Mobile stroke programs provide speedy evaluation and treatment of patients when every minute counts.
A Cincinnati-based health system with a history of innovation in stroke care has launched a mobile stroke unit.
Nearly 800,000 people have strokes annually, according to the American Heart Association. A rapid response to stroke is crucial for positive outcomes. If a stroke is caused by a clot lodging in a blood vessel supplying the brain, most patients need the clot-busting drug tissue plasminogen activator (tPA) within three hours.
UC Health crafted the FAST method for detecting stroke and played a leading role in the development of tPA in the late 1980s. FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call 911.
In August, UC Health launched a mobile stroke unit that responds to a patient's home when acute stroke is suspected. "The overall goal of the Mobile Stroke Unit is to bring a lot of what we can do in the emergency department for acute stroke patients to the curbside of patients, so we can diagnose and potentially treat in a very timely manner," says Christopher Richards, MD, MS, medical director of UC Health's Mobile Stroke Unit program.
The Mobile Stroke Unit deploys out of the firehouse at Springfield Township, Ohio, which is centrally located in UC Health's service area. The service is available seven days a week from 7 a.m. to 7 p.m.
The startup costs for the program—including the ambulance, equipment, supplies, and training—were $1 million. The annual operating costs, which consist mainly of personnel and supplies, are about $500,000.
How the Mobile Stroke Unit works
The Mobile Stroke Unit ambulance is manned by a paramedic, nurse, CT scan technician, and EMT/driver. A key element of the personnel is a stroke neurologist who participates in Mobile Stroke Unit calls virtually, Richards says.
"The stroke neurologist who joins the team virtually is a critical part of the operation. The decisions about clot-busting medications, reversing bleeding strokes, and blood pressure management are beyond the scope of a critical care nurse or a paramedic. So, the consultation we have from the UC Health stroke team is a critical part of the Mobile Stroke Unit," he says.
The nurse and paramedic facilitate the stroke neurologist's examination with an iPad, so the physician can not only interact with the patient but also watch as the patient is screened for symptoms such as poor coordination and speech difficulty. "The evaluation is the same as a patient would receive in an emergency room," Richards says.
A patient receives a CT scan in UC Health's Mobile Stroke Unit. Photo Credit: UC Health
Having CT scan capability in the ambulance plays an essential role, he says. "When the patient is brought to the Mobile Stroke Unit, one of the first things the team can do is give a CT scan. That is a huge differentiator in stroke care to determine whether there is a bleeding stroke, which has a vastly different treatment pathway, or a more common ischemic stroke with blockage of an artery."
The Mobile Stroke Unit works in concert with local emergency medical services ambulances, Richards says.
"What typically happens is that a patient, loved one, or bystander will call 911. They communicate with a dispatcher about what is happening. If the dispatcher suspects stroke, they will dispatch a local EMS ambulance and may dispatch the Mobile Stroke Unit at the same time. Oftentimes, a local EMS paramedic will be on the scene first and conduct screening and evaluations, then the Mobile Stroke Unit arrives."
The local EMS crew takes charge of the scene, he says.
"We help in whatever way we can with patients. To foster that relationship before we launched, we did significant outreach to our EMS partners in the areas where we would be responding to make sure they understood what we could do, what we could not do, how we could help, and how we would interact on scene."
For patients suffering ischemic stroke, the Mobile Stroke Unit plays a pivotal role in speeding up administration of tPA to dissolve blood clots, Richards says.
"Without the Mobile Stroke Unit, the best scenario is paramedics get on scene quickly, they do some screening and recognize a stroke is occurring, then there is transport to the hospital, an intake process at the hospital, and a CT scan. By being able to bring a CT scanner, tPA, and a stroke team physician virtually to the curbside, the Mobile Stroke Unit cuts out a lot of time."
Other mobile stroke programs have reported that they can speed up administration of tPA by 30 to 45 minutes. "That time could be the difference in levels of disability and in receiving tPA or not," he says.
The Mobile Stroke Unit is at the curbside for as long as an hour, and most patients are transported to local hospitals.
Keys to success
There are five elements to operating a successful mobile stroke program, Richards says.
1. Accounting for the entire episode of care: The treatment of stroke is a "chain of survival" and the chain is only as strong as its weakest link, he says. "The chain stretches from laypersons at home recognizing that a loved one may be having stroke symptoms, to the 911 dispatcher, to paramedics, then all the way down the line to the hospital. The Mobile Stroke Unit is a way to compress that chain of survival."
2. Laying a foundation: The community must be involved in establishing a mobile stroke program, Richards says. "When we set up our program, one consideration was how the Mobile Stroke Unit was going to be received by the public, who is used to their local EMS ambulance showing up and knowing they are going to be on the scene for a short period of time. It is a change of mindset for the public. Our Mobile Stroke Unit is going to be on the scene for an extended period."
3. Engaging EMS partners: Establishing a working relationship with local EMS crews is crucial, he says. "We operate in a system where we ask to be invited to participate with our local EMS agencies."
4. Creating hospital partnerships: Once patients have been evaluated and treated as needed, the UC Health Mobile Stroke Unit sends patients to the closest and most appropriate hospital, regardless of whether the hospital is part of the health system. The logistics of sharing information is pivotal, Richards says.
"When we do a CT scan in the back of the Mobile Stroke Unit, our radiologists at UC Health read those images, but that read and those images have to be accessible to a receiving hospital if it is not a UC Health facility. So, we have worked through the logistics of the interoperability of systems, which has been a critical component of our program."
The Mobile Stroke Unit program also has established protocols for communication between the virtual stroke neurologist and the treatment teams at local hospitals, he says. "That has allowed us to do a couple of things. First, while we most commonly transport patients to an emergency department, we can go directly to an interventional suite if the patient has the type of clot that neuro-interventionists can take out. We also can go directly to a neurological intensive care unit."
5. Stocking supplies: It is essential for a mobile stroke program to have medical supplies to meet the needs of patients with suspected stroke, Richards says. "We have worked closely with our pharmacy colleagues to think about which medications we should have onboard."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Stroke is one of the most common cardiovascular conditions, with nearly 800,000 strokes reported in the United States annually.
The new Mobile Stroke Unit at UC Health is manned by a paramedic, nurse, CT scan technician, EMT/driver, and virtual stroke neurologist.
The annual cost of operating the Mobile Stroke Unit is about $500,000.