• Studies in Innovation: Treating Stroke On-Scene

    Sidebar: Karen Wagner Apr 27, 2016

    Healthcare organizations around the country are working on new ways of delivering better-quality care more cost efficiently. At the crux of many of these innovative efforts is technology, as the following case study illustrates.

    For patients with ischemic stroke, which accounts for about 87 percent of all strokes, the faster treatment can be administered, the less likelihood of brain damage. That is the impetus behind Cleveland Clinic’s mobile stroke unit, which employs an ambulance outfitted with special equipment to bring high-quality stroke care directly to patients.

    The mobile unit, one of the first in the country, is part of the clinic’s telestroke program, which uses telemedicine to treat stroke victims at network hospitals in Northeast Ohio, Pennsylvania, and Florida. “We just treat the mobile stroke truck like another node on that telestroke network,” says Peter Rasmussen, MD, director, Cerebrovascular Center, Cleveland Clinic, and the initiator of the mobile stroke program. “So, the same stroke neurologist who answers our telestroke call is virtually present with the patients in the back of the mobile stroke unit.”

    Cleveland Clinic’s mobile stroke unit.

    Cleveland Clinic’s mobile stroke unit has been shown to produce substantial improvement in the speed with which some patients receive vital treatment for ischemic stroke. (Photo: Cleveland Clinic Center for Medical Art and Photography)

    Rasmussen says the program, started in June 2014 and similar to a program pioneered in Berlin, Germany, is 99 percent reliable. Patients are given a preliminary diagnosis and treatment begins at the scene. The ambulances, staffed by a paramedic, critical care nurse, and CT technologist, are supplied with portable CT scanners to detect the type of stroke; images are transmitted to neurologists at the clinic, and blood is tested using a mobile lab. If the patient is experiencing an ischemic stroke, the onboard medical team can administer intravenous tissue plasminogen activator (IVtPA) to attempt to break up the clot. The clinic’s neurologists also begin to assess the need for advanced therapies, enabling patients to be transported to the appropriate healthcare facility faster.

    In 2015, the truck was called out about 1,300 times; about 350 of the calls (about 27 percent) resulted in an actual transport of the patient. “We try to take calls for what would be the slightest concern for a stroke,” Rasmussen says.

    Of the patients who are transported, about 90 percent have a neurological disease and about 50 percent have stroke. Of patients diagnosed with stroke, about 40 percent receive IVtPA.

    “That’s one of the real success stories around the outcomes of the mobile stroke unit,” Rasmussen says. The average hospital, with a general neurologist covering the ED for stroke cases, will administer IVtPA in about 5 percent of cases, he says. For hospitals with telestroke units, that rate may increase to 12 to 15 percent. The significantly higher rate of IVtPA administration in the stroke truck is vital because the medication works best and quickens the recovery process when administered as close to the time of onset of stroke symptoms as possible. Every 15 minutes that is saved translates to a 5 percent increase in the share of patients discharged to home rather than to a skilled nursing facility or rehabilitation center.

    “We’re treating probably 10 times as many patients with tPA using the truck than if they come into one of our average emergency rooms,” Rasmussen says. “That translates directly into savings of healthcare dollars.”

    For example, he says the cost of care for a patient with ischemic stroke at Cleveland Clinic is about $12,000 for the first 90 days if the patient is discharged to home, $25,000 if the patient is discharged to a skilled nursing facility, and $36,000 if the discharge is to a rehabilitation facility. If a stroke patient’s chances of being discharged to home increase by 15 percent, costs for that episode of care can be reduced by anywhere from $13,000 to $24,000 per patient.

    In comparing a control group receiving IVtPA in a Cleveland Clinic ED to patients receiving IVtPA in the mobile unit, patients in the truck received the medication about 45 minutes faster than the control group, which Rasmussen says translates into 15 percent more patients discharged to home.

    Rasmussen says total cost savings for the health system are difficult to calculate precisely, but, “In my mind it’s probably saving anywhere between $500,000 and $1 million a year just in the population base that we’re coving in terms of direct hospital costs,” he says.

    Rasmussen says a mobile stroke unit is easily replicable, but such programs face challenges. One is complacency within the stroke care community that the existing system of care delivery for stroke is adequate.

    Rasmussen also says, “There’s this misperception that these programs are too expensive.” But the cost of the truck, minus the cost of the ambulance, is about $400,000—mainly for the CT scanner, he says. “If you think about the cost of long-term care of a stroke patient, you don’t have to save that many patients from long-term disability to recoup the cost of that CT scanner. It’s really very minimal.”

    “The other important thing about this program is that it’s really challenged conventional models of care delivery,” Rasmussen says, noting that in-hospital emergency care typically is prioritized over on-the-scene care. “If we’re really going to make improvements in quality of care and outcomes of patients, we have to stop thinking like that. We have to start thinking that what happens before the hospital is every bit as important as what happens when a patient gets to the hospital.”

    Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a member of HFMA’s First Illinois Chapter.

    Interviewed for this article: Peter Rasmussen, MD, director Cerebrovascular Center, Cleveland Clinic.