scholarly journals 011 Melbourne mobile stroke unit halves workflow for acute stroke reperfusion therapy

2019 ◽  
Vol 90 (e7) ◽  
pp. A4.3-A5
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Francesca Langenberg ◽  
Damien Easton ◽  
Michael Stephenson ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Reperfusion Therapy ◽  
Ct Scanner ◽  
Royal Melbourne Hospital ◽  
Prehospital Treatment ◽  
Endovascular Thrombectomy ◽  
Prehospital Thrombolysis ◽  
Golden Hour ◽  
Mobile Stroke Unit ◽  
Historical Controls

BackgroundThe Melbourne Mobile Stroke Unit (MSU) utilises a specialised ambulance with on-board CT scanner and multidisciplinary team to provide on-scene imaging, treatment and triage for central Melbourne, Australia. We describe the operational impact of the MSU on commencement of acute reperfusion therapy.MethodsData from the first 12 months of operation were collected for all patients receiving reperfusion therapy from November 2017. Workflow times were compared to contemporary published Australian data and historical controls from Royal Melbourne Hospital.ResultsIn the first calendar 12 months of operation, the Melbourne MSU operated 30.5 service weeks and provided prehospital thrombolysis (tPA) to n=52 patients (44% of eligible infarcts) and directed n=33 patients for endovascular thrombectomy, of which 48% required bypass from the closest non-thrombectomy hospital. The overall median onset-to-tPA for MSU patients was 97.5 mins compared to the Australian metropolitan median of 150 mins. Thrombolysis in the first ‘golden hour’ increased to 13.5% from 3.3% in-hospital. Median onset-to-groin for MSU patients receiving EVT was 162 mins compared to 234 mins from historical controls.DiscussionPrehospital treatment and triage using the Mobile Stroke Unit in metropolitan Melbourne resulted in substantial improvements in commencement of reperfusion therapy. Workflow times are approximately halved for thrombolysis and endovascular thrombectomy respectively. Prehospital thrombolysis also allowed a >400% increase in the proportion of treatment in the first ‘golden hour’.

Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit

2018 ◽  
Vol 14 (3) ◽  
pp. 265-269 ◽  
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Lauren Pesavento ◽  
Brett Jones ◽  
Edrich Rodrigues ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Intravenous Thrombolysis ◽  
Inpatient Rehabilitation ◽  
Reperfusion Therapy ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Prehospital Treatment ◽  
Mobile Stroke Unit ◽  
Stroke Team

Background Administration of intravenous idarucizumab to reverse dabigatran anticoagulation prior to thrombolysis for patients with acute ischemic stroke has been previously described, but not in the prehospital setting. The speed and predictability of idarucizumab reversal is well suited to prehospital treatment in a mobile stroke unit and allows patients with recent dabigatran intake to access reperfusion therapy. Aims To describe feasibility of prehospital idarucizumab administration prior to thrombolysis on the Melbourne mobile stroke unit. Methods The Melbourne mobile stroke unit is a specialized stroke ambulance servicing central metropolitan Melbourne, Australia and provides prehospital assessment, scanning and treatment with an integrated CT scanner and multidisciplinary stroke team. All cases were identified through the mobile stroke unit treatment registry since launch in November 2017. Results Of a total of n = 20 thrombolysis cases in the first 4 months of operation, three patients (15%) received intravenous idarucizumab 5 g for dabigatran reversal prior to thrombolysis. Mean time between idarucizumab administration and thrombolysis was approximately 10 minutes. Two of the three patients were shown to have large vessel occlusion on CTA in the mobile stroke unit and proceeded to endovascular thrombectomy. At 24 hours, only one patient had a small amount of asymptomatic petechial hemorrhage on follow-up imaging. All patients demonstrated substantial neurological recovery and were discharged to inpatient rehabilitation. Conclusions Rapid treatment with prehospital administration of idarucizumab prior to thrombolysis using a mobile stroke unit is feasible and facilitates hyperacute treatment.

