Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 33,991 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.
What this blog is for:
My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
Aphemia,
or pure motor mutism, is a phenomenon that has been reported previously
in the literature and typically is associated with small infarcts in
the inferior dominant precentral gyrus, pars opercularis, or inferior
perirolandic gyrus. Clinically, it is important to distinguish aphemia
from aphasia syndromes. Telemedicine is becoming more prevalent and
involving neurologists across the country. This is an important
consideration when addressing aphemic patients as many mistakes can be
made during a virtual exam clouding a patient’s clinical picture.
Case Presentation:
Our
patient is a 61-year-old female with a past medical history of
hypertension, diabetes, and an old right frontoparietal stroke without
any residual deficits. She presented after her family stated that she
“quit speaking” for about seven hours. Initial neurological evaluation
was done via telemedicine due to the COVID-19 pandemic and was pertinent
for decreased consciousness, inability to answer either orientation
question, a right facial droop, and aphasia. Later it was found that the
patient exhibited a pure motor mutism rather than aphasia and had an
MRI lesion in the left inferior precentral gyrus.
Conclusion:
Differentiating
aphemia from aphasia is an important clinical skill for a neurologist
to foster especially in the era of telemedicine. An intimate knowledge
of the parts of a speech exam are vital in directing emergency staff
during stroke evaluation. Additionally, distinguishing these clinical
syndromes has implications with respect to prognosis and long-term
rehabilitation.
Are you that FUCKING CLUELESS that you don't understand why the anxiety exists? Treat the primary problem. NOTHING EXISTS TO GET YOU 100% RECOVERED. Provide protocols and survivors will happily do millions of reps to get results and get recovered. Anxiety won't exist because proven methodologies will be used. We need some decent stroke leadership because we aren't even researching the correct problems.
Disabling
anxiety affects a quarter of stroke survivors but access to treatment
is poor. We developed a telemedicine model for delivering guided
self-help cognitive behavioral therapy (CBT) for anxiety after stroke
(TASK-CBT). We aimed to evaluate the feasibility of TASK-CBT in a
randomized controlled trial workflow that enabled all trial procedures
to be carried out remotely. In addition, we explored the feasibility of
wrist-worn actigraphy sensor as a way of measuring objective outcomes in
this clinical trial.
Methods:
We
recruited adult community-based stroke patients (n=27) and randomly
allocated them to TASK-CBT (n=14) or relaxation therapy (TASK-Relax), an
active comparator (n=13).
Results:
In
our sample (mean age 65 [±10]; 56% men; 63% stroke, 37% transient
ischemic attacks), remote self-enrolment, electronic signature,
intervention delivery, and automated follow-up were feasible. All
participants completed all TASK-CBT sessions (14/14). Lower levels of
anxiety were observed in TASK-CBT when compared with TASK-Relax at both
weeks 6 and 20. Mean actigraphy sensor wearing-time was 33 days (±15).
Conclusions:
Our
preliminary feasibility data from the current study support a larger
definitive clinical trial and the use of wrist-worn actigraphy sensor in
anxious stroke survivors.
But if you don't know how fast thrombectomy has to occur to get 100% recovery this really doesn't help. My definition of success is 100% recovery, NOTHING LESS! Wrong measurement.
by Nicole Lou,Staff Writer, MedPage Today
April 6, 2020
Stockholm's new prehospital stroke triage system
allowed centers to deliver endovascular thrombectomy (EVT) to the right
patients faster and without sacrificing time to IV thrombolysis,
according to a report.
Under this system, patients were transported directly to a
comprehensive stroke center (CSC) with EVT capabilities under two
conditions: if they displayed moderate-to-severe hemiparesis
on the A2L2 test and were accepted following teleconsultation with the
CSC. Thus, select patients could bypass primary stroke centers (PSCs)
that did not offer thrombectomy.
Predictive
performance of this triage system was good the first year it was
implemented, Michael Mazya, MD, PhD, of Karolinska University
Hospital-Solna, Stockholm, and colleagues reported in a paper published
online in JAMA Neurology.
Accuracy was 87% for the identification of large artery occlusion
stroke and 91% for predicting EVT initiation. Positive predictive values
were 41% and 26%, respectively, while negative predictive values were
93% and 99%.
