Every minute after blood flow is even partially cut off from the brain, 1.9 million brain cells die due to lack of oxygen. So every second counts when it comes to treating someone who is suffering a stroke.
NewYork-Presbyterian Hospital has a whole unit dedicated to slashing the time it takes to successfully treat a stroke patient. It's called the Mobile Stroke Treatment Unit, and as of this week, NewYork-Presbyterian, in collaboration with Weill Cornell Medicine, Columbia University Irving Medical Center and the Fire Department of New York, is expanding its fleet of Mobile Stroke Treatment Units to Queens and Brooklyn.
With a donation by the W.P. Carey Foundation, this makes NewYork-Presbyterian the first health system in the country to operate three of these advanced units.
Late last year, the MSTU implemented a telemedicine component for patient care, where a stroke physician now communicates with the registered nurse on the MSTU via video conferencing to evaluate patients and order CT scans.
With telemedicine, one physician can virtually evaluate patients with acute stroke that are far from the base station with high-fidelity audio/video and in real time. The result of switching over to this model has improved treatment times for patients.
Since launching telemedicine initiative on November 27, 2017, the NewYork-Presbyterian MSTU has transported and treated 29 patients using a telemedicine model of care. This includes 18 patients diagnosed with ischemic stroke, two patients diagnosed with intracerebral hemorrhage, and 9 patients diagnosed with other diseases.
Intravenous tPA, a clot-busting drug, has been administered five times without any complications. The median MSTU arrival to tPA treatment time has been 31 minutes for these patients.
"Telemedicine networks bring convenience of care and cost savings to MSTU programs as they expand throughout the country," said Michael Lerario, MD, medical director of the Mobile Stroke Treatment Unit at NewYork-Presbyterian Hospital.
"The more MSTUs in operation within a single network, the larger this benefit, as one neurologist can oversee the clinical care on multiple ambulances," he explained. "The benefit of telemedicine MSTU networks are well-known and have been published in prominent medical journals."
The onboard clinical team for the NewYork-Presbyterian MSTU consists of a specially trained registered nurse, two REMAC-certified paramedics, and a CT technician. A vascular neurologist communicates with the onboard crew via a remote audiovisual connection. Using telemedicine, the vascular neurologist oversees the stroke assessment and clinical care being performed on the MSTU.
The neurologist is responsible for ensuring the accuracy of the stroke examination, confirming the diagnosis of stroke, and ordering the administration of advanced stroke care medications, not typically carried on an Advanced Life Support ambulance.
Additionally, the CT imaging performed on the MSTU is transmitted to the NewYork-Presbyterian picture archiving and communication system so the neurologist can interpret the scans and rule out intracranial hemorrhage prior to the nurse administering the clot busting drug, tPA.
The MSTU program currently has five vascular neurologists participating in the telemedicine network who were recruited from Weill Cornell Medicine, Columbia University Irving Medical Center, NewYork-Presbyterian Queens and NewYork-Presbyterian Brooklyn Methodist Hospital.
NewYork-Presbyterian uses Cisco Jabber for telemedicine capabilities on all of its Mobile Stroke Treatment Units. The ambulance is outfitted with microphones and speakers for audio transmission. The neurologist uses a Logitech headset to communicate with the patient and crew.
Additionally, an adjustable camera that offers high-definition imaging is mounted on the ceiling of the MSTU, directly above the patient. This allows the remote neurologists to see the patient and crew during their examination and clinical treatment. The neurologist's workstation is located in their hospital office and includes a desktop computer, dual monitors, as well as a webcam device.
Using their keyboard, the neurologists can remotely control the onboard camera to tilt or zoom in on the patient. Mounted on the wall of the MSTU is a monitor that allows the patients to see and speak directly to their treating doctor.
Neurologists are able to log into the Allscripts electronic health record from their office workstation so they can enter orders and document the clinical encounter. All documentation in Allscripts can be viewed on the MSTU and throughout the receiving NewYork-Presbyterian affiliated hospital prior to patient delivery to the Emergency Department.
Lerario walks through an actual acute ischemic stroke patient example of the MSTU telemedicine in action.
"The MSTU team rushed to treat a 48-year-old man who was working in Central Park, who developed acute onset right-sided weakness, facial droop, dizziness and difficulty speaking," Lerario recalled. "The patient had told his work partner that he 'didn't feel well' and 911 was called and the MSTU was dispatched. The patient was loaded onto the MSTU and our neurologist, via telemedicine, was able to examine the patient and quickly diagnose a clinical stroke."
A head CT scan was ordered and interpreted by the remote neurologist, and it was determined safe to administer intravenous tPA, the clot busting drug for stroke, to the patient. This occured within 74 minutes of the onset of stroke symptoms. After tPA, the patient was transported and admitted to NewYork-Presbyterian Hospital for observation and further treatment. The patient returned to his baseline and was discharged home.
"Response time is a critical factor in stroke recovery and the Mobile Stroke Treatment Units now have the capacity to help even more patients," said Matthew E. Fink, MD, who oversees the MSTU program and is neurologist-in-chief at NewYork-Presbyterian/Weill Cornell Medical Center. "We are bringing the emergency room directly to a patient suffering a stroke. This is a game changer in advanced stroke care."
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