Timely Intervention
By Rebekah Moan
Radiology Today
Vol. 26 No. 2 P. 14
Mobile stroke units provide a critical service, but funding is still a challenge.
When it comes to imaging stroke patients, time is of the essence–two million brain cells die every minute during an ischemic stroke. A patient’s odds of returning to normal or near-normal are around 70% higher if they receive intravenous thrombolysis within 60 minutes of stroke onset than if they receive it 61 to 270 minutes from onset. In recognition of this, some facilities have created mobile stroke units (MSUs) that can treat patients 30 to 45 minutes sooner than if they are rushed to a hospital.
“The mobile stroke unit allows us to get to a patient who’s having an acute stroke in the fastest possible way, and then we can treat that person with thrombolytic medications,” says Matthew Fink, MD, neurologist-in-chief at NewYork-Presbyterian/ Weill Cornell Medical Center. “That allows us to literally stop the stroke as it’s developing, reverse it, and it gives us the highest probability of getting a person completely back to normal.”
NewYork-Presbyterian launched an MSU in October 2016 in partnership with Weill Cornell Medicine, Columbia University Irving Medical Center, and the Fire Department of New York (FDNY). The MSU is deployed via the FDNY through New York City’s 911 system.
Fink developed the New York program and raised the funding to implement it. It continues to operate on philanthropic funds. The MSU is an ambulance equipped with a portable CT scanner by NeuroLogica. It takes up about one-quarter of the space of a full-size CT scanner, which leaves room for four people in the ambulance. At NewYork-Presbyterian, those four people are a highly specialized team of two paramedics from the Regional Emergency Medical Services Council of New York City, a CT technologist, and a registered nurse specially trained for stroke care. The crew connects with a board-certified neurologist who performs a telemedicine consult remotely from one of the NewYork-Presbyterian hospital locations.
Because the CT scanner is a delicate instrument, the ambulance must be completely still when the patient is being scanned. A physician can diagnose the patient, and those on board can administer medications to treat strokes, such as tissue plasminogen activator (tPA) and labetalol. In ischemic stroke, timely treatment with tPA or thrombectomy results in substantial clinical improvement—a 5% decrease in mortality for every 15-minute reduction in door-to-needle times.
In cases where a patient has an intracranial hemorrhage, the MSU offers earlier neurological consultation and advanced blood pressure management with intravenous medications. That information can also be used, with the approval of FDNY online medical control, to triage a patient to the closest hospital with the necessary neurosurgical team required to treat intracranial hemorrhages.
Lessons Learned and Next Steps
When the NewYork-Presbyterian program first began in 2016, a physician was included on the ambulance crew to do a direct physical exam. However, after 1.5 years, the physician became remote instead, which is more cost-effective, according to Fink.
From 2018 to 2020, NewYork-Presbyterian had three MSUs: one each in Manhattan, Brooklyn, and Queens. Then the pandemic happened. With paramedics in short supply, the hospital had to reduce to one MSU.
“We’d love to go back up to three units,” Fink says. “We had a business plan in place to have enough of these ambulances to cover all of New York City, and we were going to submit a proposal to get funding to run eight units. I think we would have succeeded, but the pandemic affected a lot of things, and it certainly affected us.”
Fink continues to push for expanding the program in New York. However, on the West Coast, the Los Angeles MSU program is already growing.
The UCLA Health Experience
UCLA Health’s MSU launched in 2017, with a donation from the Arline and Henry Gluck Foundation, and it was the first unit of its kind in California. It serves three geographic locations, decided upon in partnership with LA County as it mapped stroke incidence and occurrence.
“We are tremendously grateful for the philanthropic donations and LA County Measure B funds which have made serving patients in Los Angeles County possible,” says May Nour, MD, PhD, the medical director of the Arline and Henry Gluck Stroke Rescue Program and a vascular and interventional neurologist at UCLA Health. “With additional philanthropic support from the Brett Torino Foundation and the Canarelli Family Foundation, we were able to expand our fleet to three mobile stroke units operating in Los Angeles County.”
Seven years after operating MSU1, UCLA has been able to expand its fleet to a total of three MSUs. The later units are equipped with the first-in-the-US Siemens portable 32-slice scanner, whereas the first unit is equipped with a Samsung 8-slice scanner. These mobile scanners can differentiate between ischemic and hemorrhagic stroke, as well as identify large vessel occlusions in the field prior to the patient’s transport to the hospital. The program has been able to achieve door-to-puncture times as short as nine minutes with partnering hospitals, which has tremendous benefits to the patient.
“We see mobile stroke units as an important part of the fabric of EMS care,” Nour says. The UCLA Health MSU program currently operates with eight fire departments to deliver mobile stroke care in three geographic areas. A firefighter paramedic, a CT technologist, and a critical care or emergency care nurse ride on every MSU. A physician can deliver care by either riding along or by telemedicine presence.
