Mobile Stroke Treatment Units: Myth or Reality?
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- Annis Robinson
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1 Mobile Stroke Treatment Units: Myth or Reality? Peter A. Rasmussen, MD Director, Cerebrovascular Center Associate Professor Surgery (Neurosurgery) Medical Director of Distance Health
2 Disclosures last 12 months Financial Interest: Blockade Medical Perflow Medical Scientific Advisory Boards Blockade Medical Medtronic Neurosurgery Perflow Medical Stryker Neurovascular Institutional/Group/Research and Educational Support: ev3/covidien Penumbra Medical Codman/J & J Immediate Past President Society of Neurointerventional Surgery
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4 Neurosurgeon s Role in Stroke Brain aneurysms Brain AVMs ICH medical and surgical and minimally invasive Carotid stenosis CEA and CAS Hemicraniectomy EC-IC Bypass Endovascular management of acute and chronic ischemia (ICAD) Programmatic leader in your hospital/health system/community
5 There are Effective Treatments for Acute Stroke
6 What is the most effective treatment for ischemic stroke? Treatment/Technique NNT Rx ment chronic hypertension 29 Stroke Units 18 IV tpa 0-90 min CEA/CAS for Asx stenosis 19 Aspirin 100 CEA/CAS for Sx stenosis 6-15 Endovascular/IA AIS 3.5-4
7 Time=Brain and the IV tpa Time Window Lancet 2010; 375: ; Lancet 2004; 363:
8 Patient Outcome vs. ΔTime (Onset to Treatment) Khatri, IMS3, ISC
9 Time is Brain! Neurons Lost Synapses Lost Accelerated Aging Per Stroke 1.2 billion 8.3 trillion 36 yrs Per Hour 120 million 830 billion 3.6 yrs Per Minute 1.9 million 14 billion 3.1 weeks Per Second 32, million 8.7 hrs (Total number of neurons in the average human brain is 130 billion) Stroke 2006;37:
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11 Target: Stroke Outcomes (15 min reduction in IV tpa DTN times) Fonarow GC, et al. JAMA. 2014;311(16):
12 Cleveland Clinic Stroke System Hospital Transfer Return to PCP Regional Administrative Infrastructure Lake Erie Euclid Hosp * Ashtabula County Med Center CCT Lakewood Hospital * Regional Hub Main Campus * Comprehensive Stroke Program Hillcrest Hospital * Regional Hub Fairview * Lutheran Marymount * South Pointe Hosp* * CCF Florida* Medina Hosp * * Primary Stroke Center Telestroke Spoke
13 Stroke Impact and CCF Overview 2013 Devastating Problem Yearly Discharge Volume Adult Prevalence Yearly Mortality Stroke Mortality Rank 5 Yr Projected IP Growth Cuyahoga County 5, % rd 3% CC Slow to Improve MC HC FVW MYMT LKWD SP Medina Euclid Luth IVtPA delivery rate 17% 10% 11% 4% 7% 6% 18% 10% 0% Door to Drug in 60 min
14 Global IVtPA Underuse Modeling indicates that 23% can be achieved with prealert, 4.5hrs, > 80 yrs UK, 24% achieved in Sweden Monks et al. Stroke 2012; Bergland,Stroke 2012 Improved DTN crucial; Foranow Stroke Meratoja, Neurology 2012 Estimated 4.5% to 5.2% USA (Boehringer Ingelheim; Adeoye Stroke 2011; Foranow Stroke 2011) Huge Variation in Europe Finland 16% (Meratoja 2012), Germany 11.7% (Minnerup Stroke 2011), Sweden 6.6% (Eriksson Stroke 2010), UK 5.8%, France 3%, Italy 1.2% (T Fischer Pers com 2013 Boehringer Ingelheim) Much lower rates in developing world <1%
15 Recognize Maximum Benefit to Patient is Earlier Treatment We cannot expect the patient s disease biology to match our systems. Because the time window to treatment for stroke with most is so short, we must match our systems to the biology. Michael Hill, MD Stroke Neurologist Univ of Calgary 15
16 Stroke Treatment Decisions Hinge on the CT Scan BP control <180 IV tpa (clot buster) Transport to Primary Stroke Center BP control <140 Warfarin reversal Mannitol Anti-epileptic medications Transport to Comprehensive Stroke Center
17 Berlin University of Saarland First in the World
18 Kostopoulous et al. Neurology 2012 Decision made in ambulance ER Target: door to needle time = 60 minutes 18
19 Berlin: Call to Needle Times
20 Randomized, single center Week on, week off Primary endpoint alarm to therapy decision Secondary alarm to end of CT, alarm to lab analysis, # pts IV tpa, 7 day neurological outcome (NIHSS) 20
21 Week on, week off randomization Compared STEMO deployment vs.stemo weeks vs. control weeks tpa utilization improved to 33% (vs. 21% in control weeks)
22 Cleveland Clinic Stroke System MC HC FVW MYMT LKWD SP Medina Euclid Luth IVtPA delivery rate 17% 10% 11% 4% 7% 6% 18% 10% 0% Door to Drug in 60 min
23 Realization that we need to make a systems change US facing a health care crisis Costs too high Access too low Need to constantly innovate our care delivery model Need to increase revenues Need to decrease costs Most cost of stroke patient is after acute hospitalization Need to reduce these costs Best way to reduce rehabilitation/disability costs is to reduce neurologic deficit Need to increase IV tpa delivery and access to endovascular therapy Need to bring highest possible level of care directly to the patient as soon as possible 23
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25 Collaboration with Local Government and Health Systems Requires collaboration with local government Go to the mayor Collaborative effort with the community Requires collaboration with local government Need to get out and sell Build excitement Change hearts and minds.
