Mobile Stroke Unit Tied to Decreased Time to Imaging, Treatment

A mobile stroke treatment unit equipped with telemedicine and a mobile computed tomography (CT) scanner was associated with faster imaging and thrombolysis compared with a traditional ED model.¹

“Time is critically important in the treatment of stroke. It is estimated that we lose 1.9 million neurons per minute in the situation of stroke, and there is clear evidence that the earlier and faster someone is treated after the start of a stroke, the better their chance at good outcome,” Muhammad S. Hussain, MD, head of the Cleveland Clinic Stroke Program in Ohio, and one of the authors of the study, told Neurology Advisor.

According to the article, published in Neurology, more favorable outcomes are associated with earlier thrombolysis in patients with acute ischemic stroke.¹

The Get with the Guidelines and Target: Stroke programs, developed by the American Heart Association and American Stroke Association, aim to provide clinicians with strategies to achieve a door-to-needle time of 60 minutes or less.²

Dr Hussain and colleagues sought to compare the evaluation and thrombolytic treatment times of patients with stroke first assessed by a telemedicine-enable mobile stroke treatment unit (MSTU) vs transportation by a traditional ambulance to the emergency department (ED).¹

Patients were assessed by a registered nurse who assisted in performing the neurological examination for the remote vascular neurologist. The MSTU was equipped with point-of-care laboratory and mobile computed tomography (CT) scanning capabilities, the data from which could be transmitted to a remote neuroradiologist. On the basis of the data obtained, the neurologist calculated the patient’s National Institutes of Health Stroke Scale (NIHSS), treatment decisions were made, and level of care was determined.¹

Data on 100 participants evaluated by the MSTU and 53 patients evaluated in the ED were analyzed. Both groups had similar demographics and NIHSS scores (6 vs 7; P =.679). After evaluation, the MSTU group had preliminary diagnoses of transient ischemic attack in 4%, possible acute ischemic stroke in 30%, and probable acute ischemic stroke in 33%.¹

The MSTU group demonstrated significantly shorter times for CT completion (by 23 minutes), CT scan read time (by 20 minutes), and international normalized ratio result time (by 45 minutes) compared with the ED group (P <.0001 for all).¹

There were also significant differences between the MSTU group and the ED group for alarm-to-thrombolysis time (median, 55.5 vs 94 minutes; P <.0001). Similar differences between the MSTU and ED groups were observed for median door-to-thrombolysis time (31.5 vs 58 minutes; P =.0012) and symptom onset-to-thrombolysis time (97 vs 122.5 minutes; P =.0485). Thrombolysis was given within 60 minutes of symptoms in 25% (N=4) of the 16 patients treated with thrombolysis in the MSTU group.¹

The study had several limitations, including a small sample size and limits on feasibility in areas that lack the necessary wireless network to transmit the data quickly and reliably.¹

Unlike previous studies, Dr Hussain noted, “we also solely utilized telemedicine for the physician’s care (other [mobile stroke units] have had a physician on board). By showing these time savings, we have shown we can effectively take the physician off the vehicle and have their presence virtually, which is important to [the] long-term cost effectiveness of this approach.”

An accompanying commentary pointed out that cost-effectiveness takes into account not only the initial and maintenance cost but also the “potential for long-term savings in quality adjusted life-years…mediated by earlier access to treatment.” Further, most mobile stroke units are associated with healthcare systems within urban areas. Rural areas with the population potentially spread over large geographic areas pose a challenge for cost-effectiveness as well.³

“Mobile stroke units can effectively decrease time to treatment by performing CT [and] assessment and delivering definitive treatment in the field as compared to traditional ambulance delivery of patients to an emergency room to get treatment,” Dr Hussain told Neurology Advisor.

Disclosures: The study was funded by the Cleveland Clinic and the Milton and Tamar Maltz Family Foundation. The authors report no disclosures.

References

1. Taqui A, Cerejo R, Itrat A, et al. Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis [published online March 8, 2017]. Neurology. doi: 10.1212/WNL.0000000000003786
2. Stroke Fact Sheet. Get with the Guidelines. The American Heart Association Website. http://www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_491528.pdf. Accessed March 13, 2017.
3. Southerland AM, Brandler ES. The cost-efficiency of mobile stroke units: where the rubber meets the road [published online March 8, 2017]. Neurology. doi: 10.1212/WNL.0000000000003833