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Department: Team Concepts

Advanced prehospital stroke care

Mobile stroke treatment unit

Schneider, B.C. PhD, RN, NE-BC

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Nursing Management (Springhouse): January 2021 - Volume 52 - Issue 1 - p 7-9
doi: 10.1097/01.NUMA.0000724908.52219.43
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According to the American Stroke Association (ASA), a stroke occurs when a blood vessel carrying oxygen and nutrients to areas of the brain is either blocked by a clot (ischemic stroke) or ruptures (hemorrhagic stroke), resulting in the deprivation of oxygen to those areas and subsequent brain cell death.1 In the US, stroke is the fifth leading cause of death and a leading cause of disability. Approximately 140,000 deaths are attributed to stroke each year. About 795,000 people experience a stroke annually, 690,000 of which are acute ischemic strokes.1

Updated in 2019, the ASA guidelines for healthcare institutions and practitioners are based on the latest evidence-based research related to stroke care. The guidelines are comprehensive, concentrating on management from the onset of acute symptoms in the prehospital phase through 2 weeks after acute stroke. Although the guidelines address the entire continuum of care for the patient who's experienced a stroke, including recommendations for stroke management in the prehospital, hospital, and posthospital phases, advances in the prehospital phase of stroke care will be the focus of this article.

One of the updated guidelines states, “stroke systems of care should be developed to ensure that fibrinolytic eligible patients and mechanical thrombectomy eligible patients receive treatment as fast as possible.”1 The most important factor in stroke recovery is time. For each minute a stroke is untreated, a person loses approximately 1.9 million neurons affecting speech, musculoskeletal movement, and memory.2 Numerous slogans and catchphrases have been developed to raise public awareness of just how important time is to stroke treatment, such as “Act FAST” and “BE FAST.” Contacting 911 upon symptom onset will get the patient to a hospital for treatment; however, what if hospital care were to come directly to the patient?

Mobile stroke treatment unit

First launched in Germany in 2010 and initiated in the US in 2014, the mobile stroke treatment unit (MSTU) brings the hospital to the patient.3 This concept isn't new, considering that physician house calls were a standard practice for a large portion of the 20th century. In 1930, physician house calls made up 40% of physician visits.4 The MSTU modernizes and amplifies the concept by not only incorporating the use of telehealth, but also bringing multidisciplinary clinical expertise and all of the modern equipment used to diagnose and treat a stroke in the hospital setting to the patient.

The MSTU brings the house call into the 21st century and can be deployed anywhere a patient is having a stroke. Similar to what one would find in most EDs in the US, the MSTU is comprised of a healthcare team: an onboard RN, paramedics, a computed tomography (CT) technician, and a (remote) neurologist. Just as a patient would experience in a hospital's ED, a team of healthcare professionals assess the patient, conduct imaging and point-of-care lab testing, and provide intervention (I.V. tissue plasminogen activator [tPA]) if indicated.

NewYork-Presbyterian Hospital (NY-P) implemented an MSTU program in 2016, courtesy of a grant. The MSTU crew includes one RN, one CT technician, two paramedics, and a dedicated neurologist via telehealth. A collaborative management model was employed to oversee the crew, including leadership from the departments of nursing, emergency medical services (EMS), and radiology.

Similar to any hospital unit employing RNs, leadership was required to oversee staff and ensure quality of care and patient safety. As with any nursing unit, the nursing staff also required training, certification monitoring, scheduling, timekeeping, and a chain of command to report concerns, incidents, and events. The priority when establishing the nursing leadership model was to meet leadership counterparts and stakeholders from other departments who were part of the program. Collaboration was key to learning the role and function of the nonnursing crew and to ensure each crew member functioned within his or her scope of practice.

Advocating for nursing was crucial given this new endeavor into the prehospital arena. For example, nursing leadership advocated for, and ensured, all nursing staff attended all relevant ambulance courses that had previously been reserved for EMS staff only, such as “scene safety.” The goal was to ensure that the safety training of the nursing staff was equal to their EMS colleagues.

Nursing orientation

To ensure that the RNs assigned to the unit had the appropriate education, orientation, and competency to care for patients and operate the unit, RNs were placed into a critical care RN orientation track with an emphasis in the neurosciences and stroke care. Orientation consisted of rigorous training time in the neuroscience ICU, neuroscience stepdown unit, and interventional neuroradiology procedure suite before proceeding to training on the MSTU.

