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Hagrass AI, Elsayed SM, Doheim MF, Mostafa MA, Elfil M, Al-Kafarna M, Almaghary BK, Fayoud AM, Hamdallah A, Hasan MT, Ragab KM, Nourelden AZ, Zaazouee MS, Medicherla C, Lerario M, Czap AL, Chong J, Nour M, Al-Mufti F. Mobile Stroke Units in Acute Ischemic Stroke: A Comprehensive Systematic Review and Meta-Analysis of 5 "T Letter" Domains. Cardiol Rev 2024; 32:297-313. [PMID: 38602410 DOI: 10.1097/crd.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.
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Affiliation(s)
| | | | - Mohamed Fahmy Doheim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | | | | | | | | | | | | - Mackenzie Lerario
- Department of Neurology, Weill Cornell Medical College, New York, NY
| | - Alexandra L Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY
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BLOJ FA, BUICU FC, FILEP CR, SUCIU BA, VUNVULEA V, MĂRGINEAN L. A cost effectiveness analysis of stroke management in Romania. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.21.04662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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3
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Al Saiegh F, Velagapudi L, Khanna O, Baldassari MP, Mouchtouris N, Hafazalla K, Roussis J, DePrince M, Tjoumakaris S, Gooch MR, Herial N, Rosenwasser RH, Jabbour P. Improved Functional Outcomes of Stroke Patients Undergoing Mechanical Thrombectomy After Arriving via a Mobile Stroke Unit. World Neurosurg 2022; 166:e546-e550. [PMID: 35863651 DOI: 10.1016/j.wneu.2022.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) have been implemented worldwide for stroke care, but outcome data are lacking to show their efficacy specifically in patients undergoing mechanical thrombectomy (MT). Here, we include patients from our stroke network MSU and compare them to patients who arrived conventionally. METHODS A retrospective review of a stroke database was performed to identify patients who underwent MT after arrival via an MSU from August 2019 to December 2020. Demographic factors, past medical history, stroke characteristics, treatment variables, complications, and functional outcomes were recorded. These were compared to date-matched patients who underwent MT after arrival via conventional means. RESULTS Seven patients were treated with MT after arriving by an MSU. These patients were compared to 50 date-matched patients who underwent thrombectomy after arrival through conventional means. No statistically significant difference between cohorts was observed in terms of demographic variables, comorbidities, stroke characteristics, or tissue plasminogen activator administration. Patients from the MSU cohort had significantly shorter time from symptom onset to groin puncture time (191.33 minutes ±77.53 vs. 483.51 minutes ±322.66, P = 0.034). Importantly, MSU-transferred patients had significantly better discharge functional status measured by using the modified Rankin Scale (1.86 ± 1.35 vs. 3.57 ± 1.88, P = 0.024). No significant difference in final thrombolysis in cerebral infarction score, complications, length of stay, or mortality was observed. CONCLUSIONS Our pilot study demonstrates the efficacy of the MSU in decreasing door-to-puncture time and a concordant improvement in the discharge modified Rankin Scale score. Further prospective studies are needed to assess cost-efficacy and optimal protocol for MSUs in stroke care.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
| | - Lohit Velagapudi
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Omaditya Khanna
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Roussis
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maureen DePrince
- Jefferson Neuroscience Network, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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4
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Rangel I, Palmisciano P, Vanderhye VK, El Ahmadieh TY, Wahood W, Demaerschalk BM, Sands KA, O’Carroll CB, Krishna C, Zimmerman RS, Chong BW, Bendok BR, Turkmani AH. Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience. Mayo Clin Proc Innov Qual Outcomes 2022; 6:327-336. [PMID: 35801155 PMCID: PMC9253412 DOI: 10.1016/j.mayocpiqo.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES To provide a better understanding of methods that can be used to improve patient outcomes by reducing the door-to-groin puncture (DTP) time and present the results of a stroke quality improvement project (QIP) conducted by Mayo Clinic Arizona's stroke center. METHODS We conducted a systematic literature search of Ovid MEDLINE(R), Ovid EMBASE, Scopus, and Web of Science for studies that evaluated DTP time reduction strategies. Those determined eligible for the purpose of this analysis were assessed for quality. The strategies for DTP time reduction were categorized on the basis of modified Target: Stroke Phase III recommendations and analyzed using a meta-analysis. The Mayo Clinic QIP implemented a single-call activation system to reduce DTP times by decreasing the time from neurosurgery notification to case