Cleveland Clinic and the University of Texas Health Science Center at Houston have been leading clinical trials of mobile stroke unit vehicles, which enable hospitals to treat patients 40 minutes faster than traditional methods.
Armed with on-board imaging equipment, telemedicine equipment and lifesaving drugs, the ambulances provide faster treatment for stroke, which can cause brain damage with every passing moment. Experts say strokes often aren't treated quickly enough.
“It's about being responsible not only for the inpatient but what happens to that patient (before they arrive and) after they leave. When we thought about these topics we were thinking about that continuum,” said Diane Robertson, director of health technology assessment information services at ECRI, ECRI, a membership organization that evaluates medical technologies.
The vehicles—which were pioneered in Germany—made ECRI Institute's Top 10 Hospital C-Suite Watch list for 2016. Many of the items help providers reduce costs and curb readmissions such as warm perfusion systems for donor organs, miniature leadless pacemakers and blue-violet LED light fixtures that kill bacteria.
MSUs are modified ambulances that include a mobile blood lab, a heads-only CT scanner and telemedicine equipment that can send diagnostic images and help first responders communicate with neurologists at the hospital. UT and Cleveland Clinic each launched a single vehicle in 2014 and exclusively used them for stroke cases. Care teams are dispatched by a 911 operator when it's believed a patient is having a stroke.
Workers on the units normally include a critical-care nurse, a CT technologist, a paramedic and a driver. Normally, the crew will perform CT scans and blood testing at the scene and begin transporting the patient while a diagnosis is underway via telemedicine, said Robert Maliff, director of applied solutions at ECRI.
The MSU model allows a physician to more quickly decide whether life-saving tissue plasminogen activator therapy should be administered to break down blood clots in a patient's brain. Not all types of stroke call for t-PA therapy, but the unit can help physicians determine whether a patient should immediately receive the lifesaving drug.
Even the most sophisticated, highly efficient stroke programs have delays in getting patients to imaging equipment or receiving test results, Robertson said. MSUs start that process earlier and streamline treatment at the hospital.
“Stroke is a very common occurrence and we don't treat it very well,” Robertson said. “We don't get patients the necessary treatment they need soon enough.”
With current modes of treatment, only 3% to 8% of U.S. stroke patients receive t-PA, because it must be administered within four-and-a-half hours of the onset of symptoms, according to the Cleveland Clinic. Patients often don't get treated within this timeframe because they don't immediately realize they've had a stroke, or because they've been misdiagnosed by first responders.
Preliminary data from both Cleveland Clinic and UT show patients on the units are treated within an average of 64 minutes, as compared to a 104-minute timeframe often found in the emergency room.
But the vehicles don't come cheap: ECRI estimates that the total fixed and continuing costs over five years for UT's rig will be $1.65 million. That includes a $375,000 mobile CT scanner, a $60,000 retrofit of the vehicle, $30,000 in telemedicine equipment and other ongoing expenses related to labor and telemedicine network coverage.
MSUs are among the innovations resulting from health systems' transition to value-based care and their ability to tackle care-delivery issues that have traditionally been outside of the hospital's responsibility. Stephanie Parker, a nurse and program manager of the UTHealth mobile stroke unit, said other providers won't embrace the units until ongoing studies provide enough data to show improved patient outcomes.
“You're not going to have wide adoption unless we can show that patients have better outcomes and that this is cost-effective,” Parker said. “If our study is positive, I could see it going across the country very quickly.”
UT is also examining whether it may be beneficial to include a physician on its unit, as is the norm for all ambulances in Germany. Funding is also a key hurdle to overcome in widespread implementation, she said, noting that the CMS needs to consider whether it will provide higher reimbursement for patients treated on the units, because hospitals will be much less likely to invest in the program if it's not cost-effective.
Dr. Shazam Hussain, head of Cleveland Clinic's stroke program, said the units could prove particularly useful in a rural setting where first responders must go vast distances to reach patients. He said some rural providers are considering having an MSU rendezvous with community ambulances that retrieve patients who live far from major hospitals. That saves time for the MSU.
Hussain compared the invention of MSUs to EKG machines, which first began to appear on ambulances to expedite heart attack treatment. There's often little hospital providers can do before a patient undergoes a CT scan, which is what makes the pre-hospital scan so effective, he said.
“I think it's becoming clear at least from the stroke standpoint, given it is a time-sensitive treatment, that we have to be looking at ways to get to our patients faster,” Hussain said.