Moreover, the 323 triage-positive stroke patients in the study received timely treatment when compared to historical controls from the previous year, when people were still being sent to the nearest stroke center:
Median onset-to-puncture time was 137 minutes vs 206 minutes (P<0.001)
Median onset-to-needle time was unchanged at 115 minutes
Median CSC IV thrombolysis door-to-needle time was 13 minutes vs 31 minutes (P<0.001)
"The
Stockholm Stroke Triage System, which combines symptom severity and
teleconsultation, results in markedly faster EVT delivery without
delaying IV thrombolysis," Mazya's group concluded.
This new patient selection strategy thus represents a new way to
answer the question of where to send a potential candidate for stroke
thrombectomy. Other options include mobile stroke units, scale-based triage, "drip-and-ship,"
and CSC mothership, according to Anne Alexandrov, PhD, RN, of the
University of Tennessee Health Science Center in Memphis, and Klaus
Fassbender, MD, of Saarland University Medical Center in Homburg,
Germany.
"It
remains to be determined which patient selection strategy ... will be
most effective. This question may be answered differently in various
regions and various health care environments," they wrote in an accompanying editorial.
The new triage system, implemented in routine practice in October
2017, covered the Stockholm region, an urban area with 2.3 million
inhabitants. The region was served by one CSC and six PSCs, study
authors noted.
Their population-based prospective cohort study was conducted across Sweden from October 2017 to October 2018.
Of the 2,905 patients transported by priority "code-stroke" ambulance
to a hospital for suspected acute stroke during this period, 11% were
triage-positive for direct transport to CSCs under the new system
(median age 73 years, 48% women).
Triage-positive patients were slightly younger, presented with higher stroke severity, and had lower onset-to-first-hospital-door times compared with triage-negative individuals.
EVT was performed in 26% with triage-positive results and 1.4% with triage-negative results.
The study's findings may not be generalizable to locations outside Stockholm, cautioned Mazya and colleagues.
This
was illustrated by the fact that due to local practices, PSCs
considered 46.6% of patients with acute ischemic stroke to be
large-vessel occlusion (LVO)-negative without confirmation by vascular
imaging, according to Alexandrov and Fassbender.
"We recommend validation of our system's predictive accuracy for
large-artery occlusion and EVT also in settings with other criteria for routine vessel imaging and EVT treatment," Mazya's group urged.
Another limitation of the study was its before-after design,
Alexandrov and Fassbender said. "Time-related factors, such as better
awareness about stroke or improved performance of EMS and hospital teams
over the study period, could be confounding factors that may have
affected the study's results," they suggested.
Disclosures
Mazya, Alexandrov, and Fassbender disclosed no conflicts.
A
“weekend effect” resulting in higher mortality rates for patients with
stroke admitted on weekends has been reported. We examine this
phenomenon for patients with acute ischemic stroke (AIS) presenting to
telestroke (TS) sites to determine its effect on stroke alert process
times and outcomes. From October 2015 to June 2017, we reviewed patients
with AIS receiving intravenous alteplase within our TS network. We
compared patients presenting to TS sites on weekdays (Monday 07:00 to
Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday
06:59). We analyzed door-to-alert activation, alert activation-to-TS
evaluation, door-to-imaging, and door-to-needle times. Rates of
favorable outcome (modified Rankin Scale score ≤2) and death at 90 days
were compared. We identified 89 (54 weekday and 35 weekend) patients
(mean age: 71.8 ± 13.3 years, 47.2% women) during the study period.
Median door-to-alert activation (P = .01) and door-to-needle (P
= .004) times were significantly longer for patients presenting on
weekends compared to weekdays. There were no significant differences in
median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P
= .56) at 90 days did not differ. While there were no significant
differences in outcomes, patients presenting on weekends had longer
door-to-alert activation and door-to-needle times. Efforts to improve
methods in efficiency of care on weekends should be considered.
This is completely unacceptable. 'CARE' NOT RESULTS. Until we get stroke survivors in charge this tyranny of low expectations will continue. 100% recovery is the only goal. NOT this 'care' model.
by Shannon Firth, Washington Correspondent, MedPage Today
WASHINGTON -- A telemedicine-based
payment model to improve care for patients experiencing stroke and other
cerebral emergencies in rural, underserved communities won support from
the Physician-Focused Payment Model Technical Advisory Committee
(PTAC).
PTAC voted 11-0 on Monday in favor of the ACCESS Telemedicine model.