start. RESULTS Fourteen studies were selected for the analysis, consisting of 2277 patients with acute ischemic stroke secondary to large-vessel occlusions. After intervention, all the studies showed a reduction in the DTP time, with the pooled DTP improvement being the standardized mean difference (1.37; 95% confidence interval, 1.20-1.93; τ2=1.09; P<.001). The Mayo Clinic QIP similarly displayed a DTP time reduction, with the DTP time dropping from 125.1 to 82.5 minutes after strategy implementation. CONCLUSION Computed tomography flow modifications produced the largest and most consistent reduction in the DTP time. However, the reduction in the DTP time across all the studies suggests that any systematic protocol aimed at reducing the DTP time can produce a beneficial effect. The relative novelty of mechanical thrombectomy and the consequential lack of research call for future investigation into the efficacy of varying DTP time reduction strategies.
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Affiliation(s)
- India Rangel
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Vanesa K. Vanderhye
- Department of Neurology, Mayo Clinic, Phoenix, AZ
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL
| | | | | | | | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
| | | | - Brian W. Chong
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
- Department of Radiology, Mayo Clinic, Phoenix, AZ
| | | | - Ali H. Turkmani
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
- Correspondence: Address to Ali H. Turkmani, MD, Department of Neurological Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054 9.
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Bosch PR, Karmarkar AM, Roy I, Fehnel CR, Burke RE, Kumar A. Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity. JAMA Netw Open 2022; 5:e224596. [PMID: 35357456 PMCID: PMC8972034 DOI: 10.1001/jamanetworkopen.2022.4596] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Importance Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. Objective To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. Design, Setting, and Participants This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022. Exposures Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other. Main Outcomes and Measures Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke. Results Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke. Conclusions and Relevance In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.
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Affiliation(s)
- Pamela R. Bosch
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
| | - Amol M. Karmarkar
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
- Sheltering Arms Institute, Richmond, Virginia
| | - Indrakshi Roy
- Center for Health Equity Research, Northern Arizona University, Flagstaff
| | - Corey R. Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Robert E. Burke
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Amit Kumar
- College of Health and Human Services, Northern Arizona University, Phoenix Biomedical Campus, Phoenix
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Czap AL, Harmel P, Audebert H, Grotta JC. Stroke Systems of Care and Impact on Acute Stroke Treatment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bender MT, Mattingly TK, Rahmani R, Proper D, Burnett WA, Burgett JL, LEsperance J, Cushman JT, Pilcher WH, Benesch CG, Kelly AG, Bhalla T. Mobile stroke care expedites intravenous thrombolysis and endovascular thrombectomy. Stroke Vasc Neurol 2021; 7:209-214. [PMID: 34952889 PMCID: PMC9240459 DOI: 10.1136/svn-2021-001119] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of mobile stroke programmes has increased with evidence, showing they expedite intravenous thrombolysis. Outstanding questions include whether time savings extend to patients eligible for endovascular therapy and impact clinical outcomes. OBJECTIVE Our mobile stroke unit (MSU), based at an academic medical centre in upstate New York, launched in October 2018. We reviewed prospective observational data sets over 26 months to identify MSU and non-MSU emergency medical service (EMS) patients who underwent intravenous thrombolysis or endovascular thrombectomy for comparison of angiographic and clinical outcomes. RESULTS Over 568 days in service, the MSU was dispatched 1489 times (2.6/day) and transported 300 patients (20% of dispatches). Intravenous tissue plasminogen activator (tPA) was administered to 57 MSU patients and the average time from 911 call-to-tPA was 42.5 min (±9.2), while EMS transported 73 patients who received tPA at 99.4 min (±35.7) (p<0.001). Seven MSU patients (12%) received tPA from 3.5 hours to 4.5 hours since last known well and would likely have been outside the window with EMS care. Endovascular thrombectomy was performed on 21 MSU patients with an average 911 call-to-groin puncture time of 99.9 min (±18.1), while EMS transported 54 patients who underwent endovascular thrombectomy (ET) at 133.0 min (±37.0) (p=0.0002). There was no difference between MSU and traditional EMS in modified Rankin score at 90-day clinic follow-up for patients undergoing intravenous thrombolysis or endovascular thrombectomy, whether assessed as a dichotomous or ordinal variable. CONCLUSIONS Mobile stroke care expedited both intravenous thrombolysis and endovascular thrombectomy. There is an ongoing need to show improved functional outcomes with MSU care.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Walter A Burnett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jason L Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Joshua LEsperance
