A new, souped-up ambulance cruising Santa Monica could improve the odds of recovery for stroke patients.
The new mobile unit, a pilot program of UCLA Health, sports a CT scanner—a first for an ambulance in California—a mobile lab to test blood samples, stroke medications and a specialized medical staff including a critical care nurse, CT technician, paramedic and a neurologist.
“With the UCLA Health Mobile Stroke Unit, we are bringing the hospital to the patient instead of the patient to the hospital, in order to save as much brain as possible [after a stroke],” said Jeffrey Saver, neurologist and director of the UCLA Comprehensive Stroke Center.
Odds of a stroke rise with age with the risk, doubling every decade after age 55. And minorities, African-Americans in particular, are at higher risk than whites for earlier and more disabling strokes. In California 2.5 percent of adults over age 18 have had a stroke, a key reason why the LA County Board of Supervisors joined a private philanthropist to fund a thirty month trial of the mobile stroke unit. The $1.5 million from the county comes from revenue on a package tax.
Close to ninety percent of strokes in the U.S. are called ischemic strokes—the result of a blood clot that keeps blood from flowing to the brain and causing brain cells to die.
Many of those strokes can be effectively treated by administering a drug called tissue plasminogen activator (TPA) which breaks up the clot but must be given within about three hours of when symptoms started or the patient was last known to be okay. But a CT scan is needed to determine whether a stroke is ischemic or hemorrhagic—bleeding in the brain—and a neurologist must assess each patient to determine what treatment would be most effective. TPA poses a risk for hemorrhagic patients so other drugs must be used in those cases and TPA is not always the correct therapy for ischemic strokes. “By providing the right treatment, at the right time, to the right patient, we offer the greatest possibility of improved clinical recovery, and we think we can speed up the best treatment with the mobile stroke unit,” said May Nour, a neurologist at UCLA and the clinical director of the new program. Nour has been the neurologist on the UCLA stroke ambulance since the unit launched in mid-September.
The imperative for fast stroke treatment is actually work led by Saver of UCLA. A 2013 study published in JAMA by Saver and other researchers looked at files of close to 60,000 ischemic stroke patients treated at 1,395 hospitals in the U.S. between 2003 and 2012. The median age was 72 and the average amount of elapsed time from stroke to beginning treatment with TPA was two and a half hours. The researchers found that for every 15-minute faster interval of treatment, going home was 3 percent more likely, walking at the time of discharge was 4 percent more likely, having symptoms of hemorrhaging in the brain was 4 percent less likely to occur, and death was 4 percent less likely.
A small study published this year in Neurology compared about 100 stroke patients treated in the Cleveland Clinic’s mobile stroke unit with about 50 treated only at the hospital found that the mobile unit patients got TPA about 40 minutes faster. But an editorial in the same journal by Andrew Southerland, an assistant professor of neurology at the University of Virginia, said that given the cost of the mobile stroke units, the ambulances have to show that they can both reduce disability from stroke and be cost effective.
While many stroke experts, including those at UCLA, make the case that deploying mobile units to rural areas far from stroke treatment centers could reduce stroke disability and save money, Southerland said that one challenge to rural use of the units is that you’d need several to cover the full geographic area of a rural region to be sure that everyone had equal access and that may not prove to be cost effective, though he is hopeful about a recently launched national clinical trial—which includes UCLA—that will look at both cost effectiveness and recovery outcomes in part by evaluating patients treated on the mobile stroke units every three months to assess their level of disability.
And expanding the use of the units beyond just strokes may also help with cost effectiveness, said Southerland. Saver, who has a wish list of a fleet of four to seven mobile stroke ambulances for UCLA, hopes the hospital’s trial unit can be used beyond stroke to test, for example, speedy administration of new drugs developed for different kinds of strokes as well as to deploy the unit for other neurologic emergencies such as traumatic brain injuries for fast assessment and fast treatment.
For now the mobile stroke unit operates every other week—with the off week acting as a control to compare the time it takes to start TPA in the mobile unit and at the hospital. The mobile unit works in tandem with the Santa Monica fire/rescue department—and will work with other fire/rescue departments as the deployment is widened to other parts of Los Angeles County. Paramedics in the field radio the stroke unit—on weeks it’s operational—when a stroke is suspected. Santa Monica has a relatively low stroke rate—up to 100 per year, according to Saver, compared with 800 to 1,000 per year for Long Beach, one of the areas where the unit will operate during 2018.
Since its launch in mid-September, the unit has assessed and transported eight suspected stroke patients back to UCLA. Two patients had what are known as transient ischemic strokes, and the symptoms resolved on their own; six had had previous strokes and were not feeling well, but not having new strokes and didn’t need treatment. One patient, however, a woman in her 70s, felt a bit weak, did not have the classic stroke signs of a droopy mouth and slurred speech, but did have weakness in one arm. The paramedics called the mobile stroke unit which responded and did a CT scan which showed Nour that the patient had bleeding on the brain. The patient was immediately transported to UCLA where she had surgery that day and has since been released without suffering any adverse consequences of the bleeding. “The paramedic wasn’t sure the patient was having a stroke,” said Nour, “but since he knew he could call us he deferred to our unit which resulted in the patient’s very prompt treatment.”
Peter Panagos, professor of emergency medicine and neurology at Washington University in St. Louis, and vice chair of the American Stroke Association’s stroke council says he thinks the mobile units are valuable to the community even beyond the assessment and treatment they provide. “Just the marketing for a mobile stroke unit improves education about stroke symptoms” said Panagos. When community members see a mobile stroke unit driving around, or parked in a church or school parking lot, it generates questions and raises awareness of stroke and stroke prevention, even though you can’t quantify that return on investment.”
Beginning sometime next year the mobile stroke unit will run every week as it expands to other counties in Los Angeles and then will rely on a neurologist based at the hospital who reviews scans and patients through a video hookup—a less expensive option than having a neurologist on board. For now, insurance does not cover the unit’s care for a patient but Saver hopes that the national clinical trial will provide the data that will convince insurers to pay for assessment and treatment in a mobile stroke unit. Legislation is also pending in Congress that calls on Medicare and other insurers to cover stroke telemedicine, which could, if passed, be extended to cover assessment and care on mobile stroke units as well.
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