However, in accordance with a new voting protocol meant to further
clarify the committee's wishes, the committee also voted 9-2 to
recommend further development of the proposal in ways specified in their
comments. Two members voted for implementation of the proposed model as
is.
PTAC
is an independent committee of health policy experts and clinicians
established by Congress to advise the Secretary of Health and Human
Services (HHS) on which alternative payment models (APMs) to test and to
scale.
Submitted by the University of New Mexico Health Sciences Center
(UNMHSC), the ACCESS model meets a significant need: Rural, underserved
community hospitals can't afford to hire neurological specialists, and
emergency department (ED) physicians at those same rural hospitals
aren't comfortable diagnosing patients with cerebral-emergent problems,
committee members agreed.
Because of these twin issues, patients are often transferred to
tertiary hospitals, sometimes unnecessarily. The goal of ACCESS is to
reduce unnecessary transfers to these tertiary hospitals for benign
cases, while reducing the time to diagnosis and treatment for
time-sensitive conditions, by leveraging telemedicine consults.
The model is built around a two-way audiovisual program, housed on an
online telemedicine platform, that allows clinicians in underserved
areas to connect with neurologists and neurosurgeons at tertiary care
centers.
"What ACCESS does is it aims to expand ... access to expertise of a
neurological and neurosurgical nature to docs in rural hospitals so that
they could make more timely, and maybe more accurate, judgments about
the need for hospitalization to more sophisticated hospitals," explained
PTAC member Len Nichols, PhD, director of the Center for Health Policy
Research and Ethics at George Mason University in Fairfax, Virginia.
Nichols was the lead reviewer on the three-member preliminary review
team.
For
instance, in patients with acute ischemic strokes, time to diagnosis
and treatment with tissue plasminogen activator (tPA) is critical, but
many ED physicians in rural hospitals do not feel comfortable providing
such treatment, and "rural hospitals are 10 times less likely to give
tPA than their urban counterparts," according to the UNMHSC proposal.
In New Mexico, where the ACCESS model has been integrated into the
state's Medicaid and Managed Care Organization's Physician Health Fee
Schedule, the rate of tPA use jumped from 2% of ischemic stroke patients
to 20%, which is considered "high normal use" for U.S. medical centers,
according to the proposal. Cost of ACCESS
UNMHSC proposed establishing an "APM ... in which the rural site can
bill for a bundled payment for all elements (consult, technology,
education, quality assurance). This would add sustainability of the
ACCESS model, while still reducing overall healthcare costs to payers,"
and would include a follow-up consultation with the neurological expert
within 24 hours.
"The payment is contingent upon delivering high quality care via
telemedicine and recommendation of a diagnosis and disposition to the
local [ED] provider based on discussion, audiovisual assessment of the
patient and/or review of digital imaging," according to the proposal.
In
New Mexico's ACCESS model, the total cost of a neurology consult is
$850, while neurosurgical consults are $1,200. Payment is made to the
rural hospital that is responsible for paying the tertiary hospital.
ACCESS received a Health Care Innovation Award (HCIA) from the Center
for Medicare and Medicaid Innovation, but the pilot study that stemmed
from that award did not include enough people to produce a statistically
"rigorous analysis," noted PTAC.
However, additional materials from UNMHSC suggest the model led to a sharp decline in unnecessary transfers.
Before the ACCESS model in New Mexico was piloted, a rural hospital
transferred approximately 90% of patients with neurological ailments to a
tertiary hospital for care. Of those patients that were transferred,
only 20% were admitted by the receiving hospital; the other 70% were
discharged and another 10% were held for observation before being
discharged.
After ACCESS implementation, 15% of patients with a neurological
ailment were transferred, and 92% of those patients were admitted; 5%
were observed and 3% were immediately discharged.
While
the potential impact on patient care appeared clear based on the
"totality of the evidence," Nichols said it was also reasonable to
believe the model would lower costs. 'Richer Dataset'
Nichols said he did not support implementation of ACCESS as is, because the proposed payment levels need review.
"In my opinion, it's close," said Nichols who voted for
implementation as specified by PTAC comments. "What needs to be fleshed
out is a richer dataset, which I believe [the Center for Medicare and
Medicaid Services] either has, or could acquire without a great deal of
work."
"I don't think you want to take those numbers in that chart and throw
them to the world," he added, referring to the suggested $850 and
$1,200 payments for neurologists and neurosurgeons, respectively.
