Short Attention Span Summary
Plan to have your stroke in Cleveland
A mobile stroke treatment unit (MSTU) with telemedicine-enabled prehospital technology significantly shortened the time to thrombolytic administration: 97 vs. 122 minutes. This was a study of the first 100 patients treated in this unit, only 16 of which received tPA. This was no ordinary EMS rig. It had sophisticated telecomm equipment and an onboard CT scanner. Since the NNT drops to 4.5 from 9 if tPA is given in the first 90 vs 180 minutes for stroke, it makes sense to reduce unnecessary delays. Although we know tPA was given faster, no other patient-centered outcome measures were reported, and they acknowledged this as a chief limitation. Cost-effectiveness is another major obstacle for this kind of unit.
A MSTU reduced the time to treatment drastically. EMLoN has a rather scathing review of this paper called All Aboard the tPA Hype Bus, which is pretty funny to read.
Neurology. 2017 Mar 8. pii: 10.1212/WNL.0000000000003786. doi: 10.1212/WNL.0000000000003786. [Epub ahead of print]
Taqui A1, Cerejo R1, Itrat A1, Briggs FB1, Reimer AP1, Winners S1, Organek N1, Buletko AB1, Sheikhi L1, Cho SM1, Buttrick M1, Donohue MM1, Khawaja Z1, Wisco D1, Frontera JA1, Russman AN1, Hustey FM1, Kralovic DM1, Rasmussen P1, Uchino K1, Hussain MS; Cleveland Pre-Hospital Acute Stroke Treatment (PHAST) Group.
1 From the Cerebrovascular Center (A.T., R.C., A.I., S.W., M.B., M.M.D., Z.K., D.W., J.A.F., A.N.R., P.R., K.U., M.S.H.), Department of Neurology (N.O., A.B.B., L.S., S.-M.C.), and Critical Care Transport Team (A.P.R., F.M.H., D.M.K.), Cleveland Clinic, OH; and Department of Epidemiology and Biostatistics, School of Medicine (F.B.S.B.), and Frances Payne Bolton School of Nursing (A.P.R.), Case Western Reserve University, Cleveland, OH.
To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance.
We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014-November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges.
Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset.
Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.
© 2017 American Academy of Neurology.