26 Mobile Stroke Treatment Unit: Diagnosis and Emergency Care Don t wait for the patient to get to the ED Bring the CT and stroke expertise to the patient Initiate treatment at the scene Dramatically cut time-to-treatment decisions Triage patient to appropriate stroke resource 26
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28 Portable CT Technology CereTom (Neurologica, Danvers, MA) 8 slice CT CTA/CTP capable Able to scan head Used for a number of years in our NICU Reasonable quality
29 Telemedicine Inter-rater reliability reasonable to in person assessment Berlin kappa 0.69 Houston with mock patient absolute agreement Well-proven in Telestroke networks Reliable Broadband has been limiting step in Germany Berlin: only 18/30 technically successful connections Verizon 4GLTE
30 Distribution of 911 calls for Stroke by Hour of Day
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32 Operations Stroke patient calls 911 activates Emergency Medical System Municipal ambulance dispatched simultaneously with MSTU (8a-8p) Local ambulance arrives first usual assessment, IV, O 2, draws blood samples MSTU arrives mutual care/hand off of care CT(A) head performed -> transmitted for neuroradiologist and neurologist review Point of Care Testing for CBC, INR, creatinine, glucose Telestroke System -> vascular neurologist virtually with the patient and team, Initiate IV tpa or other care as appropriate Triage to appropriate hospital (level of care) in stroke system
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37 Has been very reliable Telemedicine Review of 108 transports, 5 drop outs 3 brief (< 30 seconds), did not affect clinical care 2 longer (> 30 seconds), truck moved 10 feet and signal returned 1 unable to restore connection Stroke neurologist communicated by telephone with critical care transport nurse, determined cause to be seizure, transported to closest ED. Relationship w Verizon Wireless VPN
38 Program Operations Patient Transport Algorithm Patient Condition identifies Hospital resources needed to effectuate subsequent care Patient Transport effectuated to nearest Hospital with clinical resources available to meet care needs Patient request will override the default mechanism (Care Continuity, Community Preference) Level 1 Hospital Hospital with Specific Neuro-Intensive Care Unit and Stroke Intervention Capabilities Level 2 Hospital Hospital with Stroke- Intervention Capabilities Level 3 Hospital Primary Stroke Center Level 4 Hospital Any hospital facility 38
39 Treatment Paradigm of the Future? 43 y.o. with prior history of drug abuse, CHF Was with girlfriend who left briefly, came back 10 minutes later to find him with left hemiplegia Called 911 EMS and MSTU dispatched MSTU arrived 40 minutes last known well
40 MSTU Telemedicine Stroke Neurologist signed in to see patient with dense left sided weakness and altered LOC, difficulty speaking NIHSS 20
41 Non contrast CT
42 Treatment Initiated IV tpa initiated at 11 minutes after patient on board MSTU! (Door to needle) Transferred to Cleveland Clinic Main Campus for consideration of intraarterial stroke therapy (due to high NIHSS, hyperdense MCA sign)
43 Initial runs right M1 MCA occlusion
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45 One pass with aspiration cath M1 recanalized, M3 thrombus (angular branch remaining)
46 Patient Course Improved next day with near resolution, only facial droop remained (NIHSS 1) Stroke due to underlying CHF (EF 10%) Discharged home on hospital day 4
47 Pre-hospital Stroke Treatments Dispatches Transports IVtPA Tx Hemorrhagic strokes 7 19 Updated 12/31/
48 Advanced Therapy Treatment Pre-hospital CTA Imaging Potential Endovascular Candidate Endovascular Tx 6 6 (7) 48
49 Methods Case Control Study MSTU quality data prospectively collected and maintained in a Redcap database Enterprise Stroke system data collected and maintained in separate Redcap database Comparison of MSTU patients with patients presenting to Cleveland Clinic Enterprise Hospitals within or adjacent to City of Cleveland border from January 1, 2014 to December 31, 2014 Must have had stroke alert called within 30 minutes of arrival to hospital. Control patients presenting to hospital from 8am 8pm Statistical analysis: Comparison of medians by Wilcoxon Rank Sum, proportions by Pearson s Chi squared (JMP software)
50 Primary Stroke Metrics
51 911 Alarm to.. ~45 min saved = 15% more patients d/c d home $12k v. $40k cost for first 90 days of care..
