The available evidence indicates that mobile stroke unit care is as safe as conventional care for treating people with stroke. Both the Saarland and PHANTOM-S trials found no differences between deaths at seven days or intracranial hemorrhages in patients treated in the mobile stroke unit compared with patients who received conventional treatment.6,7
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Cost-Effectiveness
In Germany, separate cost-effectiveness and benefit-cost studies about the use of mobile stroke units have been conducted.26,27 In Berlin, on the basis of data from the PHANTOM-S study, researchers found that the use of mobile stroke units, despite large initial and ongoing costs, may be cost-effective compared with conventional treatment (incremental cost-effectiveness ratio = €32,456).26 In Saarland, researchers calculated the benefit-cost ratio of delivering care using a mobile stroke unit at different distances from its home base and found that at a distance of 30 km, the benefits of providing prehospital care with a mobile stroke unit exceeded the costs (benefit-cost ratio = 1.96).27
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Other Uses
Researchers are also investigating the speed and reliability of on-board laboratories35 and the use of mobile stroke units to evaluate and reverse warfarin-related intracranial hemorrhage36 and diagnose intracranial hemorrhage.37,38 Wanting to evaluate other uses of the on-board CT scanner, researchers in Saarland assessed a patient with head trauma in the mobile stroke unit and concluded that this additional use of the mobile stroke unit was worthy of research.32 Also under investigation is the feasibility of using automated stroke imaging software on a mobile stroke unit to assist decision-making in the treatment and triage of patients39 and to distinguish stroke from other conditions that can cause similar symptoms (stroke mimics).40
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Concurrent Developments
Other interventions that may improve the early care and management of people who have had a stroke include high-tech solutions, such as using mobile telestroke systems to assess patients in prehospital settings42–45 or sending a neurologist with a portable ultrasound machine to respond to stroke calls.46,47 Another option may be to improve dispatchers’ abilities to screen for stroke.48 Allowing paramedics to administer medications (such as NA-1, lisinopril, or transdermal glyceryl trinitrate) may also help improve functional outcomes after a stroke.49–51
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Implementation Issues
How a mobile stroke unit service would function in Canada is not yet known. Evidence from the pilot project in Edmonton will help address this gap.11 There is limited information about how mobile stroke units are implemented in other countries, but some common issues are described below.
Using Mobile Stroke Units in Urban and Rural Settings
Currently, the most robust evidence for the use of mobile stroke units comes from the PHANTOM-S trial, which took place within the densely populated urban centre of Berlin.7 Although the Saarland trial6 included both urban and rural dispatches of its mobile stroke unit, there is little evidence about how mobile stroke unit services may be impacted by the locations they serve.
In Berlin, researchers used data from the PHANTOM-S trial to evaluate whether time-to-treatment benefits seen in the trial were affected by the distance the mobile stroke unit must travel to provide care.45 Of the 530 patients included in the analysis, the 200 in the mobile stroke unit group received care more quickly than the 330 patients treated conventionally at all dispatch distances.45 However, these results may not be generalizable to other systems because of geographic differences.45
In Saarland, the benefit-cost analysis conducted by researchers included a distance component and found that although denser populations (such as city centres) are associated with greater benefit-cost ratios, even in rural settings the benefit of providing care using a mobile stroke unit exceeds the costs.27
Another proposed option is that in rural areas or areas with low population density, a mobile stroke unit could be dispatched to meet regular emergency services at predesignated points to transfer patients en route.20
Equipment Reliability
Observational research about implementing mobile stroke unit services have briefly described issues with equipment reliability.6,8,15,41 Communication disruptions caused by operator error or poor wireless network connections between the mobile stroke unit and the hospital have been reported, but these disruptions did not impact patient care.15,41 In Saarland, the point-of-care laboratory was unavailable (reasons not provided) for 10 patients.6 Difficulties using the CT scanner because of steep streets,6,8 blocked equipment,41 and overweight patients6 have also been reported. Edmonton’s mobile stroke unit includes a self-levelling feature to address problems with terrain.11
Staffing Models
The staffing of mobile stroke unit teams varies and is one of the largest ongoing costs of operating the service. Several suggestions for containing these costs and streamlining care have been proposed, including cross-training a paramedic as a CT technician;8 replacing specialists, such as radiologists, with technicians;6 and reducing the team to essential members (e.g., stroke-trained paramedics).27
Substituting on-board physicians with telestroke consultation may also be possible.15,52 In Cleveland, early observational research of 100 patients evaluated in a mobile stroke unit found that telestroke consultations were successful 99% of the time and concluded that safe and timely care can be provided without having a physician physically present on the mobile stroke unit.15 In Houston, researchers also found good agreement between on-board assessments and those done by telestroke consultation.52
“Because mobile stroke units contain a CT scanner, health care providers may be exposed to radiation (or in the case of the CT operator, will be exposed to radiation) they would not otherwise encounter in other prehospital care models.”
