Abstract 21: Can Telemedicine Replace an On-board Vascular Neurologist in Deciding about Tissue Plasminogen Activator Treatment? A Pre-Specified Substudy of the BEST-MSU Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Tzu-Ching Wu ◽  
Stephanie A Parker ◽  
Amanda L Jagolino ◽  
Amy Yu ◽  
Jose-Miguel Yamal ◽  
...  
Keyword(s):  
Treatment Decision ◽  
Stroke Patients ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen ◽  
Prehospital Triage ◽  
Remote Assessment ◽  
Technical Failures

Background: Faster treatment with tPA may be achieved by optimizing prehospital triage with mobile stroke units (MSUs). The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study is a prospective comparative effectiveness trial of outcomes in patients randomized to MSU or standard management (SM). Purpose: To evaluate the inter-rater agreement for tPA eligibility between a telemedicine vascular neurologist (TM-VN) and the onboard vascular neurologist (OB-VN) in acute stroke patients seen on the MSU. Methods: Cluster randomization of MSU and SM weeks started on August 18, 2014. On scene, both the TM-VN and OB-VN evaluated the patient and independently documented their tPA treatment decision, NIHSS and CT interpretation. Agreement was determined using Cohen’s kappa (K) statistic. TM related technical failures that impeded remote assessment were recorded. Results: The remote TM-VN evaluated 173 patients. In 4 (2%) cases the TM-VN was not able to make a decision about tPA because of technical difficulties ( 1 case due to TM camera failure and 3 cases due to poor connectivity). The TM-VN agreed with the OB-VN on 88% of evaluations, with a K of 0.73 representing substantial agreement. Baseline NIHSS correlation between the TM-VN and OB-VN was 0.88. Agreement about ICH on CTH was a near-perfect K of 0.97. Conclusions: We conclude from these results that remote VN assessment of stroke patients in the MSU via TM is clinically and technologically feasible, reliable and accurate. TM assessment of CTH and NIHSS was also comparable to the OB evaluation. These findings will allow either OB-VN or TM-VN assessment for the remainder of the study.

scholarly journals Mobile Stroke Unit Hits the Road in Houston

US Neurology ◽  
2015 ◽  
Vol 11 (01) ◽  
pp. 59
Author(s):  
James C Grotta ◽  
Keyword(s):  
Symptom Onset ◽  
Stroke Unit ◽  
Quality Adjusted Life Years ◽  
Stroke Treatment ◽  
The Road ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Life Years ◽  
Tissue Plasminogen ◽  
Quality Adjusted Life

After 1 year of preparation, the nation’s first Mobile Stroke Unit (MSU) delivering acute stroke treatment with tissue plasminogen activator (tPA) in the prehospital setting was launched in mid 2014. The unit is being operated as part of a clinical trial comparing MSU management to standard management to determine how much faster patients can be treated, how much better patients do if treated in the first hour after symptom onset than if treated later, if the physician on board the MSU can be replaced by a remote physician via telemedicine, and the costs and quality-adjusted life years saved by the MSU approach. We are treating on average over two patients per week with intravenous tPA, with more than 30 % treated within the first hour of symptom onset.

scholarly journals Impact of mobile stroke units

2021 ◽  
pp. jnnp-2020-324005
Author(s):  
Klaus Fassbender ◽  
Fatma Merzou ◽  
Martin Lesmeister ◽  
Silke Walter ◽  
Iris Quasar Grunwald ◽  
...  
Keyword(s):  
Cost Efficiency ◽  
Current Knowledge ◽  
Vascular Imaging ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Stroke Research ◽  
Mobile Stroke Unit ◽  
Novel Strategy

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

scholarly journals Air-Mobile Stroke Unit for access to stroke treatment in rural regions

2018 ◽  
Vol 13 (6) ◽  
pp. 568-575 ◽  
Author(s):  
Silke Walter ◽  
Henry Zhao ◽  
Damien Easton ◽  
Cees Bil ◽  
Jonas Sauer ◽  
...  
Keyword(s):  
Rural Areas ◽  
Stroke Unit ◽  
Systems Of Care ◽  
Intravenous Thrombolysis ◽  
Rural And Remote ◽  
Stroke Patients ◽  
Stroke Treatment ◽  
Remote Areas ◽  
Mobile Stroke Unit ◽  
Rural And Remote Areas

