Mobile Stroke Treatment Units: Lessons Learned From an Early Adopter

Podcast Transcript

Intro:  Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:  Mobile Stroke Treatment Units bring the emergency room to the patient's doorstep. Everything from assessment to CT angiography, to thrombolysis with TPA administration and transport to the most appropriate hospital, completed within the steps and minutes of arriving at the patient's doorstep. In today's episode of Neuro Pathways, we discuss lessons learned from an early adopter of mobile stroke care. I'm your host, Glen Stevens, neurologist neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm pleased to have Dr. Andrew Russman join me for today's conversation. Dr. Russman is medical director of Cleveland Clinic's Comprehensive Stroke Center and Mobile Stroke Treatment Unit in Cleveland Clinic's Neurological Institute. Andy, welcome to Neuro Pathways.   

Andrew Russman, DO:  Thank you, Glenn. Happy to be here.

Glen Stevens, DO, PhD:  So let's get started. As an early adopter, your team recognized that this technology would be valuable to your practice. Why does your team feel the Mobile Stroke Treatment Unit is important and significant in your stroke system of care?

Andrew Russman, DO:  Well, when we think about providing care for patients with acute stroke, especially if you're thinking about patients who are having acute ischemic stroke, time is brain. For every minute the brain goes without blood flow, we're losing 1.9 million neurons. And if we think that every minute counts, we know from prior studies that have been done, especially the target stroke data from the American Heart Association Get With The Guidelines program, that even 15 minutes difference can be the difference for a patient and being able to be ambulatory, to being able to be independent with walking. It significantly reduces hospital mortality after acute ischemic stroke. It increases the rate of patients who are receiving those therapies, and the complications of those therapies are reduced as a result. So time to treatment, especially for those who are candidates for thrombolysis, or candidates who are maybe eligible for endovascular therapy, like those with large vessel occlusion, time to treatment is such an important concept.

And so the Mobile Stroke Treatment Unit brings the elements of the emergency department that are involved in providing acute stroke treatment, which is so important from a time-based perspective, it brings it to the patient's doorstep. So the time from treatment is not loading on an ambulance and driving to an emergency department, it's at doorstep. So we've cut out the transport time, so that gives us a natural time-based advantage. But then these Mobile Stroke Treatment Units are so much more efficient because of the capabilities of those ambulances, they have a CT scanner, they have a mobile lab, they have a two-way audio visual system, and it allows to connect the crew on the ambulance, which is a critical care nurse, or paramedic, an EMT, a CT technologist, with a vascular neurologist remotely to provide very efficient management for patients.

And so it's the combination of that efficiency, the ability to more quickly work through the process of imaging, lab, decision-making for a patient with acute stroke, and the critical nature of these time-based decisions. That is really the capability of mobile stroke care and why it's so important, bringing this to the patient's doorstep, reduces disability, improves clinical outcomes. It makes the capability of the patient to be able to recover from their stroke, and all the intangible things that go along with return to function. It makes those things much more likely to occur. And for that reason, Mobile Stroke care is really the next phase of care in stroke patients. And it's something that we are seeing embraced throughout the United States.

Glen Stevens, DO, PhD:  Moving forward with this, can you talk me through the operations of your Mobile Stroke Unit? Specifically, tell me the parties that are involved, and how do you engage others from within and outside the organization to buy into it?

Andrew Russman, DO:  On the Mobile Stroke Treatment Unit is a dedicated team that includes a critical care nurse, a paramedic, emergency medical technician, a CT technologist, and virtually through a two-way audio visual connection, a vascular neurologist. This team is essential to the operations of the unit, and they work together with local EMS, and the local EMS dispatch system. So a patient is having stroke symptoms, they call 911, and the dispatcher identifies that the patient is having those symptoms. Then they co dispatch to the scene of where the patient is, the Mobile Stroke Treatment Unit and the local EMS unit. The first responders, the local EMS unit, they go into the home, they identify, "Oh, this seems like the patient may be having a stroke." And they wave in the Mobile Stroke Unit that's also waiting at the patient's doorstep. And at that point, the Mobile Stroke Unit will assist in the care, help to extract the patient from the home, and load them on a Mobile Stroke Treatment Unit.