PTAC
member Grace Terrell, MD, disagreed. "My feeling is close actually
counts ... which is why I voted to implement because, the nature of us
as economists and clinicians, is that we will never find anything
perfect enough." Terrell is an internist and CEO of Envision Genomics of
Huntsville, Alabama, and was on the preliminary review team. She voted
for implementation of the ACCESS model as is.
Earlier in the discussion, Terrell underscored the significant access
problem to specialty care in rural areas and expressed that the need
for the model was "universal."
PTAC Chair Jeff Bailet, MD, president and CEO of Altais (formerly
Blue Shield of California) in San Francisco, voted to recommend
implementation of the model with further development. Bailet stressed
that the model was beneficial to patients and could be vital in helping
rural hospitals keep their doors open.
"Once these rural hospitals collapse, you will never have them come back into the community," he said.
Harold Miller, president and CEO for the Center for Healthcare
Quality and Payment Reform in Pittsburgh, said that payment in the
ACCESS model needs to be tied to quality. For instance, if services are
not delivered in a timely manner, or if a clinician gives a bad
recommendation, the payment should be lower, he suggested.
Terrell proposed that the PTAC letter to the HHS secretary include a
comment about the possibility of using centers of excellence to help
address the quality concerns that Miller mentioned.
Ryan Stevens, MHA, executive director of Neurological Clinical
Services at the University of New Mexico Medical Group in Albuquerque,
represented UNMHSC at the meeting. He said he was pleased with the
committee's decision, and that he was looking forward to working with
CMS to develop ways to improve accountability, "without adding too much
administrative burden."
He said he liked Terrell's idea of developing centers of excellence
within the ACCESS program that would set defined performance criteria to
be met by program participants.(YOU need to get involved otherwise the criteria will be the failed status quo, not 100% recovery.)
They still just talk about 'stroke care' and good clinical outcomes as if those are good measurements. The only goal to be measured in stroke is 100% recovery. Until that is the measurement, all this stroke research is a waste of time. You have one goal in stroke and you are completely failing at it. I blame the mentors and senior researchers for not stating that explicitly.
It should make zero difference. Based upon the objective damage diagnosis that should lead directly to prescriptions for stroke protocols. But NO, your incompetent doctor doesn't even know what is being done to treat you. S/he is writing three prescriptions to OT, PT and ST saying E.T.(Evaluate and Treat). I think a doctor should be responsible enough to know exactly what stroke rehab is being done and the efficacy of that rehab.
BACKGROUND:Telemedicine has changed over the last years, becoming an
integrated service used in various clinical settings such as stroke
units or radiological departments, but also as an important tool for
home rehabilitation. Assessment of usefulness and efficiency of
performing teleconsultations to manage stroke from acute care hospital
to tertiary care rehabilitation hospital has not been referred by
scientific literature.
AIM:This article analyzes the process of
discharging stroke patients from acute care to intensive rehabilitation,
based on the comparison between conventional bedside patient
evaluations and teleconsultation patient evaluations, to assess
efficiency and efficacy of two different discharging workflows.
DESIGN:Retrospective study.
SETTING:Consultations were carried out
between the Acute Care Stroke Unit (ACSU) and the Stroke Rehabilitation
Unit (SRU) of Valduce Hospital System.
POPULATION:257 stroke patients
underwent physiatric consultation during 2 years considered in this
study and 101 patients were considered eligible for intensive
rehabilitation treatment after a physiatric consultation.
METHODS:we
compared the efficiency and efficacy of the dismission workflow of
bedside medical consultation and teleconsultation over a 12 months
period. We considered the following outcome measures: time elapsed
between consultation and rehabilitation unit admission, number of
re-admissions to acute care hospital, complications occurred during
rehabilitation, length of stay in the rehabilitation hospital and
clinical outcomes of rehabilitation process.
RESULTS:we observed a
significant reduction in waiting time from the acute event to the
admission in rehabilitation department, an improvement in efficiency of
the admission process itself in the rehabilitation unit and a reduction
of clinical complications occurred during rehabilitation period, without
changes in rehabilitative outcomes.
CONCLUSIONS:it has been highlighted
that the use of telemedicine to perform medical consultation as a tool
to evaluate patients eligible for tertiary care rehabilitation hospital
admission from stroke care unit is feasible and more efficient when
compared with conventional bedside consultations.
