A new study in JAMA Neurology has shown promising results in speeding up evaluation and therapy in patients with strokes using a mobile stroke response team with remotely located radiologists & stroke neurologists.
The Mobile Stroke Treatment Units (MSTU) were launched by the Cleveland Clinic last year to respond to potential stroke calls coming in via 911 in parallel to EMS. While similar teams have used teams that include neurologists who travel with the group, the Cleveland Clinic MSTU uses a telemedicine platform to enable remote evaluation by a stroke neurologist.
The Cleveland Clinic MSTU includes an RN, paramedic, EMT, and CT technologist who bring with them a mobile CT unit and onboard point-of-care testing capabilities including INR, blood glucose, electrolytes, platelet counts, and more.
When the team arrives and an acute stroke is suspected after initial evaluation, they complete a full assessment, get IV access, do a dry CT, and get blood to run the POC labs. They then remote in the stroke neurologist who can remotely evaluate the patient with all of that information in hand via an EHR where it’s all loaded. The neurologist can then recommend tPA administration, which can be done in the MSTU.
They looked at different process measures to see if use of the MSTU sped up delivery of care for stroke patients in comparison to a historical comparison group of 56 patients from the six months before the study started.
They found a shorter time to obtaining the head CT (13 mins vs. 18 mins, p = 0.003) though it’s notable that time to the actual CT read was the same in both groups (25 mins). The time to getting blood work, specifically INR, was much shorter (13 mins vs. 44 mins, p < 0.001). And the all important time to tPA administration was shorter as well (32 mins vs. 58 mins, p < 0.001).
In looking at feasibility, they noted some important hiccups in the process. For example, in one of the MSTU encounters, the telemedicine station power was turned off – preventing the stroke neurologist from remotely evaluating the patient. There were also six video disconnects and two episodes where there was significant delay in CT image file transfer over the wireless network.
The concept is interesting and certainly promising in acute stroke care, where the standard of care is a peripherally administered medication with a pretty small time window. I can’t imagine operating an MSTU is cheap, especially given the number of staff required as well as equipment maintenance. In the more far flung areas, where we often think about these types of systems performing best, incidence of acute strokes may not justify a 24-7/365 service requiring four trained healthcare professionals.
Costs could be mitigated by trying to use existing staff at hospitals where there is some redundancy. Or the scope of practice for this team and the specialists available to them could be expanded so that they could respond to more than just strokes. For example, chest pain calls in remote areas where tPA is the preferred therapy could be tackled by a similar team with cardiology support.
Over time, we’ll probably start seeing data on outcomes and cost effectiveness from systems like the MSTU. And that data, rather than hype or exaggerated promises of impact, can help guide decisions on deployment in other locales.