The first thing we're going to do is we're going to work on getting IV access, we're going to obtain a non-contrast CT scan of the brain, and we're going to complete a neurologic exam or assessment using the NIH stroke scale. Then clinical decision is occurring associated with viewing the CT imaging, seeing the clinical exam, and determining whether the patient is a candidate for a thrombolysis, either intravenous thrombolysis with IV tPA, or whether the patient has a potential large vessel occlusion on their CAT scan or a CAT scan angiogram that we're able to perform. And our plan is to take the patient to the facility within their system of care. We want to keep people in their existing system of care, but they need to go to the hospital with the right capability within that system.

So patients having large blood vessel occlusions are taken to facilities with the capability to perform endovascular therapy and retrieve that clot. And we have to work together with locally EMS, with local fire departments. We have to work together with teams in emergency departments, and we work together within our own team to optimize these processes, share information with our partners, and continue to improve our performance, to have the best clinical outcome for patients.

Glen Stevens, DO, PhD:  Excellent. Sounds like a real collegial environment that you're building up there. So let me ask you a couple of specific questions. Does the stroke neurologist read the CT scan or is a neuroradiologist also involved?

Andrew Russman, DO:  Yeah. So neuroradiologist is available remotely, and they're providing the documentation, the interpretation of the images, and they're in close communication with the vascular neurologist. The vascular neurologist is looking at the images at the same time as the neuroradiologist. So we're not necessarily dependent on the neuroradiologist to determine whether the patient is having a bleeding type stroke or more of a blockage. However, we're essentially looking at the image simultaneously. So we're talking very early in the process.

Glen Stevens, DO, PhD:  So I was going to ask you this question, you just kind of mentioned it. I'm sure that you get surprised, sometimes patient has an intracerebral hemorrhage, and thank God we didn't give them tPA. How often do you see a blood that's there, and it's not a ischemic stroke?

Andrew Russman, DO:  Yeah. So if we look at the total number of transports that we do every year, maybe about 10% of those are intracerebral hemorrhage. And among those, they're immediately candidates for different types of treatment at that time, almost all of the patients presenting with intracerebral hemorrhage have uncontrolled blood pressure at the time we evaluate them, we carry specialized blood pressure medicines, especially for instance, we carry intravenous Nicardipine, we're able to start that medicine pretty quickly. We also have the ability to push medicines like Labetalol or Hydralazine while on the unit.

So we get started very early in the process of controlling that blood pressure, and potentially controlling that bleeding as a result. We then will identify, is this somebody who is having bleeding that could qualify them for some type of urgent surgical therapy to evacuate their hematoma? And so that's part of the determination that goes on early in the process is, that patient who has a bleed in their brain is not somebody who's going to go to, let's say, a primary stroke center for follow on care. They're going to need to go to a Comprehensive Stroke Center with the neurosurgical capability to manage that patient if they needed surgical evacuation of the hemorrhage, but also they're already starting that treatment that they need for that intracerebral hemorrhage while they're on the unit.

Glen Stevens, DO, PhD:  Just curious, do you have a single unit or do you have more than one Mobile Stroke Unit?

Andrew Russman, DO:  We currently have one unit, we'd love to have three. These units are something that in order to operate them, we have to cover a certain amount of population and have a certain amount of population density. They work well for now in urban areas for the most part and semi urban areas. So they work well in a suburban environment where there's enough population density to justify that. We can cover, let's say, that population density within the Northeast Ohio area, there's enough density in all Cuyahoga County, and major parts of Summit County, and the Eastern parts for instance, of Lorraine County, Western parts of Lake County.

So these areas could certainly justify an expansion of a Mobile Stroke program, but it's quite an undertaking to build and maintain these units. We do again, have one current unit and we're in the process of building a second unit that will take over. The current unit is getting to the point where we're going to probably move it into a reserve function, and move our new unit into the primary role. So we can stay in service as much as possible.

Glen Stevens, DO, PhD:  Would you like to comment on cost effectiveness? People are always interested in cost. Any data out there to help us with that?