CLINICAL
REHABILITATION IMPACT:this study reveals teleconsultations as a useful
tool to improve efficiency of the stroke management workflow.(Yeah when all you are doing is writing E.T. three times on a prescription pad there really is no need to even see the patient.)
Don't try to push this off as a success. It is still a complete failure, administration should be in the ambulance. If that isn't your goal get the fuck out of medicine.
A novel telemedicine program increased alteplase administration rates and shortened door-to-needle times without an increase in adverse outcomes, according to a study published in Stroke.
“When a stroke happens, minutes matter,” Mai Nguyen-Huynh, MD, MAS, vascular neurologist and research scientist in the division of research at Kaiser Permanente in Oakland, California, said in a press release. “Faster treatment with intravenous [alteplase], which dissolves the stroke-causing clot and restores blood flow to the brain, is strongly associated with better functional outcomes for stroke patients.”
Researchers analyzed data from 310 patients (mean age, 71 years; 50% women) who received alteplase (Activase, Genentech) before the telemedicine program was implemented and 557 patients (mean age, 74 years; 53% women) who received it after the program was initiated in 21 Kaiser Permanente Northern California hospitals.
The telemedicine program included ambulance prenotification, neurological evaluation, medical history review from electronic medical records, notification of potential transfer for endovascular stroke treatment, alteplase administration in the CT suite and rapid transport to the suite. A teleneurologist was on-call to examine and monitor the patient.
The primary outcome was the door-to-needle time for the administration of alteplase. Secondary outcomes were symptomatic intracranial hemorrhage, rate of alteplase administrations per month and disposition at discharge.
Alteplase administrations increased from 34 per month before implementation to 62 per month once the program was in place (P < .001). Door-to-needle times decreased from 52 minutes to 34 minutes (P < .001).
Alteplase administration times of less than 60 minutes occurred in 87.1% of patients during the program vs. 61% before it was implemented (P < .001). Patients who were treated within 30 minutes increased from 4.2% before the program was initiated to 40.8% after the program started (P < .001).
The rate of symptomatic intracranial hemorrhage was similar before (2.2%) and after (3.8%) the program was in place (P = .29).
“Future studies are needed to better evaluate the long-term sustainability of the intervention and its effect on clinical outcomes, including mortality and long-term disability,” Nguyen-Huynh and colleagues wrote. – by Darlene Dobkowski
Disclosures:The study was funded by the Permanente Medical Group. Nguyen-Huynh reports she received funding from the Permanente Medical Group.
So fucking what? What are your results getting patients 100% recovered? Use the correct measurement endpoint not crap like delivery. You need to call the president and ask why they are using crap like delivery measurements rather than results. Using those measurements should be a fireable offense. We have to call out failure every place we see it. https://eurekalert.org/pub_releases/2017-12/kp-spr121417.php
Kaiser Permanente's standardized protocols enhanced
by use of telemedicine, 'door to needle times' average just 34 minutes
at all 21 Northern California hospitals
Kaiser Permanente
Kaiser Permanente hospitals in Northern California are delivering
clot-busting medication to new stroke patients more than twice as fast
as the national average. This follows the regionwide adoption of an
integrated telemedicine program, according to new research published
Dec. 15 in the journal Stroke.
This is the among the first peer-reviewed, published studies to show
how the successful implementation of standardized treatment protocols
and telemedicine for acute ischemic stroke in a large, integrated system
of hospitals can dramatically reduce the time it takes to start
critical treatment.
"When a stroke happens, minutes matter," said lead author Mai
Nguyen-Huynh, MD, MAS, vascular neurologist and research scientist with
the Kaiser Permanente Division of Research. "Faster treatment with
intravenous r-tPA, which dissolves the stroke-causing clot and restores
blood flow to the brain, is strongly associated with better functional
outcomes for stroke patients."
Intravenous r-tPA, also known as alteplase, is the only medication
approved by the Food and Drug Administration to treat acute ischemic
stroke.
American Heart Association and American Stroke Association guidelines
recommend "door-to-needle" times of 60 minutes or less for intravenous
r-tPA. Studies show that less than 30 percent of acute ischemic patients
in the United States are currently being treated within this window.
