Establishing the First Mobile Stroke Unit in the United States

Abstract

Background and Purpose-Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States. Methods-Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol. Results-The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun. Conclusion-The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described.

Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management

“…8,9 The process and logistics of establishing the first MSU in the United States in Houston, TX, and initiating the Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study compared with standard management by emergency medical services (EMS) study have been published previously. 10 Herein, we describe the results of the prespecified, nonrandomized run-in phase of the study and summarize the initial lessons learned during this implementation phase. Given that ours was the first MSU to be established in the United States, we had no experience using such a paradigm of delivering stroke care.…”

Application of emerging technologies to improve access to ischemic stroke care

“…For example, the University of Texas (Houston) is prospectively collecting long-term AIS and intracerebral hemorrhage patient outcome data to refine their use of an MSTU and optimize treatments. 34 Furthermore, the advent of CT angiography-capable MSTUs in the US may ultimately streamline stroke care of patients with large vessel occlusion by bypassing hospitals and even stroke centers that lack endovascular capability. 36 However, the capital investment required to implement and staff a full-time MSTU may prove prohibitive for many centers.…”

“…36 However, the capital investment required to implement and staff a full-time MSTU may prove prohibitive for many centers. 34 Demonstration of improved patient outcomes and cost-effectiveness versus traditional prehospital stroke care are a prerequisite to widespread adoption of the MSTU model. Continued data from initial experiences with MSTUs and randomized trials of MSTU deployment versus traditional prehospital stroke care will help delineate the role of MSTUs and shape the landscape for prehospital stroke treatment in the coming years.…”

In-Transit Telemedicine Speeds Ischemic Stroke Treatment

“…Because improved in-hospital processes have reduced door-to-needle (DTN) time, 4 focus has shifted to prehospital time. [5][6][7][8] Emergency medical services' (EMS) identification of likely strokes helps, 9,10 and in-ambulance teleneurology has been considered but not tested clinically. 11,12 Mobile stroke transport units (MSTUs), computed tomographic scanner-equipped ambulances with a neurologist, either in person or by telemedicine, 8 to assess thrombolytic appropriateness and oversee treatment, in the prehospital setting, decrease treatment time 25 minutes.…”

“…Consequently, centers use a single MSTU with limited access hours; several operate alternate weeks. 5,6 Time to treatment can be reduced by performing assessments either before (MSTU) or during patient transport. Time saved must be balanced against additional time needed for specialized units to reach patients; for this reason, the Berlin group chose a 16-minute radius from the MSTU's base.…”