Background In recent years, important progress has been made in effective stroke treatment, however, patients living in rural and remote areas have nil or very limited access to timely reperfusion therapies. Aims Novel systems of care to overcome the detrimental treatment gap for stroke patients living in rural and remote regions need to be developed. Summary of review A possible solution to the treatment disparity between stroke patients living in metropolitan and rural areas may involve the use of specially designed aircrafts equipped with the ability to diagnose and treat acute stroke at remote emergency sites. We describe technical solutions for an Air-Mobile Stroke Unit (Air-MSU) concept, where an aircraft is customized with the ability to perform multimodal computed tomography, in addition to onboard laboratory equipment and telemedicine connection. The Air-MSU is envisioned not only to allow intravenous thrombolysis in the field but also to allow prehospital triage to a comprehensive stroke center through use of contrast intracerebral vascular imaging. Several options for the Air-MSU approach are described, and issues regarding the potential medical benefit, optimal operating environment, technical realization, and integration in pre-existing solutions (e.g., flying doctor service) are addressed. Conclusion The Air-MSU may represent a novel tool to reduce treatment disparity for stroke patients in rural and remote areas. However, this approach requires further implementation research to determine the overall benefit to these communities.

scholarly journals Benefits of stroke treatment delivered using a mobile stroke unit trial

2017 ◽  
Vol 13 (3) ◽  
pp. 321-327 ◽  
Author(s):  
Jose-Miguel Yamal ◽  
Suja S Rajan ◽  
Stephanie A Parker ◽  
Asha P Jacob ◽  
Michael O Gonzalez ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cost Effectiveness ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Healthcare Utilization ◽  
Stroke Unit ◽  
Standard Management ◽  
Mobile Stroke Unit ◽  
Tissue Plasminogen

Rationale Mobile stroke units speed treatment for acute ischemic stroke, thereby possibly improving outcomes. Aim To compare mobile stroke unit and standard management clinical outcomes, healthcare utilization, and cost-effectiveness in tissue plasminogen activator-eligible acute ischemic stroke patients calling 911. Sample size 693. Eighty percent power with 0.05 type I error rate to detect a difference of 0.09 in mean utility-weighted modified Rankin scale between groups. Design Phase III, multicenter, prospective cluster-randomized (mobile stroke unit versus standard management weeks) comparative effectiveness study in tissue plasminogen activator-eligible patients. Outcomes Primary: Ninety-day mean utility-weighted modified Rankin scale. Coprimary: cost-effectiveness based on EQ5D quality of life and one year poststroke costs. Analysis Two-sample t-test and linear regression adjusting for covariates; incremental cost-effectiveness ratio and net benefit regression. Results As of March 2017, 288 tissue plasminogen activator-eligible patients have been enrolled (173 in the mobile stroke unit arm and 115 in the standard management arm). Two new centers start in early 2017 with target end of recruitment September 2019. Conclusion This is the first randomized study to test for disability, healthcare utilization, and cost-effectiveness of a mobile stroke unit. The progress of the study suggests that it is feasible. Management of tissue plasminogen activator eligible acute ischemic stroke patients by a mobile stroke unit could potentially result in less disability and healthcare utilization, and be cost effective. Mobile stroke units are very costly. This trial may determine if the fixed cost can be justified by a reduction in disability and healthcare utilization. Clinical Trial Registration NCT02190500.

scholarly journals Models and organizational pathways in the treatment of acute stroke

2021 ◽  
pp. 4-10
Author(s):  
Romano Daniele ◽  
Grimaldi Grazia ◽  
Grimaldi Antonio
Keyword(s):  
Cerebral Artery ◽  
Intravenous Thrombolysis ◽  
Heart Association ◽  
Recombinant Tissue Plasminogen Activator ◽  
Medical Emergency ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Tissue Plasminogen ◽  
Level Of Knowledge ◽  
Large Vessels