The new study in Stroke shows that across Kaiser Permanente's 21
Northern California hospitals, 87 percent of stroke patients were
treated in 60 minutes or less, 73 percent in 45 minutes or less, 41
percent in under 30 minutes, and the average treatment time for
intravenous r-tPA was 34 minutes.
With the Stroke EXPRESS program (EXpediting the PRocess of Evaluating
and Stopping Stroke), all Kaiser Permanente emergency departments in
Northern California were equipped with telestroke carts, which include a
video camera and access to scans and tests results, enabling the stroke
specialist to conduct a patient's neurologic physical exam even when
they are many miles away.
Telemedicine was integrated into a complete reorganization of how
acute strokes are managed in Northern California, said co-author Jeffrey
Klingman, MD, chair of chiefs of neurology for Kaiser Permanente
Northern California.
"Processes that used to happen sequentially during a stroke alert,
one after another, are now happening at the same time, allowing us to
quickly, safely and confidently provide evaluation and treatment with
intravenous r-tPA to stroke patients who can benefit," he added.
Each member of the stroke team is responsible for executing tasks
in tandem, meticulously and quickly. Paramedics provide advance
notification to the emergency department that a stroke patient is on the
way. A "stroke alert" notifies a stroke neurologist, who meets the
patient upon arrival, in person or via video, to coordinate the stroke
alert. Pharmacists prepare clot-busting medication early so it is ready
to be administered once a radiologist has read neuroimaging and
confirmed that the patient is not having a hemorrhagic stroke and is
thus a good candidate for intravenous r-tPA.
Stroke EXPRESS was rolled out in all Kaiser Permanente hospitals in
Northern California from September 2015 to January 2016. The researchers
compared Kaiser Permanente members treated with intravenous r-tPAin the
nine months before implementation (337 patients) with those treated in
the nine months afterward (557 patients).
All 21 Kaiser Permanente medical centers in Northern California and
15 additional hospitals across the Kaiser Permanente program have been
recognized by the American Heart Association/American Stroke Association
for the accomplishment in the Get With The Guidelines quality program.
Lazy bastards, the goal is negative time, in the ambulance, prior to reaching the hospital. Take the subjectivity and neurologist out of the equation. It can be done.
The
administration of intravenous (IV) alteplase to patients with stroke
via telestroke (TS) can be safe and effective. It remains unclear how
quickly IV alteplase occurs during TS evaluations. We sought to compare
door to needle times (DNTs) between patients receiving IV alteplase who
present directly to our comprehensive stroke center (CSC) and those
presenting to community hospitals in our TS network. Consecutive
patients with acute ischemic stroke (AIS) who presented to emergency
departments and received IV alteplase between August 2014 and June 2015
were identified at our CSC and TS network. Median DNTs with
interquartile ranges were calculated in each cohort. During the study
period, 117 patients with AIS (mean age 71 ± 15 years, 47% women)
receiving IV alteplase were included in the analysis (65 CSC and 52 TS).
Median DNT at our CSC was significantly shorter compared to TS sites
(CSC: 43 [35-55] minutes vs TS: 54 [41-71] minutes, P < .01).
The proportion of patients receiving IV alteplase ≤60 minutes of
presentation was significantly higher at our CSC compared to our TS
network (CSC 84.6% vs TS 63.5%, P = .02). Differences in favorable discharge to home were not significant (CSC 60% vs TS 46%, P
= .14). Guideline-recommended DNTs ≤60 minutes can be achieved in
community hospitals with TS guidance. Initiatives are required to better
resemble DNTs found at stroke centers.
A telemedicine-enabled mobile stroke ambulance with a CT scanner
helped patients receive thrombolysis faster than with a traditional
ambulance, according to findings published in Neurology.
“Each link in the prehospital stroke rescue chain matters, and mobile
stroke units appear to have the greatest potential in accelerating the
process to IV thrombolysis and delivery to definitive care,” Muhammad S. Hussain, MD, of the cerebrovascular center at the Cleveland Clinic, and colleagues wrote.
Researchers analyzed data from the first 100 patients (median age, 62
years; 54% women) who were transported to the hospital by the telemedicine-enabled stroke ambulance
in Cleveland from 8 a.m. to 8 p.m., the time when most stroke
dispatches occur, July 18 to Nov. 1, 2014. The data were compared with a
control group (n = 53; median age, 63 years; 30% women) with patients
who had a stroke alert and were transported to Cleveland Clinic by
emergency medical services in 2014 during the same time frame.
