“Everything we’re doing in the Mobile Stroke Unit is an extension of the emergency department, except we’re out in the field,” says Ilana Spokoyny, M.D., a Mills-Peninsula Medical Center neurologist and the clinical and research director of the new Mobile Stroke Unit program.“The big difference is we’re able to get to patients sooner and treat them faster.”
The MSU team successfully treated their first stroke patient this past January. The family and neighbors of a local woman suspected she was having a stroke and called 911. When the team arrived, they used the CT scanner inside the specially equipped MSU ambulance to quickly take images of her brain to assess if she was suffering from a blood clot or bleeding in the brain.
Moments later, while en route to the emergency department, the MSU team determined the stroke was being caused by a blood clot and began administering the blood-clot-dissolving drug tPA (tissue plasminogen activator). As a result of this swift action, the patient left the hospital with no neurological deficits.
Dr. Spokoyny says many people have approached the MSU team to ask questions as the unit circulates throughout the community. “So just by being present we’re increasing public knowledge about stroke.”
“The MSU really is putting the power into the community, the family and the bystander to know what a stroke is and do something about it,” adds Jenny Im, R.N., MBA, director of the Neuroscience Service Line. “We can’t go out there unless they recognize the signs and call 911. That’s the missing piece.”
Time Is Brain
For stroke specialists like Dr. Spokoyny, time is of the essence. According to an article in the journal Stroke, when a patient experiences a typical large-vessel acute ischemic stroke, they lose 1.9 million neurons, 14 billion synapses and 7.5 miles of myelinated fibers every minute. Every hour a patient goes untreated, his or her brain ages 3.6 years, in terms of loss of neuron function.
That loss of brain function is why stroke is the leading cause of adult disability, leaving many stroke patients unable to walk, talk, eat or take care of themselves. When tPA is administered in a timely manner it can save brain cells from damage and reduce or even completely avoid disability. But patients must be evaluated by a neurologist and undergo a CT scan to confirm the diagnosis before they can receive the drug.The MSU saves precious moments because there is an on- board neurologist who can examine the patient immediately.
“And we’re able to perform the critical CT scan before we even leave the patient’s house,” says Dr. Spokoyny. “So we know exactly what we’re dealing with, whether it’s a blood clot, a brain bleed or something else. We start to treat the patient in the field and continue to treat them the whole ride over to the hospital.”
In a typical emergency department, such an evaluation and CT scan could take as long as an hour, Dr. Spokoyny explains. “But with the MSU, all of this diagnosis and treatment is happening before the patient even enters the hospital.”
A Clinical Trial on Wheels
The MSU is currently running as a clinical pilot program. A consortium of researchers from several medical centers, including Mills-Peninsula, are collecting data to determine if the time-to-treatment saved by the unit will help stroke patients have better outcomes, and if MSUs are cost-effective.
“We decided to have the MSU for clinical purposes, but we also felt it was important to contribute whatever practical knowledge could be gained,” says neurologist Nobl Barazangi, M.D., Ph.D., the co-medical director of the program. “So we decided to take part in the multicenter, national clinical trial.”
“It’s already been proven that the sooner a patient is treated, the better their outcome, especially with respect to tPA,” Dr. Barazangi says.Theoretically, there should also be reduced costs: upfront, because the person’s hospitalization is shorter, and later on, due to fewer disabilities. “So getting to patients faster and treating them faster makes complete sense,” she says.
The clinical trial involves recording current treatment data, then following up with MSU patients up to a year later.
Philanthropic Funding Makes the MSU a Reality
Two years ago, Joey English, M.D., Ph.D., a Sutter Health neurointerventionalist, met with James Grotta, M.D., a well- known neurologist at Memorial Hermann Medical Group in Houston, Texas, to learn more about mobile stroke units. Dr. Grotta launched the nation’s first MSU in 2014, and is director of the Mobile Stroke Unit Consortium.Dr. English then brought the concept to Janet Wagner, CEO of Mills-Peninsula. “We were so excited about it, we just kept bringing the idea up, keeping it in the forefront of conversations,” recalls Jenny Im, R.N., MBA, director of the Neuroscience Service Line. The MSU program was launched two years later, operating in partnership with the City of San Mateo and local emergency services, and funded 100 percent by Mills-Peninsula Hospital Foundation.
Six other academic medical centers across the country are also participating in the clinical trial; Mills-Peninsula is the only community hospital involved.
“We have partnered with Memorial Hermann, New York Presbyterian, UCLA, University of Tennessee, UCHealth in Colorado and Indiana University, who are all doing formal clinical trials like we are,” says Jenny. “Our goal is to publish the outcomes of our MSU pilot. We suspect the results will prove that an MSU is beneficial in the pre-hospital setting. This will allow us to obtain future funding to establish MSUs as a standard of care across the country.”
An Exciting Adjustment
Most neurologists work in hospital settings, not ambulances. So working out in the field in the MSU has been an interesting adjustment for the on-board stroke specialists. Another change has been working in conjunction with the ambulance and fire department staff who also respond to each call.
“The pre-hospital setting is the turf of paramedics and EMTs,” says Dr. Spokoyny. “We’re working in a much larger team. So to make this program successful we needed to recognize everyone’s expertise and find a good work flow.” Prior to the program launch, the three services ran extensive practice drills together.
So how does it feel to work in an emergency department on wheels? “It’s very exciting,” says Dr. Spokoyny. “I’m using my same knowledge and expertise in stroke care, but applying it in a different environment.“That’s why I feel so passionately about the MSU. It doesn’t up-end the type of care people get when they come to the hospital. It just shifts that care into the pre-hospital arena, saving precious time. I am confident that this program is going to be very successful and will help save many lives.”