Hostname: page-component-8448b6f56d-c4f8m Total loading time: 0 Render date: 2024-04-23T12:02:11.678Z Has data issue: false hasContentIssue false
  • English
  • Français

A Comparison of Time to Treatment between an Emergency Department Focused Stroke Protocol and Mobile Stroke Units

Published online by Cambridge University Press:  11 May 2021

Debbie Y. Madhok Open the ORCID record for Debbie Y. Madhok [Opens in a new window] ,
Paul H. Mangasarian ,
Kevin J. Keenan ,
J. Claude Hemphill III ,
John F. Brown  and
Anthony S. Kim
Debbie Y. Madhok*
Affiliation:
Department of Emergency Medicine, University of California San Francisco, San Francisco, CaliforniaUSA Department of Neurology, University of California San Francisco, San Francisco, CaliforniaUSA
Paul H. Mangasarian
Affiliation:
School of Medicine, University of California Davis, Sacramento, CaliforniaUSA
Kevin J. Keenan
Affiliation:
Department of Neurology, University of California Davis, Sacramento, CaliforniaUSA
J. Claude Hemphill III
Affiliation:
Department of Neurology, University of California San Francisco, San Francisco, CaliforniaUSA
John F. Brown
Affiliation:
Department of Emergency Medicine, University of California San Francisco, San Francisco, CaliforniaUSA
Anthony S. Kim
Affiliation:
Department of Neurology, University of California San Francisco, San Francisco, CaliforniaUSA
*
Correspondence: Debbie Y. Madhok, MD Department of Emergency Medicine and Neurology University of California, San Francisco 1001 Potrero Ave, Suite 6A San Francisco, California94110USA E-mail: Debbie.Madhok@ucsf.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

San Francisco (California USA) is a relatively compact city with a population of 884,000 and nine stroke centers within a 47 square mile area. Emergency Medical Services (EMS) transport distances and times are short and there are currently no Mobile Stroke Units (MSUs).

Methods:

This study evaluated EMS activation to computed tomography (CT [EMS-CT]) and EMS activation to thrombolysis (EMS-TPA) times for acute stroke in the first two years after implementation of an emergency department (ED) focused, direct EMS-to-CT protocol entitled “Mission Protocol” (MP) at a safety net hospital in San Francisco and compared performance to published reports from MSUs. The EMS times were abstracted from ambulance records. Geometric means were calculated for MP data and pooled means were similarly calculated from published MSU data.

Results:

From July 2017 through June 2019, a total of 423 patients with suspected stroke were evaluated under the MP, and 166 of these patients were either ultimately diagnosed with ischemic stroke or were treated as a stroke but later diagnosed as a stroke mimic. The EMS and treatment time data were available for 134 of these patients with 61 patients (45.5%) receiving thrombolysis, with mean EMS-CT and EMS-TPA times of 41 minutes (95% CI, 39-43) and 63 minutes (95% CI, 57-70), respectively. The pooled estimates for MSUs suggested a mean EMS-CT time of 35 minutes (95% CI, 27-45) and a mean EMS-TPA time of 48 minutes (95% CI, 39-60). The MSUs achieved faster EMS-CT and EMS-TPA times (P <.0001 for each).

Conclusions:

In a moderate-sized, urban setting with high population density, MP was able to achieve EMS activation to treatment times for stroke thrombolysis that were approximately 15 minutes slower than the published performance of MSUs.