Both the mobile stroke ambulance and an EMS squad were called to all
potential stroke calls. Once it was determined that the patient was
experiencing a stroke, the patient then received care from the
telemedicine-enabled mobile stroke ambulance. Features of mobile unit
A registered nurse, CT technologist, emergency medical technician and
paramedic were on board the ambulance while a vascular neurologist and
neuroradiologist received images, video and lab results at the hospital
over the network. The vascular neurologist instructed the team aboard
the ambulance while they transported the patient to the hospital.
In patients treated by the telemedicine-enabled mobile stroke
ambulance, the median NIH Stroke Scale score was 6 (interquartile range
[IQR], 2-12) vs. 7 in the control group (IQR, 3-12; P = .679).
Of the 100 patients who were transported to the hospital by the mobile
stroke ambulance, 33 were diagnosed with probable acute ischemic stroke, 30 patients had possible acute ischemic stroke and four patients experienced transient ischemic attack.
From dispatch call time, the telemedicine-enabled mobile stroke
ambulance took an average of 12 minutes (IQR, 8-14) to arrive to its
location and 20 minutes from the call time to when the patient entered
the mobile stroke ambulance’s door. The median time a patient was under
the care of the mobile stroke ambulance was 86 minutes (IQR, 78-94).
CT scans were completed in the mobile stroke ambulance in 33 minutes
on average from the time of alarm (IQR, 29-41) and read in 44 minutes
(IQR, 39-52). These times were significantly shorter compared with the
control group. The median time was shorter by 23 minutes for CT
completion (P < .0001), and shorter by 20 minutes for a CT reading (P < .0001). Thrombolysis administration
Sixteen of the patients treated in the telemedicine-enabled mobile stroke ambulance were given thrombolysis,
which made up 48% of the patients diagnosed with probable stroke. The
treatment was administered to patients in the mobile stroke ambulance
38.5 minutes sooner after the alarm (median, 55.5 minutes; IQR, 24-47)
than the control group (median, 94 minutes; IQR, 78-104; P <
.0001). From symptom onset, patients treated in the mobile stroke
ambulance were administered thrombolysis 25.5 minutes sooner (median, 97
minutes; IQR, 61-144) than the control group (median, 122.5 minutes;
IQR, 110-176; P = .0485).
One-quarter of patients received thrombolysis within an hour of
symptom onset, whereas no patients in the control group received it
within that time frame.
“The sooner someone is treated for stroke, the better chance they have
for survival and an improved recover,” Hussain said in a press release.
“Telemedicine makes it possible for a neurologist to see a stroke
patient, and possibly treat them, before they even arrive at the
hospital.”
In a related editorial, Andrew M. Southerland, MD, MSc, assistant professor of neurology at the University of Virginia Heath System, and Ethan S. Brandler, MD, MPH,
of the department of emergency medicine at SUNY Stony Brook Medicine,
New York, wrote, “In the meantime, ongoing efforts are needed to
streamline [mobile stroke unit] cost and efficiency before achieving
road-readiness for widespread health system development.” – by Darlene Dobkowski Disclosure:The researchers and Southerland report no relevant
financial disclosures. Brandler reports receiving research support from
Janssen Research and Development.
Not good enough. I know that negative time is possible. Leaders would settle for nothing less than negative time, in the ambulance.
These
people are only thinking of what is currently capable rather than what
the best solution is and figure out a way to get there. They are stuck
in the past just like your doctor who hasn't read a single research
article since medical school. You don't want these people anywhere near
you.
This article is a collaboration between MedPage Today® and:
Action Points
Note that this
observational study suggested found that patients in Cleveland treated
by a mobile stroke unit had shorter time-to-tPA infusion than those
transported in traditional ambulances.
It remains unclear whether functional outcomes will be improved in this group, and how cost effective the intervention may be.
Suspected stroke patients transported
to Cleveland hospitals in the nation's first telemedicine-enabled
mobile stroke unit were evaluated and treated nearly twice as fast as
those transported in regular ambulances, researchers reported.
Among patients receiving intravenous tissue plasminogen activator
(tPA), the time to treatment for those transported in the
telemedicine-enabled mobile unit was, on average, 40 minutes shorter.
One-in-four
patients receiving tPA were treated within the golden hour of symptom
onset, according to Cleveland Clinic neurologist and study researcher Muhammad S. Hussain, MD.