Radiation Safety
Because mobile stroke units contain a CT scanner, health care providers may be exposed to radiation (or in the case of the CT operator, will be exposed to radiation) they would not otherwise encounter in other prehospital care models.8,41,53 Articles describing the initial setup of mobile stroke units note that radiation exposure is a concern.8,41 In Houston, the mobile stroke unit team created a radiation safety manual, in part to ensure the safety of the operators and to meet requirements before operating the mobile stroke unit.8 Radiation shielding of the CT scanner was also assessed by a medical physicist before putting the mobile stroke unit into service.8
In Berlin, the mobile stroke unit includes a small, shielded compartment to protect staff when running the CT scanner.41 Radiation shielding and operating procedures were also tested in simulations for two weeks before seeing patients. The radiation levels measured throughout the course of the PHANTOM-S pilot study were within normal ranges.41 A 2016 study from Houston that examined radiation exposure in a mobile stroke unit found that the CT operator was exposed to radiation levels well below acceptable limits.53
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Final Remarks
Currently, there is no published evidence on the use of mobile stroke units in Canada, but research from other countries indicates that these units may allow earlier treatment with thrombolytic medicines for people with acute ischemic stroke. Moreover, mobile stroke units do not pose additional safety risks to patients.
There is limited evidence that mobile stroke units can improve functional outcomes, and further research is under way. There is also limited evidence about how staffing models and the distances mobile stroke units must travel to provide care impact patient outcomes. Additional research is needed to determine if mobile stroke units will be cost-effective in Canadian health care settings and how they might impact care in locations where patients are separated by large distances from centres that provide specialty stroke care.
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Acknowledgments
CADTH thanks the external reviewers who kindly provided comments on an earlier draft of this bulletin.
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Footnotes
Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.
While CADTH has taken care to ensure that the information prepared by it in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH.
CADTH is not responsible for any errors, omissions, injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the contents of this document or any of the source materials.
This document may contain links to third-party websites. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the third-party website owners’ own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. CADTH has no responsibility for the collection, use, and disclosure of personal information by third-party sites.
Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada’s federal, provincial, or territorial governments.
This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user’s own risk.
This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada.
The copyright and other intellectual property rights in this document are owned by CADTH and its licensors. These rights are protected by the Canadian Copyright Act and other national and international laws and agreements. You are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors.
About CADTH: CADTH is an independent, not-for-profit organization responsible for providing Canada’s health care decision-makers with objective evidence to help make informed decisions about the optimal use of drugs, medical devices, diagnostics, and procedures in our health care system.
Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
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References
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Hov MR, Lindner T, Lund CG. Prehospital radiological diagnosis of SAH and triage for neurosurgery [abstract]. Cerebrovasc Dis; Presented at 25th European Stroke Conference Proceedings; 2016 Apr 13–15; Venice, Italy. 2016. p. 193.
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Bowry R, Parker S, Rajan SS, Yamal JM, Wu TC, Richardson L, et al. Benefits of stroke treatment using a mobile stroke unit compared with standard management: The BEST-MSU Study Run-In Phase. Stroke. 2015 Dec;46(12):3370–4. [PubMed]
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2016 stroke report [Internet]. Ottawa (ON): Heart & Stroke Foundation; 2017. Mind the connection: preventing stroke and dementia. [cited 2017 Feb 24]. Available from: http://www.strokebestpractices.ca/wp-content/uploads/2016/06/HSF_StrokeReport2016_EN-Rev-1.pdf.