Stroke due to its sudden and nefarious course is today considered "a medical emergency" that requires proper prevention and adequate and time-depending treatment. To follow the adequate guidelines (AHA-ASA 2018 and ESO-ISO 2018), stroke treatment involves the use of intravenous thrombolysis (IV) with Alteplase (or recombinant tissue plasminogen activator - r-tPA) within the first 4.5 hours of symptom onset and endovascular treatment within the first 6 hours if there were obstruction of large vessels such as the intracranial internal carotid artery, the middle cerebral artery (M1-M2), the anterior cerebral artery (A1) , the basilar artery and the tract intracranial vertebral artery. After the described options of treatment the hospitalization in the "Stroke Units" is fundamental. This aspect, in the past largely undervalued, plays today a pivotal role in the patient's "care": continuous monitoring, combined with careful clinical observation, are, in fact, essential in order to both facilitate a faster possible rehabilitation of the patient , both to prevent any complications and / or exacerbation of the disease (or the possible closure of the vessel). Aim of our lecture is to describe the result of years of controlled clinical trials, which have allowed us to reach a good level of knowledge on the efficacy and safety of the various therapeutic aids, only mentioned above, and whose use is regulated in detail by the main Guidelines (LG) in force today, including the Italian ISO-SPREAD LGs of 2016 [1] and the LGs produced by the American Heart Association (AHA), of which the American Stroke Association (ASA) represents a sector, and whose latest update is from 2018 [2].

scholarly journals Improving Outcomes After Stroke: From Stroke Units to Mobile Stroke Units

Stroke ◽  
2021 ◽  
Author(s):  
Andrei V. Alexandrov ◽  
Yongchai Nilanont
Keyword(s):  
Stroke Care ◽  
Absolute Difference ◽  
Clinical Approach ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Golden Hour ◽  
Systemic Thrombolysis ◽  
Improved Outcomes ◽  
Mobile Stroke Unit ◽  
The Impact

A proactive clinical approach to stroke care improved functional outcomes with implementation of specialized in-hospital stroke units, urgently delivered systemic thrombolysis, mechanical thrombectomy and most recently with mobile stroke units deployed in the field. An 18% absolute difference in outcomes as a shift across all modified Rankin Scale strata at 3 months in the recent Berlin study may not be explained by just 8.8% more patients treated within the golden hour for thrombolytic treatment from symptom onset. These findings parallel the findings in the largest controlled multi-center BEST-MSU trial (Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit) to date. A shortcoming in blinding of the investigators to the mode of transportation is similar to blinding to the endovascular treatment in PROBE (Prospective Randomized Open, Blinded End-Point) design used in thrombectomy trials. A faster access to stroke experts and brain imaging in the field for all patients suspect of stroke regardless symptom nature, severity, duration or resolution delivered by mobile stroke units is likely the reason for improved outcomes akin the impact observed in the initial multidisciplinary approach to in-hospital stroke units and reperfusion therapies delivery.

scholarly journals Swiss guidelines for the prehospital phase in suspected acute stroke

2021 ◽  
Vol 5 (1) ◽  
pp. 2514183X2199923
Author(s):  
Georg Kägi ◽  
David Schurter ◽  
Julien Niederhäuser ◽  
Gian Marco De Marchis ◽  
Stefan Engelter ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Current Guideline ◽  
Stroke Patients ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Prehospital Phase ◽  
Acute Stroke Treatment ◽  
The Right

Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.

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 Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management

Stroke ◽  
2015 ◽  
Vol 46 (12) ◽  
pp. 3370-3374 ◽  
Author(s):  
Ritvij Bowry ◽  
Stephanie Parker ◽  
Suja S. Rajan ◽  
Jose-Miguel Yamal ◽  
Tzu-Ching Wu ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Stroke Treatment ◽  
Standard Management ◽  
Mobile Stroke Unit

Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mellanie V Springer ◽  
Ran Bi ◽  
Lesli E Skolarus ◽  
Chun Chieh Lin ◽  
James F Burke
Keyword(s):  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Regional Variation ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Stroke Treatment ◽  
Symptom Recognition ◽  
Stroke Symptom ◽  
Tissue Plasminogen ◽  
Score Range

Introduction: Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions. Methods: We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume). Results: There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05). Conclusions: Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.

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