Andrew Russman, DO:  Yeah. So there is some interesting data. There's two sets of data that we can look at. First of all, the Mobile Stroke Unit, because of how efficient is it in care, and how it may reduce disability, it's also reducing the downstream costs of care that occur. It's reducing the need for additional medical services, additional rehabilitation, by helping people to improve yet. In terms of the expenditures associated, the units are not inexpensive to operate, the unit itself usually costs over a million dollars to build one of these units, and to operate them on an annual basis is quite expensive as well. And the justification to the healthcare system is quite substantial, because of the reduced disability, again, need for further care from improved clinical outcomes for individual patients. However, if you look overall at this cost of care, one of the real benefits of Mobile Stroke Care is the reduction of the number of transports.

So if we pick up a patient with a traditional ambulance or EMS unit, and we transport them to a Primary Stroke Center, and then identified that they have a more serious problem that that Primary Stroke Center can't manage, then we have to make it a second transport, not only is that potentially contributing to further disability for the patient in delaying the time to that treatment, but it also is expensive to then go about the process of then transporting them.

And so when we look at the reduction in the number of transports and just the cost associated with to reduce transports, the Mobile Stroke Unit is also advantageous from a financial perspective, and being able to reduce those second transports, essentially because of the capabilities in unit, we never make second transports. We never have to take somebody to one facility and then another facility, because we get the patient to the right hospital the first time.

Glen Stevens, DO, PhD:  So with more than five years of learning under your belt now, what considerations would you share with others who might be looking to get into the Mobile Stroke Treatment Unit Program or get a program off the ground?

Andrew Russman, DO:  So I think one of the best lessons that we've learned is that when you're starting a program like this, building collaboration among all of your communities is so important. When you launch a program, this isn't something where you can just launch in one small area, you need to have enough population, enough organization within your EMS system to be able to support it. So as you're building the consensus within the community, it's important to develop agreements with the local communities early, so that you're starting with a large population of patients that you're going to be treating.

So step one is build consensus within the community, build consensus within the municipalities or other areas that you're going to transport, and understand the benefit of the therapy, and that everyone's buying into the importance of having the program and supporting the program. Communication is such an important element that having all the communities tied into the identification of potential patients through the dispatch system, and then being able to encompass that within your drive time capabilities of your Mobile Stroke Unit. Those drive time capabilities are such that, if you dispatch a local, unit and the Mobile Stroke Treatment Unit is too far away, and let's say we couldn't arrive in time.

Well then that sort of negates the benefit of covering that area. So we need to be dispatched early, and we need to cover an appropriate distance. So generally that's about 20 to 25 minutes drive time. So the unit, even if it leaves 20 minutes, if you think about the local EMS unit is dispatched, it arrives on scene, they're making assessments, they're ready to extract the patient from the home. By the time they're ready to extract the patient from the home, the Mobile Stroke Treatment Unit is arriving, even if we're 20 minutes away. In most of our runs, our average transport time is somewhere between 10  to 15 minutes, in terms of how far we're traveling to get to the patient. But that's well within the allowances of time that the local EMS units are arriving, assessing, and extracting the patients from their homes.

So I think again, the early lessons are, establish your relationships, keep within your allowed time and distance from your base in order to be able to provide that service as effectively as possible within your home service area for the unit, and communication is so key. So we transport a patient, we feed back that information right back to local EMS about what happened with the patient, what was the outcome of that care, understand what we could do differently. So part of the processes improvement is related to this communication. I think this is a lesson that we embraced earlier on, but I think we've become so good at it now, that it's just such a critical part of maintaining that capability. If we look at the performance of Mobile Stroke Care, so we have a measure of alarm activation to treatment with, let's say, a thrombolytic agent.

And for instance, when we first launched the unit, our alarm activation to treatment was probably in the range of about 50 to 55 minutes in terms of activation, arrival, on the unit, and then able to give them a thrombolytic drug in a certain period of time. Now we're able to go consistently from alarm activation, calling 911, to the time we're giving that thrombolytic drug, in 2019, that was 37 minutes. So if you think about that difference, we've gotten at least 15 minutes faster over the last five years, by working together with our colleagues, understanding where we can build efficiencies, and at the core of that is communication, communication among dispatchers, among local EMS, among the members of the Mobile Stroke Treatment Unit, among the vascular neurologists who are covering the unit, and then among emergency departments and hospitals where patients are being transported.

