Mobile Stroke Unit for Prehospital Treatment Feasible

December 10, 2015

Evaluating and treating patients suspected of having an acute stroke in a mobile unit using telemedicine to communicate with a neuroradiologist and stroke physician is feasible, and it may be a cost-effective way of introducing prehospital stroke treatment, a new study suggests.

The study, published in JAMA Neurology on December 7, also showed that patients cared for by the mobile unit received tissue plasminogen activator (tPA) more quickly than those who received treatment in the hospital.

"Because time is so important in stroke treatment, the idea of evaluating and treating patients in the ambulance is being pursued," senior author, Ken Uchino, MD, from the Cerebrovascular Center, Cleveland Clinic, Ohio, commented to Medscape Medical News.

Dr Ken Uchino

Other centers are starting mobile stroke unit programs, but most of these have a neurophysician on board, he added. "But this presents challenges: Namely, it is not good use of physician time to be permanently in the unit, and there will be a delay while picking them up. It is also a very costly approach."

"We wanted to study whether it is feasible to evaluate and treat suspected stroke patients in the ambulance without having a stroke doctor on board. In our study the patient evaluation was done by video and scans were transmitted electronically. This is a better use of resources as it could be possible to have one physician supervising two or more mobile stroke units. This approach opens up many possibilities," Dr Uchino said.

He added: "In our study, we showed that this approach is feasible with few technological problems and time to tPA treatment was reduced. This should translate into better long-term outcomes and reduced healthcare costs, but this would need to be confirmed."

In an accompanying editorial, Martin Ebinger, MD, and Heinrich J. Audebert, MD, Charité-Universitätsmedizin, Berlin, Germany, who run a prehospital stroke program in Berlin, agree that this approach is promising.

"[T]elemedicine could help to defuse the debate on financial investments necessary for advanced prehospital stroke care," they write.

However, they caution that unequivocal proof of better outcomes after treatment in specialized stroke ambulances is required before such a strategy becomes routine.

Mobile Unit

The study involved the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 a.m. and 8 p.m. and were evaluated by the mobile unit after the implementation of the program at the Cleveland Clinic in 2014.

Mobile CT unit. Courtesy Cleveland Clinic

A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT).

These patients were compared with a control group brought to the emergency department via regular ambulance during the same year. Process times were measured from the time the patient entered the door of the mobile unit or emergency department, and any problems encountered during his or her evaluation were recorded.

Results showed that 99 of the 100 patients attended to by the mobile unit were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes. One connection failure was due to crew error, and the patient was transported to the nearest emergency department.

Paramedics working in mobile stroke unit truck. Courtesy Cleveland Clinic

There were six telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (median, 13 minutes) and from the door to intravenous thrombolysis (median, 32 minutes) were significantly shorter in the mobile unit group than the control group, representing median savings of 18 minutes on the completion of the scan and 58 minutes on time to tPA treatment.

"I am optimistic that this is the future," Dr Uchino commented. "But it won't be practical for all locations. It will depend on the density of the population and the area that a unit can realistically cover."

Valuable Resource

In their editorial, Dr Ebinger and Dr Audebert make the point that a shortage of vascular neurologists makes them a valuable resource within hospitals, "and it seems counterintuitive to send them out on missions with uncertain outcome."

They add: "Stroke is a predestined disease for telemedicine because symptoms are audiovisually transmittable and computed tomographic images can easily be accessed remotely. Obviously, replacing a personal encounter with a telemedicine consultation has its limitations. However, in a time-critical scenario such as stroke, the advantages of fast decisions about thrombolysis or thrombectomy may outweigh the shortcomings. Most patients with stroke faced with the 2 options of no neurologist or an expert telemedicine consultation would clearly prefer the latter."

But they conclude that trials showing improved outcomes, better telecommunications technologies around the globe, and studies comparing outcomes between stroke ambulances staffed with a vascular neurologist vs telemedicine advice to paramedics are needed.

"We will then see whether we need more or less neurologists," they write.

The Cleveland Clinic mobile stroke treatment unit was jointly funded by the Milton and Tamar Maltz Family Foundation and the Cleveland Clinic. The authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online December 7, 2015. Full text Editorial

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