In 2017, the UCLA Health-LA County collaborative MSU began as a demonstration project to learn the clinical benefits of treating stroke in the prehospital setting. However, there is now evidence demonstrating its utility, as shown in studies such as the Berlin PRehospital Or Usual Delivery of Acute Stroke Care (B_PROUD) and the Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU). The studies showed that patients will have significantly better clinical outcomes if treated sooner on an MSU rather than later in the hospital.
“We hope to see direct integration throughout the world to afford this kind of substantial and meaningful recovery for stroke survivors everywhere,” Nour says. “That’s my big dream.” MSUs were first developed in Saarland, Germany, in 2008. Soon after, they spread throughout the world—everywhere from Asia to Australia— but they are far from prolific.
Since UCLA’s program began, Nour has learned about the unpredictability of the field. Stabilizing the patient, obtaining high-quality images, and collecting information about the patient can be challenging. One of the key hurdles the program has had to overcome is transferring images to the hospital because teleconnectivity varies from place to place. Images are transferred over a cellular connection, and sometimes, nursing homes or high-rise buildings can block cellular service. UCLA has ameliorated that occasional lack of signal by using bonded internet solutions for telehealth and imaging transfer.
Reimbursement Hurdles
For both UCLA and NewYork-Presbyterian, securing reimbursement for services rendered would help them expand their programs. Within the mobile stroke community, there’s been a national effort to lobby the CMS to provide reimbursement for treatment.
“We thought that would be easy because what we’re doing on the MSU is exactly the same as what we do when a patient arrives at our emergency department. Exactly the same thing,” Fink says. “If they arrive at the emergency department, the hospital gets paid for it, but if it’s on an ambulance, there’s no reimbursement for it because of the way they categorize these things.”
However, the MSU saves everyone money. If a stroke patient is treated early, and the stroke is reversed completely, that person is only in the hospital for a day or two, and then they go home, completely back to normal. There’s no hospitalization for rehabilitation, no outpatient physical therapy, no long-term care, and the person goes back to work. Yet, neither CMS nor insurance companies recognize the cost savings and agree to pay for MSUs.
“I think what’s important, in order to sustain these life-saving resources, is to make this part of the standard of care, including billing of activities,” Nour says. “CMS doesn’t recognize MSUs as unique places of service, which includes not only the transport capability but also the imaging and treatment. Our health system is supported by tremendous philanthropy and support from LA County, but in order to make this a reality across the world, the ability to bill must be resolved.”
An intriguing avenue that could yield better results for reimbursement is the use of portable and mobile MRI.
Portable and Mobile MRI
Hyperfine created an FDA-cleared portable MR brain imaging system, the Swoop, which is eligible for reimbursement at Intersocietal Accreditation Commission-accredited facilities.
The compact system stands 59 inches tall and 33 inches wide, and it weighs approximately 1,400 lbs. It’s designed for use in any professional health care setting, including medical offices. It can be moved to a patient’s bedside, plugged into a standard electrical outlet, and acquire images within minutes. Its ultralow field strength of 0.064 T eliminates the need for shielded MRI rooms.
Hyperfine President and CEO Maria Sainz is quick to point out that while the Swoop system is portable, it’s not designed for use in an ambulance. Instead, it can be moved from point A to point B within a hospital or office.
“We like to call ourselves an AI-powered, portable brain MRI,” Sainz says. “Swoop can be moved easily through hallways and elevators. It can safely scan patients without any need for shielding, reinforced floors, or specialized personnel.”
This portability makes MRI more accessible for those who need it and available for facilities that may not be able to afford multiple, full-size MR scanners.
Another MRI scanner does something similar, but it’s not portable the way the Swoop system is. Nebraska Medicine has a Philips Mobile MR 5300 BlueSeal magnet. It provides helium-free MR imaging capabilities in a mobile format, meaning a 53-ft-long trailer. The 1.5 T machine stays parked while in use but can be moved to various sites as needed.
“Nebraska Medicine ran out of space, and many large facilities run into that problem,” says Randy Duncan, a regional vice president of Shared Medical Services, the company Nebraska Medicine leases the MRI scanner from. “They need help, and this is a great resource to help them to keep up with patient needs. So many facilities don’t have room for another MRI scanner.”
The benefit of a mobile MRI machine is that it can move to rural markets and small communities that may not have access to that kind of imaging. This is particularly helpful for a condition such as a stroke, where every minute counts.
“In general, we’ve made tremendous progress in treating patients with acute ischemic stroke, but we could do better, and the way we could do better is by treating patients faster,” Fink says. “The way to do it faster is with the mobile stroke units because we get to the patients a lot faster than they can get to the hospital.”
— Rebekah Moan is a freelance journalist and ghostwriter based in Oakland. Her specialties are health care and profiles.