Glen Stevens, DO, PhD:  So as we look forward to the future, I know you'd like to have a second Mobile Stroke Unit, but anything else on the horizon, anything else we can do with it, capabilities we're not utilizing?

Andrew Russman, DO:  I think that we often talk about the need to optimize these units for other capabilities. Certainly Mobile Stroke Treatment Units already picking up patients who had stroke mimics or symptoms that are like stroke, for instance, we frequently pick up patients who have had seizures, and it's uncertain whether they've had a stroke that caused their seizure, or they just had a first seizure. And I think in those circumstances, we're already seeing and encompassing quite a lot of neurologic care. Where there's I think a greater opportunity is to optimize the use of these units in individual communities, and shift from what are largely health system or hospital based initiatives, where these programs are developing, and transition it more to counties and EMS agencies owning and operating Mobile Stroke Units. This is the transition that took place in the community decades ago when, for instance, the elevation in prehospital Advanced Cardiac Life Support or ACLS units became available, prior to a certain time frame, we just had basic units.

And then once we had these HCLs units, now communities started to embrace having these higher Advanced Cardiac Care Units that helped to initiate the process of identifying someone who was having a myocardial infarction, for instance, in the ambulance, through communication of their EKG, working together with the transport destination. The same kind of change that occurred with the adoption of these types of ACLS units, in which communities started buying and operating ACLS units, that needs to happen in the Mobile Stroke realm. Now that we've had studies showing the benefit and the improved clinical outcome associated with these units. Now communities, municipalities, in particular counties, and EMS systems, need to embrace this and include mobile stroke care as part of more systems of care that are being built through the local government agencies, rather than the onus being on local hospital systems to initiate these types of programs.

Glen Stevens, DO, PhD:  Well, our time is coming towards an end, but I think I'd be remiss without asking a COVID question, since it's changed everybody's lives. And I seem to recall that one of the concerns in the stroke world was that there'd be more proximal stenosis. Have you seen COVID change your practice or not?

Andrew Russman, DO:  Yeah, so certainly we do see patients who've had a COVID associated stroke. So for instance, I saw a patient last week who had probably an existing carotid stenosis, and then develop COVID, and COVID through a mechanism, through the angiotensin-converting enzyme to receptors that are on the endothelium or internal lining of the vessels, allows for the transit of the virus into the vessel wall, into the endothelium. And by allowing that to occur, it creates a unstable plaque environment. So if you have a carotid stenosis or a coronary stenosis, you develop this unstable plaque and sudden rupture of that plaque, and also through different mechanism creates an increased degree of clotting or thrombophilia within the vessel. And that can cause abrupt clotting within the vessel, in addition to this vessel rupture, or vessel wall plaque rupture I should say.

So certainly we've seen quite a lot of that in the stroke community. I think some of the biggest changes that in particular affect Mobile Stroke are because of the need to both protect the patient and the healthcare team, we've developed this protected code stroke process, and that's something we've been doing in emergency departments, identifying ways that we can protect the patient and the providers by appropriate gowning, gloving, masking. And we have to do the same things in the prehospital environment. The Mobile Stroke Unit, we have to gown, glove, mask, shield appropriately in order to both care for the patient, protect the caregivers, protect patients from transmission.

Glen Stevens, DO, PhD:  Well, Andy, thank you so much for joining me today. It's been a very insightful conversation. I appreciate your time and I hope I never see you personally in the Stroke Unit.

Andrew Russman, DO:  Well, thank you, Glen. It was very good to be able to participate in this program and share this information with colleagues and those in the community, because I think we need to continue to get the word out. I think you mentioned at the end about COVID, and I think one of the things we have seen that I just want to mention as a closing thought is, we see a lot of deferral of care, people deciding not to seek care, but wait, because they're concerned about COVID, they're concerned about exposure, and they're doing irreparable harm to themselves in waiting.

And so there is no time like the present, as we should encourage our colleagues and the community to get to the emergency department, call 911 when you're having symptoms. Whether a Mobile Stroke Treatment Unit responds or not, it's critical that you get care in a time-based fashion, and there's no time like the present to do so, rather than causing irreparable harm like delaying care, embrace this, call, don't ignore, the problem, it will only get worse.

Glen Stevens, DO, PhD:  Thank you, Andy.

Andrew Russman, DO:  Thank you, Glen.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.