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Webster H Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Curtis G Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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8
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Alexandrov AW, Arthur AS, Bryndziar T, Swatzell VM, Dusenbury W, Hardage K, McCormick S, Rhudy JP, Maleki AHZ, Singh S, Krishnaiah B, Nearing K, Rubin MN, Malkoff MD, McKendry C, Metter EJ, Alexandrov AV. High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit. J Neurointerv Surg 2021; 14:623-627. [PMID: 34433646 DOI: 10.1136/neurintsurg-2021-017697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/06/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported. METHODS We performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified. RESULTS 1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5-4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1-3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90-139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required. CONCLUSIONS MSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.
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Affiliation(s)
| | - Adam S Arthur
- Neurosurgery, UTHSC COM, Memphis, Tennessee, USA.,Vascular Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
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9
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Abstract
Objectives: Concise “synthetic” review of the state of the art of management of acute ischemic stroke. Data Sources: Available literature on PubMed. Study Selection: We selected landmark studies, recent clinical trials, observational studies, and professional guidelines on the management of stroke including the last 10 years. Data Extraction: Eligible studies were identified and results leading to guideline recommendations were summarized. Data Synthesis: Stroke mortality has been declining over the past 6 decades, and as a result, stroke has fallen from the second to the fifth leading cause of death in the United States. This trend may follow recent advances in the management of stroke, which highlight the importance of early recognition and early revascularization. Recent studies have shown that early recognition, emergency interventional treatment of acute ischemic stroke, and treatment in dedicated stroke centers can significantly reduce stroke-related morbidity and mortality. However, stroke remains the second leading cause of death worldwide and the number one cause for acquired long-term disability, resulting in a global annual economic burden. Conclusions: Appropriate treatment of ischemic stroke is essential in the reduction of mortality and morbidity. Management of stroke involves a multidisciplinary approach that starts and extends beyond hospital admission.
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10
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Ashcraft S, Wilson SE, Nyström KV, Dusenbury W, Wira CR, Burrus TM. Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e164-e178. [PMID: 33691468 DOI: 10.1161/str.0000000000000356] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The year 2020 was the year of the nurse, celebrating nurse scholarship, innovation, and leadership by promoting scientific nursing research, improving nursing practice, advancing nursing education, and providing leadership to influence health policy. As architects of stroke care, neuroscience nurses play a vital role in collaborating and coordinating care between multiple health professionals. Nurses improve accessibility and equity through telestroke, emergency medical services, and mobile stroke units and are integral to implementing education strategies by advocating and ensuring that patients and caregivers receive stroke education while safely transitioning through the health care system and to home. Stroke care is increasingly complex in the new reperfusion era, requiring nurses to participate in continuing education while attaining levels of competency in both the acute and recovery care process. Advanced practice nurses are taking the lead in many organizations, serving as prehospital providers on mobile stroke units, participating as members of the stroke response team, and directing stroke care protocols in the emergency department. This scientific statement is an update to the 2009 "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient." The aim is to provide a comprehensive review of the scientific evidence on nursing care in the prehospital and hyperacute emergency hospital setting, arming nurses with the necessary tools to provide evidenced-based high-quality care.
