A generous four-year grant from The Grainger Foundation in Lake Forest, Illinois, will fund the creation and deployment of the mobile stroke unit. This enhanced ambulance will contain telemedicine technology and a CT scanner enabling the brain imaging that is critical to accurate stroke diagnoses and treatment.
"We're talking about having the ability to check patients in their own driveways for bleeding in the brain or blockage in their blood vessels," says Demetrius Lopes, MD, surgical director of the Rush Comprehensive Stroke Center. "This ability is crucial, since stroke treatment decisions depend on CT scan imaging of the brain"
The mobile stroke team will respond to 911 calls reporting symptoms indicating stroke and can perform CT scans of patients promptly upon arrival. Rush radiologists will receive and analyze transmissions of these detailed brain images from the unit to determine which type of stroke the patient has experienced. Rush stroke neurologists will evaluate the patients remotely and decide what kind of treatment is indicated.
The emergency medical technician and critical care registered nurse staffing the mobile unit will administer the appropriate stroke medication after conferring with the stroke neurologist and then transport the patient to the most appropriate stroke center. The goal is to provide optimal treatment to stroke victims within the first "golden hour" after symptom onset, when it will do the most good.
"We've been trying to cut down the 'door to needle times'" - the time it takes a patient to be treated in the emergency room - as much as possible, explains James Conners, MD, medical director of the Rush Comprehensive Stroke Center. The performance of other mobile stroke units in the United States has shown that the time from onset of symptoms to treatment can be shortened in half, with the average patient being treated within 30 minutes.
Treating stroke patients in the field, within the hour
The Rush TeleStroke Network, established in 2011, makes Rush stroke specialists available around the clock for two-way consultations with physicians at community hospitals. The largest and most extensive telestroke network in the Chicago region, it has served more than 2,800 patients.
The inclusion of telemedicine technology on board the new mobile unit will allow Rush stroke specialists not only to analyze CT scans but also to interview patients from afar, and to prescribe the appropriate treatment on the spot. "The stroke team will be seeing the patient, making decisions, and treating them in the field. It's really advancing acute stroke care," Conners says.
The mobile stroke unit will be based at near west suburban Rush Oak Park Hospital. Within 15 minutes driving time from Rush Oak Park Hospital are 330,000 suburban residents, 883 of whom actually experienced strokes during 2015.
Few stroke patients currently receive clot-busting drug
A stroke occurs when blood flow to the brain stops, causing brain cells to stop receiving oxygen. Stroke is the number one cause of disability and the fifth leading cause of death in the United States. On average, someone has a stroke every 40 seconds.
About 87 percent of all strokes are ischemic - that is, strokes that are caused by a clot that blocks a blood vessel carrying blood to the brain, cutting off the brain's supply of oxygenating blood and causing brain tissue to die. The standard treatment of such strokes is a drug called tissue plasminogen activator, or tPA, which can dissolve clots and restore blood flow in the brain.
The "clot-buster" drug can restore blood flow, preventing death and minimizing disability. Studies have shown, however, that tPA works best if administered within 90 minutes of the stroke occurrence and that it doesn't do much good after several hours. At that point, after "the damage is done," the drug is simply not used, Conners says.
Because of this narrow treatment window - combined with various delays in stroke patients receiving care - only a small number of patients in this country who have ischemic strokes, no more than about 5 percent, are ever even treated with tPA.
"We know patients are up to four times more likely to have a good outcome if they are treated with tPA. Also, the sooner we treat patients, the more likely it is they will have minimal or even no disability," Conners says. "It's been so rare to treat to people within the first hour after onset, we don't even know what kind of results we could get if it becomes the standard of care."
Getting patients to the right places for the right care
In addition, tPA alone may not be sufficient treatment even when provided in time. "When someone has a bad stroke that is a large vessel occlusion (blockage) that doesn't respond to tPA, it's crucial that the patient be taken immediately to a comprehensive stroke center like Rush," Lopes says.
Neurosurgeons at these centers can perform an advanced, minimally invasive procedure called thrombectomy to remove the blockage causing the stroke. Lopes and colleagues at Rush were part of an international study that found that removal of the clot causing a severe stroke, in combination with tPA, improves the restoration of blood flow to the brain and may result in better long-term outcomes.
Only comprehensive stroke centers offer this procedure, and Rush is one of only six such centers in the Chicago area certified by the Joint Commission (the leading health care accrediting organization). "If you're not assessing patients in the field, you're missing an opportunity," Lopes says. "If patients who need thrombectomy aren't taken directly to a comprehensive center, it will cause significant delays in their receiving the care they need.
"The CT in the mobile stroke unit will allow us not only to obtain brain but also blood vessel pictures," Lopes continues. "This information is essential to determine the level of care the patient needs."
Stopping the bleeding
The mobile stroke unit also will enhance treatment for patients who suffer from a hemorrhagic stroke, which occurs when a blood vessel in the brain leaks or bursts. Those patients can't receive tPA, which could be fatal to them, and need a different type of medication to stop their bleeding.
"With the CT scan, the mobile stroke team can separate the bleeding strokes in the brain from the blockage strokes," Lopes says. "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 life-saving if you're able to get to the hospital and get the patient right into surgery and alleviate the pressure on the brain."
The hope is that the new program will capture 75 percent of strokes in the service area in time to deliver optimal treatment for all stroke patients. The unit initially will operate from 8 a.m. to 6 p.m. Studies have shown that stroke is most common in the morning, and that most strokes that occur in the middle of the night do not wake the patients.
A second aspect of the Rush program is community outreach and education in the region. It's important for people to be able to recognize stroke symptoms if they see them in friends, loved ones or themselves, and to understand the importance of calling a 911 dispatcher immediately, according to Conners. A third "prong" of the new program will be establishing partnerships with other hospitals and local municipalities in the service area.
Reducing the number of people who suffer the devastating effects of stroke would not only be a major health boon to individuals and the community, but it also would save a great deal of money. The estimated lifetime cost of a stroke for an individual presently is $200,000. The average annual cost of caregiving for a stroke victim is $11,300. Because of the aging population of the United States, the total cost of stroke under the present system of care has been projected to rise from $71.6 billion in 2010 to $183.1 billion in 2030.
The Grainger Foundation, an independent private foundation based in Lake Forest, Illinois, provides support to a broad range of organizations, including educational, medical, cultural and human services institutions. It was established in 1949 by William W. Grainger, founder of W.W. Grainger, Inc.
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