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Looking to improve access to hyperacute stroke care? Here are some solutions that might help.

by Miles Cottier and Liz Roberts

Strokes remain one of the world's leading causes of death and disability, killing well over 5 million people annually and representing over half of the total neurological disease burden. The associated costs are huge. The UK, for example, expects to see a spending increase of 194% in stroke care over the next 20 years. The emotional burden is high, too: over 80% of Canadians over the age of 60 are affected by stroke in some way.

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Why do health systems still struggle to manage cost and outcomes in stroke care?

While technology and clinical care have come a long way, there are several challenges that undermine even the most advanced approaches. First, there are relatively few stroke specialists, often located far from the patient. Further, the onset-to-treatment time needs to be as short as possible (ideally within "the golden hour"), so any delay in care can have severe consequences.

Multidisciplinary teams integrated across different settings can help overcome these issues, spreading expertise to areas where patients wouldn't typically have access to rapid care. But this model is difficult to extend to more remote areas.

How MSUs can increase access to stroke care

Some organisations are overcoming accessibility challenges with Mobile Stroke Units (MSUs)—ambulance units with onboard CT-scanning technology and a specialist team who can provide treatment onsite and decide if advanced treatment is required. Already MSUs have demonstrated improvements in metropolitan alarm-to-treatment time.

Royal Melbourne Hospital in Australia saw a significant reduction in treatment delays compared to standard emergency department admissions, with almost 50% of patients being treated within the "golden hour". Charité-Universitätsmedizin Berlin, one of the first European MSUs, saw a 10-fold rise in successful "golden-hour" treatments when compared to conventional treatment.

The problem is MSUs can typically only operate within a 20km radius from the base hospital—otherwise there's not enough time to ensure “golden hour” treatment. Those in less urban areas therefore may still struggle to access treatment fast enough. Additionally, with specialists in short supply, MSUs can be difficult to staff, and are expensive to implement.

How technology can help

To overcome these challenges, some organisations are combining telestroke with MSUs. Telestroke allows specialists to diagnose, triage, and treat patients virtually using internet-based telecommunication technology. This is beneficial in connecting rural patients with rapid care. In fact, telestroke operations show comparable time-to-treatment rates in rural areas to standard systems in urban areas.

We haven't yet seen large-scale roll out of a combined model, but pilot studies have been positive. Located in suburban New Jersey, US, Overlook Medical Centre was one of the first to pilot this model. Using in-transit telestroke in MSUs, it showed a 13 minute improvement patient treatment times.

Cleveland Clinic in Ohio, US was also one of the first to pilot a MSU-telestroke operation, solely using telemedicine for physician presence. The staff on board the MSU includes a nurse, paramedic, emergency medical technician, and CT technologist. A vascular neurologist and neuroradiologist provide support virtually. In the pilot, 99% of patients were evaluated successfully via telemedicine in the MSU, and the model saw a significant decrease in time-to-treatment compared to a control group brought to the emergency department via ambulance. Inspired by their success, other organisations are now beginning to roll out 24/7 operations.

Organisations looking to implement similar models to improve access to stroke care should keep a few considerations top-of-mind:

  • Can we define a realistic catchment area that allows "golden hour" treatment to be achievable at maximum distance?
  • Does the catchment area have sufficient network connectivity to enable telestroke communications?
  • Do we have access to the necessary resources to launch this capital-intensive model?

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