The study, which compared evaluation and treatment times among the
first 100 patients transported in the Cleveland Clinic mobile stroke
treatment unit (MSTU) to 53 patients brought to hospitals in traditional
ambulances, was published March 8 in the journal Neurology.
Significant patient characteristics and stroke severity were similar between the two groups.
Transportation in the telemedicine-enhanced MSTU was associated with significant reductions in:
median alarm-to CT scan completion times (33 minutes versus 56 minutes, P<0 .0001="" li="">
median alarm-to-thrombolysis times (55.5 minutes versus 94 minutes, P<0 .0001="" li="">
median door-to-thrombolysis times (31.5 minutes versus 58 minutes, P=o.oo12),
and symptom onset-to-thrombolysis times (97 minutes versus 1.22.5 minutes, P=0.0485).
In an interview, Hussain told MedPage Today that the only
other mobile stroke units in use when the Cleveland Clinic MSTU went
into operation in July of 2014 were in Houston, Texas, and Germany, but
those had neurologists on board the mobile stroke units.
The
Cleveland MSTU has a nurse, a paramedic, an EMT, and a CT technician
on-board connected to a hospital-based vascular neurologist via
telemedicine. A neuroradiologist and vascular neurologist also remotely
assess images sent from the mobile stroke unit.
Mobile stroke units are now operating in Memphis, Denver, New York
City, and Toledo, Ohio, Hussain said, adding that some have physicians
on board and others are following the telemedicine model.
"We have shown that we can effectively provide the physician input
via video conferencing technology," he said, adding that the model
should prove to be significantly less costly than having a neurologist
on board.
Among the first 100 patients transported in the Cleveland Clinic MSTU
between mid-July and the end of October, 2014, tPA was administered to
16. In a subgroup of patients with probable stroke, the rate of IV tPA
administration was 48% (16/33).
More than half (57%) of patients entered the MSTU within four hours of symptom onset.
"Any
ischemic stroke patient entering the mobile stroke treatment unit at
the four-hour mark could potentially receive thrombolysis as our median
door-to-needle time was 31.5 minutes, the fastest one being 13 minutes,"
the researchers wrote. "Conversely, these patients would almost
certainly miss the thrombolysis window if they entered the door of a
traditional ambulance at four hours from symptom onset."
In an editorial published with the study, Andrew M. Southerland, MD, of the University of Virginia Health System, Charlottesville, and Ethan S. Brandler, MD,
of New York's SUNY Stony Brook Medicine, wrote that despite the early
promise of mobile stroke units in stroke care, cost-effectiveness
remains a concern.
They noted that in the Cleveland Clinic experience, the MSTU was
deployed 317 times to attain 16 tPA treatment cases classified as
probable stroke, with just four treatments within the initial hour after
symptom onset.
"These included 217 cancellations prior to arrival on site (68% of
deployments)," they wrote. "By comparison, in the Prehospital Acute
Neurological Stroke [PHANTOM-S] trial in Berlin, Germany, the mobile
stroke unit was deployed 2,027 times to achieve 200 tPA treatments, with
349 cancellations prior to arrival (17%)."
The editorial writers noted that this discrepancy may be due to
differences in protocol and emergency medical services between the
United States and Europe.
They wrote that thus far, the only published analysis of mobile stroke units examining functional outcomes, published in Lancet Neurology in September of 2016,
failed to show significance in the primary measure of the proportion of
patients with no disability at 3 months compared to conventional
medical transport.
Secondary analyses, however, were promising, "and suggested decreased
mortality and an increase in the proportion of patients who were able
to ambulate independently at three months."
"Hope remains that future trials may demonstrate the ultimate
potential of mobile stroke units to improve long-term outcomes for more
patients, by treating them more quickly and more effectively. In the
meantime, ongoing efforts are needed to streamline medical stroke unit
cost and efficiency before achieving road-readiness for widespread
health system deployment," Southerland and Brandler wrote.
Funding for this research was provided by Cleveland Clinic and the Milton and Tamar Maltz Family Foundation.
The researchers declared no relevant relationships with industry related to this study.
Reviewed by
F. Perry Wilson, MD, MSCE
Assistant Professor, Section of Nephrology, Yale School of Medicine
and Dorothy Caputo, MA, BSN, RN,
Nurse Planner
