In a western suburb of Chicago, neurologists at Northwestern Medicine Central DuPage Hospital don’t need to wait for a stroke patient to physically come through the emergency department’s doors to begin their assessment or administer treatment.
A telestroke connection to a specialized ambulance equipped with a 16-slice CT scanner and stroke-specific medications—including the clot-busting drug tissue plasminogen activator (tPA)—allows Northwestern Medicine’s neurologists to diagnose whether a patient is having an ischemic or hemorrhagic stroke and determine whether the patient should receive the clot-busting drug.
“Five years ago you wouldn’t think this was possible,” said Harish Shownkeen, MD, medical director of the stroke and neurointerventional surgery programs at Northwestern Medicine Central DuPage Hospital.
The work of Dr. Shownkeen, an AMA member, and his colleagues at Northwestern medicine draws on bleeding edge approaches to moving medicine and advance patient care.
“We are bringing the hospital to patients’ homes and treating them in the streets,” Dr. Shownkeen said. “We know that every 15 minutes earlier you treat the patient, the shorter their hospital stay and the less damage that is done.”
The patient can start receiving lifesaving treatments before the specialized ambulance is even close to the reaching the hospital and neurologists at the hospital can prepare to take a patient directly into surgery if needed rather than waiting for the patient to be assessed in the ED.
In its first year, Northwestern’s mobile stroke unit ensured that patients received critical care 30 minutes faster than traditional transportation to the hospital, an analysis showed. Ischemic stroke patients—for whom tPA is the gold standard of treatment—received the drug 52 minutes after 911 dispatched the mobile stroke unit, which began in January 2017. Patients transported in a traditional ambulance received the drug 82 minutes after someone called 911.
Shorter times mean better outcomes
Studies published in JAMA and JAMA Neurology backed up findings such as Northwestern’s in showing the difference that mobile stroke units can make.
Cutting the time between the onset of a stroke and treatment is a huge of part of helping save stroke victims’ lives, improving their quality of life after having a stroke, and cutting costs. The numbers show that the mobile stroke unit’s patients have better odds of receiving care in the first 60 minutes—commonly called the “golden hour”—after the onset of a stroke.
Dr. Shownkeen said that since deploying the mobile stroke unit, 50 percent of patients who call 911 early and have the unit dispatched receive the lifesaving care they need during that golden hour. Nationally, less than 5 percent of patients make it to a hospital to get the treatment in those crucial first 60 minutes, he said.
That’s critical because every minute the brain is deprived oxygen, 1.9 million neurons die and a patient sees a 3.6-week acceleration of the natural aging process. Limiting the amount of time that happens means that a patient is more likely to leave the hospital and head for home instead of a post-acute care rehabilitation facility. Also, studies have shown that tPA is most effective when administered 4.5 hours or fewer after the onset of stroke symptoms.
Dr. Shownkeen worked with Northwestern Medicine to bring the mobile stroke unit to Central DuPage Hospital after visiting with old Army buddies in Germany five years ago. They showed him how physicians there were using the mobile units to improve stroke treatment. At the time, Cleveland and Houston were the only U.S. cities where the approach had been tried.
“The units were mostly paid for through philanthropy. And there was no CPT code for treating patients at their home,” Dr. Shownkeen said. “This was a good way for Northwestern to give back to the community.”
Beginning in 2019, Medicare will pay for the kinds of services the Northwestern mobile stroke unit offers. The AMA strongly supports expanded coverage in telestroke services without geographic restrictions and to expanded originating sites such as mobile stroke units. And the AMA similarly advocated the same as part of the rulemaking process.
The AMA-convened Digital Payment Advisory Group identifies barriers to digital medicine adoption and proposes comprehensive solutions revolving around coding, payment, coverage and more.