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Organek N, Taqui A, Cerejo R, Itrat A, Buletko A, Cho S, et al. The speed and reliability of pre-hospital point-of-care laboratory testing on the mobile stroke treatment unit [abstract]. Neurology [Internet]; Presented at 67th American Academy of Neurology Annual Meeting, AAN 2015; 2015 Apr 18–25; Washington, DC. 2015. p. P4.314. [cited 2016 Aug 31] Available from: http://www.neurology.org/content/84/14_Supplement/P4.314.
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Gomes JA, Ahrens CL, Hussain MS, Winners S, Rasmussen PA, Uchino K, et al. Prehospital reversal of warfarin-related coagulopathy in intracerebral hemorrhage in a mobile stroke treatment unit. Stroke [Internet]. May, 2015. pp. e118–e120. [cited 2016 Aug 29] Available from: http://stroke.ahajournals.org/content/46/5/e118.full.pdf+html. [PubMed]
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Mobile Stroke Unit Reduces Time to Treatment
An innovative treatment concept has helped this suburban Chicago hospital reduce time to first medication 30 minutes in one year — but is it a viable long-term solution?
troke is the fifth leading cause of death in the United States, responsible for more than 140,000 deaths in some of the most recent data.1 When treating stroke patients, perhaps more than any other condition, time is of the essence. “We know that for every 15 minutes you delay treatment, you lose three and a half years of your life,” said Harish Shownkeen, M.D., interventional neuroradiologist at Northwestern Medicine Central DuPage Hospital (CDH) in Winfield, Ill. In an effort to reduce time to treatment and improve patient outcomes, in 2017 Shownkeen and CDH, a Joint Commission-accredited Comprehensive Stroke Center, turned to an innovative solution that has slowly been making its way across the U.S. — a mobile stroke unit.
Video https://www.itnonline.com/videos/video-creating-and-operating-mobile-stroke-unit
Bringing the Hospital to the Patient
A mobile stroke unit (MSU) is essentially an ambulance with an onboard computed tomography (CT) scanner. When a patient is suspected to be having a stroke, a CT scan of the brain is the fastest way to determine what type of stroke it is — ischemic or hemorrhagic — and therefore which medication is needed. This is the most critical step in stroke care: If the stroke is ischemic (caused by a clot), tPA is required to dissolve the clot and restore blood flow; if the stroke is hemorrhagic (caused by bleeding in the brain), a reversal agent is needed to stop the bleeding. The wrong medication could prove fatal to the patient. The MSU is equipped with all of the traditional medications, tools and resources used to treat stroke patients in a hospital setting.
The Central DuPage MSU runs with four people on the ambulance at all times:
• A medic driver;
• A critical care paramedic;
• A critical care nurse; and
• A CT technologist.
As the CT scan and other on-board tests are being performed, results are sent to a stroke neurologist and a radiologist back at the hospital via a wireless VPN router. “We’re able to live stream those physicians into the back of the ambulance where they can do an assessment of the patient,” said Mehr Mohajer-Esfahani, MSN, RN, program manager of the Mobile Stroke Unit.
None of the MSU team members work with the unit full-time — all team members are rotated in from their respective departments across the hospital.
Take a 360 degree look inside the CDH mobile stroke unit.
https://www.itnonline.com/content/360-degree-view-inside-mobile-stroke-unit-ambulance-northwestern-medicine
History of Mobile Stroke Units
The concept of the MSU originated at Saarland University in Hamburg, Germany, in 2008. A paper describing the venture, published in Plos One in 2010, noted that, “Early 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.”2 The researchers found that call-to-therapy-decision times with the MSU settled around 35 minutes.
While the concept was proven in Europe, mobile stroke units did not make their way to the U.S. until 2014. Memorial-Hermann Texas Medical Center in Houston was the first domestic site to adopt the concept, and now there are an estimated 20 MSUs across the country — with Indiana University Health announcing its intention to be the 21st in late April.
CDH was the first site in Illinois (where stroke is the third leading cause of death3) to adopt an MSU. Rush University Medical Center in Chicago added their own truck later in 2017. Shownkeen was inspired to bring the MSU to Central DuPage after seeing one while visiting friends in Germany.