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11
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Lopez-Rivera V, Salazar-Marioni S, Abdelkhaleq R, Savitz SI, Czap A, Alderazi Y, Chen PR, Grotta JC, Blackburn S, Jones W, Spiegel G, Dannenbaum MJ, Wu TC, Cochran J, Kim DH, Day AL, Farquhar G, McCullough LD, Sheth SA. Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes. Stroke 2021; 52:1022-1029. [PMID: 33535778 PMCID: PMC7902449 DOI: 10.1161/strokeaha.120.032710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
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Affiliation(s)
| | | | - Rania Abdelkhaleq
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Sean I. Savitz
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - Alexandra Czap
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Yazan Alderazi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Peng R. Chen
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
| | - James C. Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Spiros Blackburn
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Wesley Jones
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Gary Spiegel
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Mark J. Dannenbaum
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Tzu-Ching Wu
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Joseph Cochran
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Dong H. Kim
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | - Arthur L. Day
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX
| | | | | | - Sunil A. Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX,Department of Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX
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12
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Abstract
Ischemic stroke is a leading cause of death and major disability that impacts societies across the world. Earlier thrombolysis of blocked arteries with intravenous tissue plasminogen activator (tPA) and/or endovascular clot extraction is associated with better clinical outcomes. Mobile stroke units (MSU) can deliver faster tPA treatment and rapidly transport stroke patients to centers with endovascular capabilities. Initial MSU trials in Germany indicated more rapid tPA treatment times using MSUs compared with standard emergency room treatment, a higher proportion of patients treated within 60 minutes of stroke onset, and a trend toward better 3-month clinical outcomes with MSU care. In the United States, the first multicenter, randomized clinical trial comparing standard versus MSU treatment began in 2014 in Houston, TX, and has demonstrated feasibility and safety of MSU operations, reliability of telemedicine technology to assess patients for tPA eligibility without additional time delays, and faster door-to-groin puncture times of MSU patients needing endovascular thrombectomy in interim analysis. Scheduled for completion in 2021, this trial will determine the cost-effectiveness and benefit of MSU treatment on clinical outcomes compared with standard ambulance and hospital treatment. Beyond ischemic stroke, MSUs have additional clinical and research applications that can profoundly impact other cohorts of patients who require time-sensitive neurological care.
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Affiliation(s)
- Ritvij Bowry
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center-Houston, Houston, Texas
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas
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13
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Noorian AR. Prehospital EMS Triage for Acute Stroke Care. Semin Neurol 2021; 41:5-8. [PMID: 33506476 DOI: 10.1055/s-0040-1722725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Acute stroke has had major advances over the last two decades due to the introduction of pharmacologic and endovascular revascularization, which can improve functional outcome. Stroke systems of care have been developed to provide faster, more efficient care for stroke patients. A major part of these care pathways is prehospital care, when patients are triaged to appropriate levels of care. It is essential that prehospital scales are used accurately and effectively by emergency medical services to assist them with the triage process. New technologies including mobile stroke units, telemedicine, and wearable technology have been introduced as options for optimization of this emergent process.
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Affiliation(s)
- Ali Reza Noorian
- Department of Neurology, Kaiser Permanente Orange County, Irvine, California
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14
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Current Methods for the Prehospital Detection of Large Vessel Occlusion (LVO) Ischemic Stroke. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-020-00224-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Alexandrov AW, Alexandrov AV. Innovations in Prehospital Stroke Management Utilizing Mobile Stroke Units. Continuum (Minneap Minn) 2020; 26:506-512. [PMID: 32224764 DOI: 10.1212/con.0000000000000850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Using a representative case, this article discusses prehospital innovations for patients with acute large vessel occlusion ischemic stroke, including mobile stroke unit care supported by advanced field imaging.
