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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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11
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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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