MSU Protocols
Since the MSU concept is still developing in the United States, every site operates their unit a little differently. According to Shownkeen, many hospitals run their mobile stroke units in a one week on/one week off pattern. This helps reduce costs and also ensures that adequate data is still being collected on conventional EMS stroke care as a basis for comparison. “We are one of the few MSUs that run seven days a week, 12 hours a day,” Shownkeen said.
At CDH, when a possible stroke call comes in inside the unit’s primary service area — a six-town radius encompassing roughly 30 square miles — the MSU is dispatched in conjunction with local emergency services; whichever team arrives first will begin assessing the patient. If it is determined they are not having a stroke, the MSU will be recalled to the hospital.
If the patient is exhibiting stroke signs and symptoms, they will be moved to the back of the ambulance for the CT scan. Many mobile stroke units feature a small portable CT system, but the CDH MSU has a full-size, 16-slice Siemens Somatom Scope scanner onboard.
“The biggest difference is when you get on scene, you don’t really know much about the patient,” said Peter Juodka, RT(CT), a CT technologist with the Mobile Stroke Unit. “You kind of gather information as you go, as opposed to the emergency department or even outpatient where you have gathered history through events pre-hospital and in the emergency department.”
While the circumstances are very different from a technologist’s day-to-day experience, radiation safety is still a top priority. The technologist and the patient are the only people in the ambulance during the scan (unless additional assistance is needed), and the truck features a lead-lined booth from which the scanner is operated. For extra protection, the technologist wears a lead apron to cover their backside and a dosimeter to monitor radiation levels. “So the protection is there but you’re considerably closer to the scanner than you would be in a normal radiology suite,” Juodka said.
For the radiologist back in the hospital, the experience is similar to Juodka’s — akin to daily practice in many ways and completely different in others. “It’s pretty much the same workflow but things are done exponentially faster,” said Shownkeen.
MSU Training
An undertaking of this magnitude is not carried out successfully, however, without a great deal of planning and practice. Prior to go-live in January 2017, all MSU personnel underwent 12 weeks of joint training. The focus, said Mohajer-Esfahani, was two-fold: learning to work together in a heightened capacity, and doing so in the confined quarters of the ambulance. He said he was pleasantly surprised at how quickly the unit gelled in this new context.
“These guys are all a wonderful group of professionals,” he said. “They each bring a unique set of skills and characteristics that once they were able to work together, they essentially complemented each other.” Finding individuals with those complementary skills was paramount when selecting MSU personnel, Mohajer-Esfahani added. For example, all of the critical care paramedics have backgrounds in flight, specialty transport and the hospital setting. Medic drivers have a minimum of 20 years’ experience operating large vehicles. MSU critical care nurses are drawn from the Neuro Intensive Care Unit.
Mohajer-Esfahani noted that while such individual levels of experience are important, none of the MSU’s success would have been possible without the help of local EMS. “A lot of us, our backgrounds are in the hospital,” he noted. “So to start applying the things we know how to do in the hospital in the pre-hospital setting, we needed [their] guidance.”
Shownkeen added, “It takes time to get this thing going but once you establish that, now it’s like a very efficient machine.”
Time to Treatment Coming Down
While the theory behind mobile stroke units may be sound, it must be proven effective in practice to be considered a viable solution for stroke care. CDH did extensive data collection in the MSU’s first year of operation, taking an estimated 450 stroke calls in approximately 14 months. Over that span, the team has reduced the average time to initial tPA delivery from 82 minutes to 52 minutes — and they are hoping to reduce that number down to 40 minutes. In total, about one-third of patients received tPA within the “golden hour,” a key paradigm of stroke care.
“Thirty minutes in the stroke world doesn’t sound like a lot of time, but it can be the difference between living and dying, between walking out of the hospital versus going to an extended care facility, being able to talk or not talk,” Mohajer-Esfahani said.
The Future of Stroke Care
While the data is bearing out the positive clinical impacts of the MSU, whether it is a viable long-term solution is up for discussion.
As with many new technologies or endeavors, initial cost is a considerable impedance to long-term sustainability. The CDH mobile stroke unit is literally a million-dollar investment. It was made possible through a grant from Northwestern Medicine, a large health system that employs more than 4,000 medical staff at over 100 diagnostic and ambulatory sites across Chicago.
