The Mobile Stroke Unit Experience in a Mid-Sized City
Q&A with Stroke Surgical Director Tarun Bhalla, MD
In 2018, UR Medicine, the health system associated with the University of Rochester Medical Center (URMC), began operating a Mobile Stroke Unit (MSU). At the time, MSU’s were primarily found in major metropolitan areas – the first one in the U.S. was launched in Houston in 2013 – and Rochester became the test case for how the new technology could be deployed in a mid-sized city.
MSU’s are designed as stroke emergency rooms on wheels. The units are staffed with highly trained medical professionals: on the rig are a stroke-trained critical care nurse, a CT technologist, a paramedic, and an EMT. Crucially, also on-board is also a neurologist, either in person or via telemedicine. The neurologist and nurse assess the patient’s symptoms and CT images and determine whether the patient is eligible for intravenous thrombolytics (Alteplase or Tenecteplase). If eligible, the patient receives the IV thrombolytics immediately on the MSU.
The launch of the UR Medicine MSU was the culmination of years of work, championed by endovascular neurosurgeon Tarun Bhalla, M.D., the Surgical Director of the UR Medicine Comprehensive Stroke Center and an Assistant Professor of Neurosurgery, Neurology and Imaging Science. Together with the leadership of neurologist Curtis Benesch, M.D., the medical director of the stroke center, Adam Kelly, M.D., director of tele-neurology, and a team of nurses and physicians, the MSU has provided care for hundreds of stroke victims and counting since it started operation.
Dr. Bhalla discussed why bringing an MSU to Rochester was a priority, how the technology is improving outcomes, the financial, partnership-building, and staffing issues that need to be addressed, and how UR Medicine is integrating the MSU into a broader stroke awareness campaign.
What led to the development of the UR Medicine Mobile Stroke Unit?
Bhalla: In Monroe County, New York, the county that UR Medicine serves, stroke is the third leading cause of death. Although hospital-based stroke care is often a short distance away, few stroke victims are arriving at local hospitals quickly enough to truly benefit from time-sensitive drug interventions. Approximately 80-85% of all strokes are ischemic, and seconds matter in the fight to open a blocked vessel. The longer a clot prevents oxygen rich blood from perfusing the brain, the more brain cells begin to die, and the greater the likelihood of irreparable damage.
I came to UR Medicine from Cleveland, where I did my residency and fellowship, a community very similar to Rochester. During my training, I was able to witness first-hand how using new technology can improve stroke outcomes, especially in poor, underserved communities who traditionally face various barriers to stroke care. The MSU program at the Cleveland Clinic has been tremendously successful in impacting stroke care in their community.
The goal of MSUs is to reduce time to intravenous thrombolysis by bringing all of the high tech elements of stroke diagnosis and treatment to the patient, thus eliminating precious minutes associated with transport and hospital arrival from the stroke treatment timeline. Having seen the MSU’s success in Cleveland, I felt it could work equally well in addressing the stroke epidemic in the Rochester region. In 2018, I put together an interdisciplinary team to raise the money and develop the grassroots regional support necessary to successfully implement a Mobile Stroke Unit program in Rochester.
What results are you seeing?
Bhalla: The results of the first four years of MSU operations are very promising. In particular, when compared to local emergency room care in the Finger Lakes region, the MSU is able to administer IV thrombolysis to stroke patients 25-30 minutes faster from arrival, 60-70 minutes faster from patient’s was last known normal; and 55-60 minutes faster from 911 activation.
Perhaps most critical is the MSU’s ability to provide IV thrombolytics within the “golden hour,” or the first 60 minutes from the time the patient was last known to be stroke symptom free. Treatment during the golden hour is associated with optimal stroke outcomes, and provides the best opportunity for complete stroke recovery. Due to transport and diagnostic workup after hospital arrival, local emergency rooms are only able to administer IV thrombolysis within the golden hour in only about 2-3% of stroke cases. However, because the UR Medicine MSU is designed to remove those transport and post-arrival diagnostic barriers to care, it has been able to administer IV thrombolysis within the first hour in 30-33% of cases. These results are similar to those reported in 2021 by the national multi-center Best-MSU Study.
