Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

Abstract

In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs—especially in rural and remote settings—with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

“…Other potential solutions include the use of mobile stroke units, prehospital triage, telemedicine for decision support, and flying intervention teams. [29][30][31][32][33][34][35][36] Direct transportation to intervention centers may be preferable to interhospital transfers, which can be associated with delays in treatment and worse outcomes. 23,[37][38][39] The designation of additional endovascular centers in underserved areas may be part of the solution, although it may be challenging to maintain a roster of staff and neurocritical care services in such areas, and one Korean study found that outcomes were worse at small-volume compared to large-volume sites.…”

Googling Location for Operating Base of Mobile Stroke Unit in Metropolitan Sydney

“…Sites such as Lucas County serves a population of 433,689 (33); New Jersey model serves a modest population of 460,000 (34); and the Cleveland model serves a population of 390,000 (35). In Germany, there is exploration on the deployment of MSU in rural areas (16). In Edmonton, Canada, there is extension of the operating radius as far as 250 km from base (12).…”

“…There may be a need to allocate resources equitably from inner Sydney to outer Sydney while planning the location of MSU hub. This is an issue that is not unique to Australia but is also relevant in Europe (16) and Canada (12). In London, this had been addressed by reducing the number of hospitals providing thrombolysis service (24, 39).…”

“…Subsequently, a geospatial optimization analysis suggested that such a model can operate up to 76 min from base (15). In another paper, in this special issue of Frontiers in Neurology, the role of MSU in performing triaging of patients for therapy in the rural setting was explored (16). In this study, we propose the use of ggmap interface to Google Maps API to assign the base for operating MSU in Sydney based on proximity of the hub to the suburbs less well-resourced in terms of closeness to hospitals providing ECR and thrombolysis (14).…”

Early In-hospital Management of Acute Ischemic Stroke

“…Therefore, proper early diagnosis and management is very important. As the reason above, pre-hospital stroke service is one of major concerns of treatment, includes emergency medical services(EMS) and pre-stroke education 13,18) . Distance and travel time to the nearest stroke center is a crucial issue for time-sensitive stroke treatment 5,13) .…”