Cost considerations are two-fold, according to Shownkeen: At present, the various elements of mobile stroke care are not reimbursed by the Centers for Medicare and Medicaid Services (CMS), the benchmark by which private insurers guide their policies. Furthermore, drugs like tPA are expensive — a 2016 study found that a standard 100 mg vial of the thrombolytic agent cost approximately $6,400, representing a 111 percent price increase over a decade.4
“It’s going to take a certain amount of patients that are treated to get something that is statistically significant to make a decision whether this is a better way to go about things ... But in the meantime we all agree that giving the drug earlier is the best way to treat stroke,” said Shownkeen.
If these cost hurdles can be surmounted, the idea could eventually be a boon for underserved areas as well. “When we are envisioning the future behind mobile stroke units, there is a huge opportunity to be able to take something and put it in a mobile device and be able to put it in areas that otherwise don’t have access to stroke care of this nature,” added Mohajer-Esfahani.
“It’s just a wonderful opportunity for the community and for us as healthcare providers to be able to own and operate, and experience, something that’s such a grand scale of care,” said Juodka. “We’re treating patients that are extremely time-sensitive with brain matter because it’s something that you potentially don’t ever get back. We’re trying to save people’s brains [and] save their livelihood.”
VIDEO interviews and tour of the CDH mobile stroke unit
References
1. Murphy S.L., Xu J., Kochanek K.D., et al. National Vital Statistics Reports: Deaths: Final Data for 2015, Nov. 27, 2017. Centers for Disease Control and Prevention.
2. Walter S., Kostpopoulos P., Haass A., Helwig S., et al. Bringing the Hospital to the Patient: First Treatment of Stroke Patients at the Emergency Site, PLOS ONE, Oct. 29, 2010. https://doi.org/10.1371/journal.pone.0013758
3. Leidig R.C. Illinois Stroke Data Report, September 2015, Illinois Department of Public Health. http://www.healthcarereportcard.illinois.gov/files/pdf/9_24_15_OPPS_IL%20Stroke_Data_Report.pdf
4. Kleindorfer D., Broderick J.P., Demaerschalk B.M., et al. The Cost of Alteplase Has More Than Doubled Over the Past Decade. International Stroke Conference 2016, Poster Board Number P78 / Presentation Number WP78. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_471706.pdf
https://www.itnonline.com/article/mobile-stroke-unit-reduces-time-treatment
UCLA Trials Ambulance Equipped with CT Scanner for Rapid Stroke Treatment
OCTOBER 27TH, 2017 MEDGADGET EDITORS CRITICAL CARE, EMERGENCY MEDICINE, MEDICINE, NEUROLOGY, PUBLIC HEALTH, RADIOLOGY
According to the AHA (American Heart Association), when it comes to stroke, it’s all about acting FAST (face, arms, speech, time). And while comprehensive stroke centers have gotten pretty good at triaging and imaging and treating patients, the time it takes for the ambulance to transport the patient to the hospital eats up precious minutes.
The University of California, Los Angeles will now be trialing an ambulance equipped with everything a typical ambulance has, but also a CT scanner and CT tech to operate it, a blood lab, a neurologist, critical care nurse, and a paramedic. The technology is not exactly new, and CT equipped ambulances have already been tried in other places. The goal here is to see if stroke patients have better outcomes when served via the new Mobile Stroke Unit compared to traditional ambulance, and whether there may be a cost savings to society by avoiding costly post-stroke therapy and rehab in these patients. Answers to these questions will help determine whether there will be a wider adoption of such ambulances, and if the relevant public health authorities will be willing to pay for them.
The imaging is provided by a CereTom mobile CT scanner made by NeuroLogica, now a part of Samsung. The 8-slice scanner is made just for imaging the head, and is small enough to rig up inside a large enough ambulance. The neurologist inside the ambulance will guide the process and analyze scans. In the future, though, it is expected that the doctor won’t have to come along, but will connect via two way video and voice connection to communicate with everyone in the ambulance. The scans will also be immediately transferred to the doc’s computer for quick assessment.
Flashback: Specialized Stroke Ambulance Features CereTom Portable CT Scanner to Reduce Time to Treatment…
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