Leading the Pack in Mobile Stroke Care

While in service for just over a year, Capital Health’s Mobile Stroke and Neuro Unit (MSU) has already made a positive impact in the way stroke care is delivered in New Jersey’s Mercer County. Spearheading the MSU initiative were Capital Health’s Michael Stiefel, MD, director of the Capital Institute for Neurosciences and Stroke and Cerebrovascular Center, and James Boozan, MICP, divisional director of emergency medical services.

After speaking with several healthcare systems that had integrated MSUs into their patient care, Stiefel and Boozan began planning their program in the spring of 2016, and with the help of a $2 million grant from the Bristol-Myers Squibb Foundation, they obtained the truck by August of that year. 

Before diving into the project, Boozan and Stiefel reached out to the other hospitals in the United States and Europe that utilize MSUs. None of them reported any significant negatives to dissuade Capital Health from pursuing its own program. Boozan noted that the New Jersey Department of Health was very helpful throughout the planning process. 

“They were cautious, and I appreciate that because they gave good insight and suggestions about the licensing process,” says Boozan. “The Office of Emergency Medical Services was also very supportive. We didn’t have any roadblocks.” 

The MSU, manufactured by Frazer, has a CT scanner inside and accommodates point-of-care lab testing. It is staffed with a CT tech, critical care nurse, and paramedic. 

The MSU crew welcomes the BLS and ALS crews that are on scene to participate in the patient care process. “You want to be a pit crew [and] work as a well-greased team,” Boozan says.

“You want to make sure you have enough help to stabilize the patient, and that’s why it’s important for us to work with these agencies,” says Boozan, commenting on the variety of complications a stroke patient can present, like a compromised airway, vomiting, combativeness, and altered level of consciousness. “They can observe the NIH Stroke Scale being done, and they learn from it—they learn the nuances of what types of presentations strokes give, and they will see the results of the CT scan.”

The Care Process

Upon arrival, if the MSU team suspects a patient is having a stroke, they perform a brain CT scan, which takes about 3–4 minutes. The crew waits outside the truck. Once the scan is completed, the crew steps back inside and continues caring for the patient while the CT tech transmits the image to a neuroradiologist at Capital Health. Still at the scene, the crew contacts the stroke neurologist at Capital Health via a HIPAA-compliant video platform. The critical care nurse and neurologist then perform the NIHSS test. 

If the patient has no exclusion criteria, such as a recent heart surgery or being on blood-thinning medications, and imaging rules out a bleed in the brain, the ER physician will give the all-clear for the nurse to administer tPA to the patient while still in the MSU. Those with lower NIHSS scores are transported to a primary stroke center, whereas higher-acuity patients can be taken to the nearest comprehensive stroke center for potential endovascular treatment if appropriate.

“The standards and guidelines are changing every day, and we’re trying to provide the patient with the best outcome by making sure we get them the best care and to the appropriate facility,” says Boozan. Just days before this interview, the American Heart Association/American Stroke Association released new acute ischemic stroke care guidelines. The most notable change in the guidelines was the extension of the treatment window from 6 hours to up to 24 hours after the last known normal, "with a really significant likelihood of improvement from endovascular therapy, so it’s exciting for us,” Boozan says.

Like many EMS calls, a lot of the MSU calls are not as they were dispatched, leading to a high cancellation rate for the truck.

“That’s OK, because the idea is to catch the ones that matter,” says Boozan. At first the MSU only covered about 30% of Mercer County, but it achieved 100% coverage by December 2017, when all the other area hospitals were fully trained on accepting patients from the MSU. In total the MSU was dispatched on 480 calls in its first year, which resulted in 125 full workups. Of those 125 patients, 22 received tPA.

“You want to start this truck being very careful, meticulous, and doing things slowly and correctly rather than jump in and hope you do a good job,” says Boozan. “We were never working on how many more we could get; it was ‘Did we do it and do it right?’ And make sure we’re looking at what processes could change and improve.”

Commitment and Cost

Stiefel believes the program is worth the investment. “There are different approaches to everything in life. You’re either a leader or a follower, and Capital Health has always been that leader,” he says. “We are providing the most advanced stroke care in the world to the people of Mercer County. We are going to be the leader on stroke care—that’s our commitment, and that can come at a cost.”