Economic evaluation of the Melbourne Mobile Stroke Unit

2020 ◽  
pp. 174749302092994 ◽  
Author(s):  
Joosup Kim ◽  
Damien Easton ◽  
Henry Zhao ◽  
Skye Coote ◽  
Garveeta Sookram ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Standard Care ◽  
Stroke Care ◽  
Reperfusion Therapy ◽  
Sensitivity Analyses ◽  
Local Data ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Mobile Stroke Unit ◽  
Life Years

Background The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. Aims To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). Methods The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. Results In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. Conclusions There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.

scholarly journals Transdisciplinary Design Aspects of an Air Mobile Stroke Unit

2020 ◽  
Author(s):  
David Chipperfield ◽  
Michael Cheesman ◽  
Cees Bil ◽  
Greg Hanlon
Keyword(s):  
Clinical Outcomes ◽  
Stroke Unit ◽  
Hospital Care ◽  
Rapid Response ◽  
Diagnosis And Treatment ◽  
Ct Scanner ◽  
Golden Hour ◽  
Rural And Urban ◽  
Mobile Stroke Unit ◽  
Time Critical

Stroke is highly treatable but time critical. The greatest opportunity to improve outcomes is in the first ‘Golden Hour’ after onset. Pre-hospital care for stroke in Australia is patchy and poorly coordinated, resulting in gross disparities in clinical outcomes between rural and urban Australians. Clinical outcomes are at least twice as poor for rural Australians compared to their urban counterparts. A proposed solution is an Air MSU, an aircraft configured for rapid response to stroke victims so that diagnosis and treatment can commence onsite. This concept follows the tradition of the Royal Flying Doctors Service who have been providing medical services to rural Australians since 1928. This paper discusses the conflicting medical and aerospace requirements for an aircraft equipped with a CT-scanner including supporting equipment and personnel.

scholarly journals Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1613-1615 ◽  
Author(s):  
Alexandra L. Czap ◽  
Noopur Singh ◽  
Ritvij Bowry ◽  
Amanda Jagolino-Cole ◽  
Stephanie A. Parker ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Stroke Unit ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Unique Identifier ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Unit Management ◽  
Mobile Stroke Unit

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.

scholarly journals Melbourne Mobile Stroke Unit and Reperfusion Therapy

Stroke ◽  
2020 ◽  
Vol 51 (3) ◽  
pp. 922-930 ◽  
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Damien Easton ◽  
Francesca Langenberg ◽  
Michael Stephenson ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Reperfusion Therapy ◽  
Mobile Stroke Unit

Abstract 3: Early Recanalization of Large Vessel Occlusions by tPA on the Mobile Stroke Unit

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Alexandra L Czap ◽  
James C Grotta ◽  
Mengxi Wang ◽  
Stephanie Parker ◽  
Patti Bratina ◽  
...  
Keyword(s):  
Clinical Improvement ◽  
Stroke Unit ◽  
Arterial Occlusion ◽  
Large Vessel ◽  
Secondary Outcome ◽  
Hospital Treatment ◽  
Endovascular Thrombectomy ◽  
Wilcoxon Rank Sum Test ◽  
Mobile Stroke Unit ◽  
Derived Data