Keywords

Emergency Medical Servicesischemic strokemobile stroke unitstroke
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 36 , Issue 4 , August 2021 , pp. 426 - 430
Check for updates
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Benjamin, EJ, Virani, SS, Callaway, CW, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492.CrossRefGoogle ScholarPubMed
Heron, M. Deaths: leading causes for 2014. Natl Vital Stat Rep. 2016;65(5):1–96.Google ScholarPubMed
Saver, JL, Fonarow, GC, Smith, EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309(23):2480–2488.CrossRefGoogle ScholarPubMed
Adams, HP Jr, del Zoppo, G, Alberts, MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(5):1655–1711.CrossRefGoogle ScholarPubMed
Kang, DW, Chalela, JA, Dunn, W, Warach, S; NIH-Suburban Stroke Center Investigators. MRI screening before standard tissue plasminogen activator therapy is feasible and safe. Stroke. 2005;36(9):1939–1943.CrossRefGoogle ScholarPubMed
Kidwell, CS, Chalela, JA, Saver, JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823–1830.CrossRefGoogle ScholarPubMed
Adams, HP Jr, Brott, TG, Furlan, AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the stroke council, American Heart Association. Circulation. 1996;94(5):1167–1174.CrossRefGoogle ScholarPubMed
Kwiatkowski, TG, Libman, RB, Frankel, M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator stroke study group. N Engl J Med. 1999;340(23):1781–1787.CrossRefGoogle ScholarPubMed
Hacke, W, Kaste, M, Bluhmki, E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–1329.CrossRefGoogle ScholarPubMed
Clark, WM, Wissman, S, Albers, GW, Jhamandas, JH, Madden, KP, Hamilton, S. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS study: a randomized controlled trial. Alteplase thrombolysis for acute noninterventional therapy in ischemic stroke. JAMA. 1999;282(21):2019–2026.CrossRefGoogle ScholarPubMed
Powers, WJ, Derdeyn, CP, Biller, J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–3035.CrossRefGoogle ScholarPubMed
Tilley, BC, Lyden, PD, Brott, TG, Lu, M, Levine, SR, Welch, KM. Total quality improvement method for reduction of delays between emergency department admission and treatment of acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA stroke study group. Arch Neurol. 1997;54(12):1466–1474.CrossRefGoogle ScholarPubMed
Fonarow, GC, Zhao, X, Smith, EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632–1640.CrossRefGoogle ScholarPubMed
Schwamm, LH, Fonarow, GC, Reeves, MJ, et al. Get with the guidelines-stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119(1):107–115.CrossRefGoogle ScholarPubMed
Walter, S, Kostpopoulos, P, Haass, A, et al. Bringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS ONE. 2010;5(10):e13758.CrossRefGoogle Scholar
Parker, SA, Bowry, R, Wu, TC, et al. Establishing the first mobile stroke unit in the United States. Stroke. 2015;46(5):1384–1391.CrossRefGoogle ScholarPubMed
Calderon, VJ, Kasturiarachi, BM, Lin, E, Bansal, V, Zaidat, OO. Review of the Mobile Stroke Unit experience worldwide. Interv Neurol. 2018;7(6):347–358.CrossRefGoogle ScholarPubMed
Ebinger, M, Winter, B, Wendt, M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. 2014;311(16):1622–1631.CrossRefGoogle ScholarPubMed
Ebinger, M, Kunz, A, Wendt, M, et al. Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy. JAMA Neurol. 2015;72(1):25–30.CrossRefGoogle ScholarPubMed
Bowry, R, Parker, S, Rajan, SS, et al. Benefits of stroke treatment using a Mobile Stroke Unit compared with standard management: the BEST-MSU study run-in phase. Stroke. 2015;46(12):3370–3374.CrossRefGoogle ScholarPubMed
Ehrlich, S. ZSFG FY1516 Annual Report. San Francisco (SF); San Francisco Department of Public Health 2016. https://www.sfdph.org/dph/hc/HCAgen/HCAgen2016/Nov%2015/01a%20ZSFG%20FY1516%20Annual%20Report_20161103.pdf. Accessed October 1, 2018.Google Scholar
Walter, S, Kostopoulos, P, Haass, A, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomized controlled trial (published correction appears in Lancet Neurol. 2012;11(6):483). Lancet Neurol. 2012;11(5):397-404.CrossRefGoogle Scholar
Cerejo, R, John, S, Buletko, AB, et al. A mobile stroke treatment unit for field triage of patients for intraarterial revascularization therapy. J Neuroimaging. 2015;25(6):940–945.CrossRefGoogle ScholarPubMed
Weber, JE, Ebinger, M, Rozanski, M, et al. Prehospital thrombolysis in acute stroke: results of the PHANTOM-S pilot study. Neurology. 2013;80(2):163–168.CrossRefGoogle ScholarPubMed
Wendt, M, Ebinger, M, Kunz, A, et al. Improved prehospital triage of patients with stroke in a specialized stroke ambulance: results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke. 2015;46(3):740–745.CrossRefGoogle Scholar
Wu, TC, Nguyen, C, Ankrom, C, et al. Prehospital utility of rapid stroke evaluation using in-ambulance telemedicine: a pilot feasibility study. Stroke. 2014;45(8):2342–2347.CrossRefGoogle ScholarPubMed
Rasmussen, PA. Stroke management and the impact of mobile stroke treatment units. Cleve Clin J Med. 2015;82(12 Suppl 2):S17–S21.CrossRefGoogle ScholarPubMed
Itrat, A, Taqui, A, Cerejo, R, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: taking stroke treatment to the doorstep. JAMA Neurol. 2016;73(2):162–168.CrossRefGoogle ScholarPubMed
Taqui, A, Cerejo, R, Itrat, A, et al. Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis. Neurology. 2017;88(14):1305–1312.CrossRefGoogle ScholarPubMed
Lin, E, Calderon, V, Goins-Whitmore, J, Bansal, V, Zaidat, O. World’s first 24/7 Mobile Stroke Unit: initial 6-month experience at Mercy Health in Toledo, Ohio. Front Neurol. 2018;9:283.CrossRefGoogle ScholarPubMed
Madhok, DY, Keenan, KJ, Cole, SB, Martin, C, Hemphill JC 3rd. Prehospital and emergency department-focused mission protocol improves thrombolysis metrics for suspected acute stroke patients. J Stroke Cerebrovasc Dis. 2019;28(12):104423.CrossRefGoogle ScholarPubMed