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16
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Weinberg JH, Sweid A, DePrince M, Roussis J, Herial N, Gooch MR, Zarzour H, Tjoumakaris S, Topley T, Wang A, Wydro G, Durland L, Elliot R, Fox J, Rosenwasser RH, Jabbour P. The impact of the implementation of a mobile stroke unit on a stroke cohort. Clin Neurol Neurosurg 2020; 198:106155. [PMID: 32818753 DOI: 10.1016/j.clineuro.2020.106155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the 'time is brain' concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline. METHODS We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020. RESULTS Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07+0:03, scene arrival to CT start was 0:10+0:03, CT start to teleneuro start was 0:05+0:03, teleneuro start to scene departure was 0:06+0:05, scene departure to hospital arrival was 0:12+0:06, and hospital arrival to arterial puncture was 2:59+1:01. The mean time of dispatch to arterial puncture was 3:34+1:02. The mean teleneuro consult duration was 0:04+0:02. The mean time of last know well (LKW) to tPA administration was 1:28+0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37+0:09 and scene arrival to tPA administration was 0:28+0:07. CONCLUSION MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown.
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Affiliation(s)
- Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Mauren DePrince
- Department of Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - John Roussis
- Department of Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Thomas Topley
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Alvin Wang
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Gerald Wydro
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Lawrence Durland
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Robert Elliot
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - James Fox
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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17
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Holodinsky JK, Kamal N, Zerna C, Ospel JM, Zhu L, Wilson AT, Hill MD, Goyal M. In What Scenarios Does a Mobile Stroke Unit Predict Better Patient Outcomes?: A Modeling Study. Stroke 2020; 51:1805-1812. [PMID: 32389068 DOI: 10.1161/strokeaha.119.028474] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- The mobile stroke unit (MSU) brings imaging and thrombolysis to patients in the field. The MSU has the potential to decrease time from onset to thrombolysis; however, this depends on the location of the patient, the MSU, and the hospital. The MSU will only be able to treat a small subset of patients it is dispatched to. Using conditional probability modeling, we evaluate in which scenarios the MSU exhibits clear benefit over the direct-to-mothership method. Methods- Previously published conditional probability models for drip-and-ship versus mothership transport were modified to reflect MSU workflow. It was assumed that the MSU was dispatched from the endovascular therapy center. Eight scenarios were generated, varying treatment efficiency on the MSU and at the endovascular therapy center and the threshold for dispatching the MSU (low threshold: low treatment rate but few missed patients; high threshold: higher treatment rate, potential for missed treatment opportunities). Results- The relative difference in outcomes between the MSU and mothership was small. Geographic areas where the MSU is superior to mothership increase in size as treatment time on the MSU decreases. When a high-threshold dispatch system is used, the area where the MSU is superior decreases, but the relative difference in predicted outcomes between the MSU and mothership increases. The largest relative difference favoring the MSU was found in areas where the patient would forgo access to alteplase, based upon a 4.5-hour treatment threshold, using mothership transport. Conclusions- There are few scenarios where MSU transport predicts substantially superior outcomes to the mothership method when the MSU is dispatched from the endovascular therapy center. Outcomes using the MSU are maximized when dispatch criteria that maximize patients eligible for thrombolysis treatment are used and treatment times on the MSU are short relative to those of the endovascular therapy center.
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Affiliation(s)
- Jessalyn K Holodinsky
- From the Evaluative Clinical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada (J.K.H.)