Introduction: The benefit of intravenous tPA in acute ischemic stroke patients with large vessel occlusions (LVOs) is limited but time dependent. We evaluated pre-hospital treatment with tPA on the Mobile Stroke Unit (MSU) to explore the recanalization rate in patients with LVOs and its effect on clinical improvement upon ED arrival. Methods: Prospectively derived data were analyzed from patients on the Houston MSU who were treated with tPA and had LVOs identified by hyperdense artery on MSU CT or arterial occlusion on MSU CTA. The primary outcome was early recanalization, categorized as resolution of LVO on repeat vascular imaging in the ED or on emergent angiography versus no recanalization. Secondary outcome was change in baseline NIHSS at 24 hours. Differences in NIHSS were evaluated using Wilcoxon rank sum test with continuity correction. Results: Seventy-one patients received tPA and had proximal LVOs both in the anterior and posterior circulation. Eleven had recanalization on CTA upon ED arrival (15.5%), while 7 had recanalization on emergent angiography (9.9%). The total early recanalization rate with tPA was 25.4%. Forty-seven patients with persistent LVOs on ED arrival (66.2%) underwent endovascular thrombectomy (EVT). Time from symptom onset (last known normal) to tPA bolus did not differ significantly between the early recanalization vs non-early recanalization groups (64.5 minutes [IQR 43.0-78.5] vs 64.0 minutes [52.5-92.0]; p = 0.41). Early recanalization resulted in greater improvement in baseline to ED arrival NIHSS (median NIHSS change 4.0 [0-11.8] vs 0 [0-3.5]; p = 0.01). There were no differences in ED arrival to 24 hour NIHSS between the early recanalization versus non-early recanalization groups irrespective of EVT. Conclusions: Recanalization by ED arrival occurs in 25% of LVO patients with tPA treatment on a MSU and was associated with early clinical improvement. Subsequent EVT did not “make up” for the clinical benefit of early recanalization.

Abstract 175: Faster Prehospital Workflow in the Melbourne Mobile Stroke Unit Halves Onset to Reperfusion Therapy

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Francesca Langenberg ◽  
Damien Easton ◽  
Lindsay Bent ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Reperfusion Therapy ◽  
Mobile Stroke Unit

010 The melbourne mobile stroke unit substantially improves thrombolysis times and pre-hospital triage

2018 ◽  
Vol 89 (6) ◽  
pp. A5.2-A5
Author(s):  
Henry Zhao ◽  
Skye Coote ◽  
Lauren Pesavento ◽  
Francesca Langenberg ◽  
Patricia Desmond ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Stroke Unit ◽  
Life Support ◽  
Hospital Treatment ◽  
Future Research ◽  
Stroke Patients ◽  
Time Saving ◽  
Royal Melbourne Hospital ◽  
Stroke Treatment ◽  
Mobile Stroke Unit

IntroductionThe Melbourne mobile stroke unit (MSU) project is the first Australian pre-hospital stroke service that delivers on-scene imaging, treatment and triage. The MSU vehicle consists of a Mercedes Sprinter-5 chassis with on-board CereTom 8-slice portable CT scanner and telemedicine capabilities. On-board crew consists of a neurologist/telemedicine, nurse, radiographer and two paramedics (advanced-life-support and mobile-intensive-care). The MSU service is co-dispatched within 20 km of Royal Melbourne Hospital. We describe the service activity since project launch.MethodsData are sourced from the Melbourne MSU registry, an ongoing prospectively collected database of all MSU dispatched cases since November 2017.ResultsIn the first 50 operational days, there were a total of n=255 dispatches (5.1/day), of which 47% of patients received on-scene attendance. On-scene CT was performed on 52% of all attendances. Of n=29 suspected ischaemic stroke cases<6 hours of symptom onset (24% of attended), n=10 (34%) received pre-hospital thrombolysis and n=6 (21%) were directed for endovascular thrombectomy. 30% of patients were thrombolysed within 90 min of symptom onset. A total of n=7 (14% of all stroke) patients were recommended to bypass the closest hospital to a specialist centre for endovascular, neurosurgical or other services. The median scene-to-thrombolysis time of 36.5 min was substantially better than Australian in-hospital averages and represented an estimated 30–45 min time saving compared to in-hospital treatment.DiscussionThe Melbourne MSU project shows that pre-hospital diagnosis and treatment of stroke patients is feasible and associated with substantial time saving in providing acute stroke treatment and triage. Future research will focus on optimising MSU dispatch and cost-effectiveness analysis.

scholarly journals Bringing Emergency Neurology to Ambulances: Mobile Stroke Unit

