Keep an eye out for a new ambulance on the streets of suburban Chicago: Rush University Medical Center’s mobile stroke unit (MSU) came into service on November 6, 2017. This unit is just the second of its kind in Illinois and the eighth in the United States. Neighboring the third-largest city in the U.S., the MSU provides considerable advances in stroke care.
The ambulance will be stationed at Rush Oak Park Hospital and operate within a five-mile radius. Rush University Medical Center partnered with Superior Ambulance Service Inc. to make the MSU accessible to people of the nearby suburbs.
“Receiving the correct treatment for stroke quickly can mean the difference between life and death or disability,” says James Conners, MD, medical director for the Rush comprehensive stroke program as well as the MSU, “but in most cases treatment must be provided to patients shortly after a stroke to be effective.”1 The goal is to treat these patients more quickly and improve the likelihood they will have a positive outcome after their stroke.
The Rush mobile stroke unit will be one of the few mobile stroke units that can also treat for hemorrhagic strokes. For these the MSU will carry Kcentra and Vitamin K for patients taking medications such as warfarin. The Rush unit will also carry Praxbind for patients taking the blood thinner Pradaxa. A prehospital nurse will be able to help control the blood pressure of patients by having nicardipine and labetalol available for use. If the stroke is found to be a significant hemorrhage, an overseeing physician, via a telemedicine system, can order the PRHN to administer mannitol.
Features of the MSU
The MSU was made possible by a grant from the Grainger Foundation, which provided the funding for a four-year program. Built by Excellance, the MSU sits on a Freightliner M2 chassis that has a built-in CT scanner. Having the CT scanner in the ambulance to help diagnose strokes has been compared to having cardiac monitors in the ambulance to help diagnose heart attacks. This is a new generation of ambulance that can cut treatment times in half. “Presently patients cannot be treated for their stroke until they get to an emergency department,” says Conners. “This new mobile stroke treatment unit will bring immediate stroke diagnosis and treatment to patients at their homes or wherever they’re in need, which will improve their chances of a good recovery.”1
The MSU, staffed by a prehospital registered nurse (PHRN), expanded-scope paramedic, CT technologist, and emergency medical technician, will operate from 7 a.m. to 7 p.m. seven days a week. The nurse and CT tech are provided by Rush, while Superior provides the paramedic and EMT. In addition to having the CT scanner, the PHRN will be able to perform point-of-care labs via an i-STAT analyzer. The MSU will also be equipped with an InTouch telemedicine system that will allow staff on the ambulance to communicate with the on-call neurologist at Rush University Medical Center.
CT scans will be sent electronically to the neurologist to review and diagnose. The physician will be able to see and talk to the patient via the telemedicine system and perform their own evaluation. Once scans are reviewed, the doctor will indicate the order sets needed to begin treatment. If an ischemic stroke is present, the PHRN can administer tPA. “With the CT scan,” says Demetrius Lopes, MD, surgical director of the Rush comprehensive stroke center, “the mobile stroke team can separate the bleeding strokes in the brain from the blockage strokes. If it’s a bleeding stroke, we can initiate measures in the field to control blood pressure, optimize patient coagulation, and alert the surgical team in the hospital to get ready. It can be lifesaving if you’re able to get to the hospital and get the patient right into surgery and alleviate the pressure on the brain.”1
One of the biggest factors that makes mobile stroke units the future of medicine is the amount of time they can save between the onset of symptoms and the time of treatment. Results from programs around the world have shown significant improvements in needle times. Within the radius of the Rush mobile stroke unit lie a multitude of primary stroke centers but limited comprehensive stroke centers. If the patient diagnosis necessitates treatment at a comprehensive center but the patient is taken to the closest primary stroke center first, this greatly increases the time it takes for definitive treatment.
Rather than transferring from a primary stroke center emergency department to a comprehensive stroke center, patients will be directly triaged by the team on the MSU to a comprehensive stroke center if appropriate. This in-field change has the potential to decrease treatment times by 1–2 hours, greatly improving the patient’s chances of recovery. Other mobile stroke units around the United States have shown, on average, 30 minutes from the time of onset to the time of treatment in the MSU.
The MSU will be dispatched to calls based on information received by 9-1-1. It will be sent with local EMS if the call goes out as a stroke. If the initial responding EMS unit determines the patient hasn’t had a stroke, they can cancel the MSU en route. EMS units at calls that weren’t originally dispatched as strokes can also request the MSU if they find their patient meets stroke criteria.
The Broadview Fire Department was the first department to sign on to use the Rush mobile stroke unit. “This is an exciting advance in healthcare that provides our residents with definitive, immediate care in the 9-1-1 setting,” Broadview Fire Chief Tracy Kenny says. “Our paramedics are trained to the highest level and are able to see the need for the mobile stroke unit’s intervention when a patient is experiencing signs of a stroke. Our ability to get initial information, [obtain] vitals, and do the much-needed ALS interventions prior to their arrival prepares the patient for advanced technology that comes to the scene, increasing the chances of survival and/or recovery.”1
Stroke education and community outreach are other main aspects of this program. When the MSU team isn’t busy treating stroke patients, members will be out in the community educating people on the signs and symptoms of stroke and when to call 9-1-1. The team has provided education to assisted-living facilities, local churches, and community centers, as well as participated in health fairs to teach stroke prevention and recognition.
The MSU works closely with all local emergency departments. When patients are determined to not need a comprehensive stroke center, they will be transported to primary stroke centers throughout the community. MSU staffers have visited the different emergency departments within the service area to educate their personnel on the MSU and its operations. Mock patients and calls have been set up for training with all involved. Creating the working partnerships and relationships with EMS and area healthcare organizations is critical to increasing knowledge of the MSU’s abilities, allowing the team to reach as many potential patients as possible.
This type of program has obvious benefits for rural areas. We are bringing it into an urban setting in hopes of demonstrating it will also make a difference there. While being in a city presents different challenges, we believe the number of strokes in a city landscape will further prove the MSU’s value. The goal of the mobile stroke unit is to show that even in a setting with rapid local EMS responses, we can improve the care of patients by beginning treatment more quickly and transporting them to a hospital that can deliver care without the potential delays built into current systems.
Expanding the Reach
This MSU at Rush Oak Park Hospital is only the beginning of a long-term plan to vastly improve stroke care. As the program develops, Rush envisions the potential for an entire fleet of mobile stroke units. The first step of this plan will be gathering data on times to treatment and patient outcomes and then sharing it with the international stroke community.
The ultimate goal is to show the benefits of these programs, which can demonstrate the need to expand their services with more units and hours of operation. In a perfect world, one of these ambulances available in every neighborhood would be the norm for emergency stroke care.