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada (N.K.)
| | - Charlotte Zerna
- Department of Community Health Sciences (C.Z., M.D.H.), University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine (C.Z., J.M.O., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine (C.Z., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada
| | - Johanna M Ospel
- Department of Clinical Neurosciences, Cumming School of Medicine (C.Z., J.M.O., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Department of Radiology, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Luke Zhu
- Department of Bioengineering, University of Washington, Seattle (L.Z.)
| | - Alexis T Wilson
- Department of Clinical Neurosciences, Cumming School of Medicine (C.Z., J.M.O., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine (C.Z., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences (C.Z., M.D.H.), University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine (C.Z., J.M.O., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine (C.Z., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Calgary Stroke Program, Cumming School of Medicine (M.D.H.), University of Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine (M.D.H.), University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine (C.Z., J.M.O., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine (C.Z., A.T.W., M.D.H., M.G.), University of Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine (M.G.), University of Calgary, Alberta, Canada
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18
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Czap AL, Singh N, Bowry R, Jagolino-Cole A, Parker SA, Phan K, Wang M, Sheth SA, Rajan SS, Yamal JM, Grotta JC. Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time. Stroke 2020; 51:1613-1615. [PMID: 32295510 DOI: 10.1161/strokeaha.119.028626] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods- We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results- Median DTPT was 53.5 (95% CI, 35-67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0-63.5) versus 94.5 minutes (interquartile range, 69.8-117.3; P<0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8-35.5) versus 27.0 minutes (interquartile range, 23.0-31.0) (P<0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=-0.2, P=0.07). Conclusions- Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration- URL: https://clinicaltrials.gov; Unique identifier: NCT02190500.
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Affiliation(s)
- Alexandra L Czap
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Noopur Singh
- Department of Biostatistics and Data Science, School of Public Health (N.S., M.W., J.-M.Y.), University of Texas Health Science Center, Houston
| | - Ritvij Bowry
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Amanda Jagolino-Cole
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Stephanie A Parker
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Kenny Phan
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Mengxi Wang
- Department of Biostatistics and Data Science, School of Public Health (N.S., M.W., J.-M.Y.), University of Texas Health Science Center, Houston
| | - Sunil A Sheth
- From the Department of Neurology, McGovern Medical School (A.L.C., R.B., A.J.-C., S.A.P, K.P., S.A.S.), University of Texas Health Science Center, Houston
| | - Suja S Rajan
- Department of Management, Policy and Community Health, School of Public Health (S.S.R.), University of Texas Health Science Center, Houston
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, School of Public Health (N.S., M.W., J.-M.Y.), University of Texas Health Science Center, Houston
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.C.G.)
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19
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Zhao H, Coote S, Easton D, Langenberg F, Stephenson M, Smith K, Bernard S, Cadilhac DA, Kim J, Bladin CF, Churilov L, Crompton DE, Dewey HM, Sanders LM, Wijeratne T, Cloud G, Brooks DM, Asadi H, Thijs V, Chandra RV, Ma H, Desmond PM, Dowling RJ, Mitchell PJ, Yassi N, Yan B, Campbell BC, Parsons MW, Donnan GA, Davis SM. Melbourne Mobile Stroke Unit and Reperfusion Therapy. Stroke 2020; 51:922-930. [DOI: 10.1161/strokeaha.119.027843] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU.
Methods—
Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates.
Results—
In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes (
P
<0.001) for dispatch to hospital arrival and 15 minutes (
P
<0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0–49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1–71.9],
P
<0.001). This included a median time saving of 17 minutes ([95% CI, 7.6–26.4],
P
=0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT.
Conclusions—
The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.
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Affiliation(s)
- Henry Zhao
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
| | - Skye Coote
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Damien Easton
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Francesca Langenberg
- Department of Radiology (F.L., P.M.D., R.J.D., P.J.M., B.Y.), Royal Melbourne Hospital, Victoria, Australia
| | - Michael Stephenson
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
- Department of Epidemiology and Preventive Medicine (K.S.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
- Department of Community Emergency Health and Paramedic Practice (K.S.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
- Discipline of Emergency Medicine, University of Western Australia, Australia (K.S., S.B.)