Stiefel acknowledges that while experimental practices in medicine can be pushed in the wrong direction, an MSU will never affect the quality of the care given. “If it’s only going to improve [patient care], even though it hasn’t been proven, this is what we’re going to do,” he says.

Whereas some systems have tried neurologists in their MSUs, Capital Health decided to use a HIPAA-compliant telemedicine route, which was more cost-effective and convenient, as the neurologists could remain at the hospital while carrying an iPad to answer calls and assess patients on the go. 

As far as drawbacks of the MSU?

“There’s only one,” says Stiefel. “You can’t be everywhere.” If there are two simultaneous stroke calls, both patients will still receive the standard of care. “MSUs are not yet a part of a set standard,” Stiefel adds. “The standard of care at the scene is an ambulance and paramedics who then transport the patient to the most appropriate stroke center to get tPA, endovascular treatment, or both. So we are never deviating or providing less than the standard.”

If anything, the MSU may exceed today’s standard of stroke care. Boozan says while EMS providers can drop off a patient at the emergency room and leave for another call, the MSU team must begin and end patient care completely before they make themselves available for the next caller.

“It’s really critical that the information is relayed meticulously as to the [time] last known normal, the medications they’re on, allergies or history, risk factors—a good report,” says Boozan. “It’s not uncommon that these patients can’t give the ED team the information they want, so it’s really important for us to get it right for the receiving emergency department.” 

Other Benefits

Stiefel says a major advantage of the MSU is the ability to transport patients to the appropriate facility right from the scene based on the CT scan results. It’s critical that patients are brought to the appropriate hospitals so as not to delay care. Those with strokes that can be cared for by a primary stroke center, or patients who may not be having a stroke, will be directed to hospitals such as St. Francis, Robert Wood Johnson, Capital Health Medical Center-Hopewell, or Princeton if they are closer.

“The goal of this MSU was not to bring everyone here [Capital Health]. We’re set up for severe strokes and the most critical neuroscience patient,” says Stiefel. “We don’t want to inundate the team with people who can be well cared for at a hospital closer to their home and may only need the IV medicine. Why bring someone to a hospital that’s farther from their house when they don’t need to? You want to do that for the right reasons. There has to be trust among the healthcare providers. That’s very important.”

In addition to advantages in patient care, the MSU has contributed to improving interhospital relations.
“It breaks down political barriers,” says Stiefel. “Medicine is a business. There are different hospitals that belong to different networks. Everybody wants to do what’s best for the patient, so regardless of the networks they belong to, they want to be a part of the MSU. I think it has broken down those barriers and reminded us of why we got into this, which is really caring for the patient.”

In terms of making technological improvements with the MSU, the CT scanner currently only reaches a patient’s upper cervical spine, so Stiefel would like to see the machine receive advanced imaging capabilities to determine if endovascular care is needed. Patrick Sorells, RN, the MSU team nurse, hopes the technology within the vehicle will get smaller to make more room for the team to provide care.

More important, however, Sorells would like the cost of the trucks to decrease to make them available to more populations. In the meantime, though, he says local EMS providers should utilize the MSU’s provisions.

“It’s a resource that’s available to them,” says Sorells. “Even if they’re not sure if the patient is having a stroke, we’re still an extra set of resources that has a lot of experience we bring to the team.” The MSU crew recommended the downloadable app RACE, for Rapid Arterial Occlusion Evaluation, as a tool to assist providers during stroke assessments.

Stiefel agrees, stressing the importance of prehospital care providers’ role in stroke care.

“I think EMS is probably one of the most integral parts of a stroke team. Even though they’re not in a hospital, they are our eyes and ears,” he says. “I tell EMS this all the time. They can initiate the stroke service just as quickly and with the same degree of confidence I can. So EMS [providers] understanding the nuances of stroke and what each hospital offers is going to make the biggest difference for that patient.”

Valerie Amato, EMT, is assistant editor for EMS World. Contact her at vamato@emsworld.com.