Once training on these units was completed, RNs then trained on the MSTU. The first RN to orient to the MSTU did so with physician and paramedic colleagues. Physicians assisted with advanced neurologic assessment training and paramedics assisted with ambulance training. Information technology staff were also available to train RNs on the MSTU's telehealth equipment. Subsequent RNs hired for the MSTU were trained by the first RN to start with the program.

In early 2018, NY-P expanded the MSTU program to serve communities outside of the borough of Manhattan. An MSTU was added to the New York City boroughs of Brooklyn and Queens. These additional MSTUs required the hiring of more nursing staff, as well as training. The orientation and management model used for the initial MSTU carried over to these new units, improving patient access to comprehensive stroke care in New York City.

Outcomes

With the expansion of the program to a total of three MSTUs, NY-P's MSTU program is the largest in the world. It's also the first program to entirely integrate the hospital's electronic medical record (EMR) system with an MSTU, allowing for remote access to the EMR. RNs can document their assessment findings and medication administration, as well as see provider orders electronically. Since the inception of NY-P's MSTU program, the time between the onset of ischemic stroke symptoms and the administration of I.V. tPA has been significantly reduced; in general, MSTU programs prove to be at least 30 minutes faster than standard care.

In 2012, Walter and colleagues published the first randomized controlled trial demonstrating that an MSTU could reduce alarm to tPA administration (median) time to 35 minutes, compared with 76 minutes with conventional hospital treatment.5 The number of patients who received therapy within 60 minutes from symptom onset also significantly increased, from 4% to 57%. Results from a subsequent study conducted in Germany by Ebinger and colleagues demonstrated similar results; decreased time to treatment and an increase in thrombolysis during the first 60 minutes from symptom onset.6

NY-P's MSTUs have also demonstrated similar results, with improved median treatment times. Time from symptom onset to tPA administration was 86 minutes for NY-P's MSTU, compared with 145 minutes for conventional hospital care. MSTU dispatch to tPA administration time was 58 minutes, compared with 78 minutes using conventional ambulance dispatch, transport to hospital, and tPA administration. And MSTU arrival to tPA administration time was 46 minutes, compared with 74 minutes using conventional ambulance arrival, transport to hospital, and tPA administration.

Although MSTU programs across the globe have proven effective in reducing the time between the onset of stroke symptoms and administration of thrombolytic medication, research hasn't consistently shown favorable functional outcomes with MSTUs.3,5-7 However, MSTU research is very much in its infancy and clinical trials are currently ongoing. Retrospective analyses suggest that MSTUs are a cost-effective way to provide acute stroke care.3

Final thoughts

Although advances in technology have greatly impacted how healthcare is provided to patients, technology is no replacement for caregivers. The MSTU is a wonderful piece of equipment, but it's the crew that makes the program successful. Without nurses, patients wouldn't receive hands-on assessments or receive needed medications; without paramedics, the MSTU doesn't respond to the scene; without a CT technician, brain imaging can't be completed; and without providers, orders can't be written and brain imaging can't be interpreted.

It's important to note that nurses in the MSTU program truly bring the experience of the hospital to the patient. In addition to clinical knowledge and skills, nurses provide compassion, empathy, professionalism, and trust for patients and families during what may be one of the worst experiences of their lives—a stroke. These nurse-patient relationships, combined with the clinical and technical skills of the crew and advanced technologic equipment of the MSTU, allow for the highest level of quality care to be provided to patients experiencing a stroke.

REFERENCES

1. American Stroke Association. About stroke. 2020. www.stroke.org/en/about-stroke.
2. Saver JL. Time is brain—quantified. Stroke. 2006;37(1):263–266.
3. Ehntholt MS, Parasram M, Mir SA, Lerario MP. Mobile stroke units: bringing treatment to the patient. Curr Treat Options Neurol. 2020;22(2):5.
4. Kao H, Conant R, Soriano T, McCormick W. The past, present, and future of house calls. Clin Geriatr Med. 2009;25(1):19–34.
5. Walter S, Kostopoulos P, Haass A, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial. Lancet Neurol. 2012;11(5):397–404.
6. Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. J Am Med Assoc. 2014;311(16):1622–1631.
7. Tsivgoulis G, Geisler F, Katsanos AH, et al. Ultraearly intravenous thrombolysis for acute ischemic stroke in mobile stroke unit and hospital settings. Stroke. 2018;49(8):1996–1999.
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