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
- Discipline of Emergency Medicine, University of Western Australia, Australia (K.S., S.B.)
| | - Dominique A. Cadilhac
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Translational Public Health Research Division, Stroke and Ageing Research Group, School of Clinical Sciences Department of Neurology (D.A.C., J.K.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Joosup Kim
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Translational Public Health Research Division, Stroke and Ageing Research Group, School of Clinical Sciences Department of Neurology (D.A.C., J.K.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Christopher F. Bladin
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Eastern Health, Faculty of Medicine, Nursing and Health Sciences (C.F.B., H.M.D.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Leonid Churilov
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine, Austin Health, Melbourne Medical School (L.C.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Douglas E. Crompton
- Department of Neurology, Northern Health, Faculty of Medicine, Dentistry and Health Sciences (D.E.C.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Helen M. Dewey
- Eastern Health, Faculty of Medicine, Nursing and Health Sciences (C.F.B., H.M.D.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Lauren M. Sanders
- Department of Neurology St. Vincent’s Hospital Melbourne, Faculty of Medicine, Dentistry and Health Sciences (L.M.S.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Faculty of Medicine, Dentistry and Health Sciences (T.W.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Geoffrey Cloud
- Alfred Health (G.C.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Neurosciences, Central Clinical School (G.C.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Duncan M. Brooks
- Department of Radiology (D.M.B., H.A.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Hamed Asadi
- Department of Radiology (D.M.B., H.A.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Department of Neurology (V.T.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Ronil V. Chandra
- Department of Radiology (R.V.C.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Henry Ma
- Department of Neurology (H.M.), Monash Health, Department of Medicine, School of Clinical Science, Monash University, Melbourne, Victoria, Australia
| | - Patricia M. Desmond
- Department of Radiology (F.L., P.M.D., R.J.D., P.J.M., B.Y.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Richard J. Dowling
- Department of Radiology (F.L., P.M.D., R.J.D., P.J.M., B.Y.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Peter J. Mitchell
- Department of Radiology (F.L., P.M.D., R.J.D., P.J.M., B.Y.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Nawaf Yassi
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
| | - Bernard Yan
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Radiology (F.L., P.M.D., R.J.D., P.J.M., B.Y.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Bruce C.V. Campbell
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia (H.Z., M.S., K.S., S.B., N.Y., B.C.V.C.)
| | - Mark W. Parsons
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Geoffrey A. Donnan
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health (D.A.C., J.K., C.F.B., V.T., N.Y., G.A.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Stephen M. Davis
- From the Department of Neurology, Melbourne Brain Centre (H.Z., S.C., D.E., L.C., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Royal Melbourne Hospital, Victoria, Australia
- Department of Medicine and Radiology, Faculty of Medicine, Dentistry and Health Sciences (H.Z., S.C., D.E., P.M.D., R.J.D., P.J.M., N.Y., B.Y., B.C.V.C., M.W.P., G.A.D., S.M.D.), Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW Mobile stroke units (MSUs) have revolutionized emergency stroke care by delivering pre-hospital thrombolysis faster than conventional ambulance transport and in-hospital treatment. This review discusses the history of MSUs technological development, current operations and research, cost-effectiveness, and future directions. RECENT FINDINGS Multiple prospective and retrospective studies have shown that MSUs deliver acute ischemic stroke treatment with intravenous recombinant tissue plasminogen activator (IV r-tPA) approximately 30 min faster than conventional care. The 90-day modified Rankin Scores for patients who received IV r-tPA on the MSU compared to conventional care were not statistically different in the PHANTOM-S study. Two German studies suggest that the MSU model is cost-effective by reducing disability and improving adjusted quality-life years post-stroke. The ongoing BEST-MSU trial will be the first multicenter, randomized controlled study that will shed light on MSUs' impact on long-term neurologic outcomes and cost-effectiveness. MSUs are effective in reducing treatment times in acute ischemic stroke without increasing adverse events. MSUs could potentially improve treatment times in large vessel occlusion and intracranial hemorrhage. Further studies are needed to assess functional outcomes and cost-effectiveness. Clinical trials are ongoing internationally.
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Wira CR, Aydin A. Mobile Stroke Units—the Changing Face of Emergency Medicine Stroke Management. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00207-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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