2017 ◽  
Vol 38 (06) ◽  
pp. 713-717 ◽  
Author(s):  
Ritvij Bowry ◽  
James Grotta
Keyword(s):  
Clinical Outcomes ◽  
Stroke Unit ◽  
Mechanical Thrombectomy ◽  
Cost Effective ◽  
The United States ◽  
Conclusive Evidence ◽  
Golden Hour ◽  
Intravenous Tissue Plasminogen Activator ◽  
Mobile Stroke Unit ◽  
Emergency Neurology

AbstractIschemic stroke results from blocked arteries in the brain, with earlier thrombolysis with intravenous tissue plasminogen activator (tPA) and/or mechanical thrombectomy resulting in improved clinical outcomes. Mobile Stroke Unit (MSU) can speed up the treatment with tPA and facilitate faster triage for patients to hospitals for mechanical thrombectomy. The first registry-based MSU study in Germany demonstrated faster treatment times with tPA using a MSU, a higher proportion of patients being treated within the first “golden hour,” and a suggestion of improved 3-month clinical outcomes. The first multicenter, prospective, randomized clinical trial comparing MSU versus standard care was started in 2014 after the launch of the MSU in Houston, TX, demonstrating the feasibility and safety of MSU operation in the United States, and reliability of telemedicine to evaluate stroke patients for tPA eligibility. Although conclusive evidence from clinical trials to support MSUs as being cost effective and improving clinical outcomes is still needed, there are a myriad of other clinical and research applications of MSUs that could have profound implications for managing patients with neurological emergencies.

Abstract 99: Mobile Stroke Unit CTA and Direct Notification of Interventional Team Shortens Door-to-Puncture Time by One Hour

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Alexandra L Czap ◽  
Noopur Singh ◽  
Ritvij Bowry ◽  
Amanda Jagolino-Cole ◽  
Stephanie A Parker ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Additional Time ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Single Center Experience ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Comparative Effectiveness Study ◽  
Baseline Characteristics ◽  
Safety Guidelines

Introduction: Endovascular thrombectomy (ET) is an effective but time sensitive treatment of acute ischemic stroke. Time from Emergency Department (ED) arrival to start of ET (door-to-puncture time, DTPT) is a modifiable metric. One of the most time consuming steps in prolonging DTPT is identification of large vessel occlusion (LVO) by CT angiography (CTA). BEST-MSU is a prospective multicenter comparative effectiveness study of tPA-eligible patients managed on a mobile stroke unit (MSU) vs Emergency Medical Services (Standard Management, SM). After discovering that DTPT was greater than 60 minutes in both groups at three BEST-MSU centers in 2018, we began to routinely obtain CTA on the MSU and directly alert the ET team at receiving hospitals if a LVO was identified. We hypothesized this would shorten DTPT by over 30 minutes. Methods: In this single center experience, we compared the median (interquartile range, IQR) DTPT and MSU on-scene time for MSU patients having on-board CTA and then ET from 9/2018 to 7/2019 to corresponding MSU ET patients (excluding any that had on-board CTA) from 8/2014 to 8/2018. All CTAs were completed after tPA bolus and during tPA infusion on a Ceretom 8 slice scanner with OptiStat hand injector. All imaging occurred on-scene with the MSU stationary. Consent was obtained for all patients and strict radiation safety guidelines followed. Results: 13 consecutive patients having CTA on-board the MSU and then ET were compared to 84 patients in the pre-on-board CTA group. Baseline characteristics including median NIHSS score (20 in both groups) and frequency of tPA (85% on-board CTA vs 89% pre-on-board CTA) were comparable. Median DTPT was 60 minutes shorter with on-board CTA and direct notification of the interventional team from the MSU; 34 minutes (IQR 30-57) vs 94.5 minutes (IQR 69.75-117.25) (p < 0.001). Despite the additional time to obtain the CTA on the MSU, on-scene time was only slightly prolonged and did not offset the reduction in DTPT (on-board CTA 30 minutes (IQR 28-33) vs pre-on-board CTA 27 minutes (IQR 23-31) (p = 0.01). Conclusion: Pre-hospital identification and notification of LVO by a MSU allows a one hour reduction of DTPT, and can be utilized to establish a direct to angiosuite protocol.

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