52 911 Alarm to Drug Administration Data as of 9/18/2014
53 MSTU Thrombolysis Rate Thrombolysis Rate: Based on MSTU encounter Dx (n=100 patients) IV tpa given for 100 MSTU runs: 16% Rate in probable stroke = 16/33 = 48.4% Based on Final Dx (known for 87 pts) Rate in AIS: 9/29 = 31.0% Rate in AIS + clinical TIA = 11/41 = 26.8%
54 Hospital Discharge Diagnosis MSTU Patients
55 Transport Destinations: First 155 Patients Cleveland Clinic: 69 Metro Hospital: 27 University Hospital: 19 Lakewood Hospital: 11 Euclid Hospital: 7 Marymount Hospital: 5 Fairview Hospital: 5 South Pointe Hospital: 4 Parma Hospital: 3 Southwest General Hospital: 2 St. Vincent Charity: 1 Lutheran Hospital: 1 Hillcrest Hospital: 1 Data as of 12/31/2014
56 Pre-hospital treatments Hemorrhagic strokes transported: 7 1 Kcentra-coumadin coagulopathy patient treated in the field July August September October November December Dispatch to Scene Arrival 13 mins MSTU Door to Doctor MSTU Door to CT complete MSTU Door to CT Read MSTU Door to Lab Results MSTU Door to Drug Total Time on Scene Data as of 12/31/2014
57 MSTU comparison to CCHS EDs MSTU HC MC Fairview Medina MYMT ACMC LKWD SP # IV tpa Administration in ED Door to Drug (Target <60 min) month data 12 hrs/day operation 12 month data
58 MSTU Programs Comparison Worldwide
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60 Number of Patients Who Benefit and Are Harmed per 100 Patients tpa Treated in Each Time Window Lansberg et al, Stroke Minutes Benefit Harm
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62 Hemorrhagic strokes transported: 7 Pre-hospital ICH Can offer BP control, anticoagulation reversal 1 st patient ever treated with K- centra (4 factor PCC) in the field INR 3.2 on POC in MSTU On arrival to NICU, INR normalized (1.1) Triage directly to neurosurgical center
63 Right Patient, Right Place, the First Time Thus far, no patients have required a second transfer
64 Concerns? Cost Traffic Politics Never work in my market No one will work together Excuses! Don t be pusillanimous!
65 Cost of a Mobile Stroke Treatment Unit Portable CT scanner: ~$400k Truck Chassis: Ambulance Box: Total Cost: $60-110k ~$150k ~$750k Personnel: ~$500k/yr One MSTU can service ~1M citizens ~10-15 year life expectancy 65
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69 CCHS Emergency Stroke Care Capabilities 35.0% 30.0% IV tpa Delivery Rates 31.0% 25.0% 20.0% 15.0% 12.3% TPA Rate 10.0% 5.0% 3.8% 0.0% Pre Telestroke (Fairview, Medina) Post Telestroke (Fairview, Medina) MSTU Telestroke was initiated in Fairview and Medina Hospitals in Their specific cumulative IVtPA experience before and after initiation of Telestroke capabilities are represented by the Pre-Telestroke and Post-Telestroke labels above. The MSTU began operations in 2014; the data represents its IVtPA administration rate during its first year of operations.
70 EMS CLE Old Stroke System of Care EMS EMS PSC Spoke PSC Spoke EMS EMS PSC Spoke EMS CSC Hub With or without Telestroke EMS PSC Spoke EMS
71 CLE Current/Future Stroke System of Care EMS EMS EMS PSC Spoke PSC Spoke EMS CSC Hub EMS EMS PSC Spoke EMS PSC Spoke EMS With Telestroke
72 EMS Future Stroke System of Care? EMS MSTU EMS PSC Spoke PSC Spoke EMS CSC Hub EMS EMS PSC Spoke EMS PSC Spoke EMS
73 Denver and Toledo Worldwide MSTU Programs
74 Mobile Stroke Treatment Units: Popping Up All Over the Place!
75 Patients First - the Rest will follow
76 Summary - The Right Reasons to do this. No doubt about role of time in therapy initiate treatment as fast as possible Low rates of IV tpa administration (and now IA therapy) despite stroke units and Joint Commission accreditation demand change to the System Brings highest level of expertise as soon as possible Intelligent triage decisions to maximize use of scarce resources Patients first: Will decrease neurologic deficit, disability and costs to society MSTUs are here to stay will be a part of US stroke systems broadly
77 Acknowledgements City of Cleveland Mayor Jackson/Marty Sweeney Cerebrovascular Center and Critical Care Transport Michael Modic and Robert Wyllie Matt Stanton/Brian Perse (CV Center Administrators) Stacey Winners (MSTU Program Manager) Cleveland Pre-Hospital Acute Stroke Treatment (PHAST) Study Group
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79 Title of Presentation Arial Regular 22pt Single line spacing Up to 3 lines long Date 20pts Author Name 20pts Author Title 20pts
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