Our data also demonstrates that reduced times to treatment on the MSU translate into overall average reductions in length of stay among those treated on the MSU, as well as greater likelihood of discharge to home as opposed to rehabilitation facilities. We are proud of these results and continue to evaluate and study our processes so that we may continue to improve stroke outcomes.
How does the MSU fit into broader stroke awareness efforts in the community?
Bhalla: Stroke awareness is essential in the fight to reduce overall rates of stroke death and disability. This includes recognition of stroke symptoms and the critical importance of activating 911 when strokes occur. The essential first step in expediting stroke intervention comes when the patient recognizes stroke symptoms and immediately activates emergency medical services. There is no stroke treatment once an area of ischemic brain dies, and so the importance of stroke symptom recognition and 911 activation must be communicated broadly and repeatedly in order to truly have an impact on the stroke epidemic. That is why we felt it was so essential to make stroke literacy a part of the MSU program.
Our efforts to bring stroke education to the community started with our team securing a multi-year > $1M grant from the Mother Cabrini Health Foundation in 2020. This allowed us to enact a stroke literacy program locally by developing a coalition of local nonprofit agencies dedicated to working with underserved local citizens, including Action for a Better Community, Ibero American Action League, and Lifespan of Greater Rochester. Together, we developed the Rochester Stroke Literacy Coalition, whose mission is to improve stroke outcomes in underserved communities who are at higher risk for stroke through widespread, intensive stroke literacy programming.
In practice, coalition community health educators provide in-person and multimedia stroke education events and classes within underserved communities. These may be impromptu interactions in local barber shops, apartment buildings, or grocery stores; or involve classes at community centers, churches, and adult care facilities. The MSU team has also developed bilingual multimedia education, including billboards, online campaigns, radio and online public service announcements, citizen interview videos, bus advertisements, and various print offerings. Through these online and in-person programs, we have reached thousands in our community with stroke literacy messaging.
What were some of the challenges you had to overcome to bring the MSU to Rochester?
Bhalla: Like any new medical technology, there were multiple challenges to introducing a MSU program in our region. First, we had to research and raise the funds necessary to purchase a high-tech ambulance able to support a CT scanner. We then had to develop a partnership with a regional EMS agency capable of managing the ambulance, handling dispatch, and providing paramedic and EMT staff.
Once all the mechanics of the program were in place, we also had to navigate a complex prehospital environment, and garner local government and EMS support for the inclusion of the MSU within an already well-defined regional ambulance network.
Once we obtained financial and community support, we had to work with regional dispatch to develop a 911 dispatch protocol and to establish a rapid response plan in coordination with co-responding EMS agencies. Without time and care in cultivating well-developed relationships and building operational procedures, the MSU could not have been successful.
We also had to ensure that hospital administration and relevant departments were supportive of an MSU program. It was particularly vital that our partners in vascular neurology take part in development and support of the program, as their participation in the MSU’s daily operations are critical to the unit’s success.
Finally, we had to take equal care and time to hire and train highly qualified personnel from both the ambulance and hospital realms in order to establish an advanced stroke service. And while we have established the significant value of the MSU in reducing times to treatment and producing good overall outcomes, we find ourselves affected by the same staffing shortages plaguing regional hospitals.
What are plans for the future growth?
Bhalla: MSUs around the country have demonstrated effectiveness at reducing time to stroke treatment and our MSU has also emphasized stroke literacy to increase the number of people eligible for MSU services. We have been fortunate in that our hospital administration has been very supportive of the positive data associated with our MSU, and supports MSU efforts to increase hours of operation, something that remains challenging in the current post-COVID healthcare environment. We are committed to expansion, especially as the unit serves removes barriers to care, especially in underserved communities.