Results of a proof-of-concept study suggest interventionalists could be more easily transported than stroke patients.
Flying an interventionalist from a comprehensive stroke center to a regional hospital order to perform mechanical thrombectomy for acute ischemic stroke, rather than transporting the patient, is feasible and likely saves both time and money, according to a proof-of-concept study.
Details on the “helistroke” concept being tested at Johns Hopkins Hospital in Baltimore, MD, were published online May 2, 2017, ahead of print in the Journal of NeuroInterventional Surgery.
“We have been in the process of building a second interventional-ready suburban hospital, which has NIH researchers doing probably the world’s best MRI triage work for stroke, but they didn’t have interventional capabilities,” lead author Ferdinand K. Hui, MD (Johns Hopkins Hospital), told Neurovascular Exchange in a telephone interview.
The region lacks the neurovascular volume to put in a full team of neurointerventionalists, he said. “So the question is, how can be we set up a situation where we can get the right oversight for the interventions that are at the hospital, so that the neurologists and the management are comfortable having neurointerventions being done?”
Hui and his team looked at the potential options and noted that a workable model already exists for liver transplantation. “We fly doctors to harvest organs,” he said. “Why not fly me to do the cases?” This is less expensive than transferring patients, which requires the support and coordination of care teams and equipment. Helicopter transfer is also faster and more reliable than transferring a doctor by car or ambulance.
The investigators worked with hospital and Medevac companies to provide the rationale and funding for helicopter transfer of Hui to the regional hospital, an in-network certified primary stroke center with an angiography suite located about 40 miles away. They planned so that a transport system would be activated when an appropriate patient with large vessel occlusion and a National Institutes of Health Stroke Scale (NIHSS) score > 8 was identified and MRI was performed.
The proof-of-concept case unfolded as follows:
- 12:13: Case identified, verification that no in-house emergencies prevented physician departure, and Medevac consulted.
- 12:24: Weather clearance obtained and stroke intervention confirmed as a go.
- 13:07: Groin puncture occurred.
- 13:42: Intervention completed.
The total time from decision-to-treat to groin puncture was 43 minutes. Groin puncture was completed 77 minutes from decision-to-treat.
Baseline NIHSS score, recanalization time, and the presence of atrial fibrillation were all independent predictors of 90-day outcome.
The Johns Hopkins physicians are continuing to use the system. So far, they have treated three patients in this manner, and they plan to publish again when they have a larger cohort. While the long-term goal at their location is to find in-house physicians to take care of these cases, Hui pointed out that the helicopter transport-based model could work long-term for some suburban or rural hospitals that are located long distances from urban centers.
The approach is surprisingly affordable for centers that already have helipads, he argued. The cost to fly Hui in for a case is about equivalent to the cost of one catheter used in the procedure. Hui hopes insurance companies will recognize the long-term savings of covering the cost of transportation. “If we can shave 2 hours off transport time and therefore get a 20% higher rate of a good outcome, that means that 20% of the time instead of rehab for the patient, they leave. If the patient leaves, the insurance company wins,” he pointed out.
A Niche Solution
Hormozd Bozorgchami, MD (Oregon Health & Science University, Portland), told Neurovascular Exchange that the study’s concept is “pretty cool,” though he did wonder how the interventionalist returns home after procedure and how they would manage if multiple strokes require treatment in the same region.
Bozorgchami speculated that the system might work well in certain niche situations but said it is not likely to be widely applicable. “A lot of different factors are necessary to provide good stroke care,” he said. “It probably is cheaper to fly in an interventionalist than it is to fly patients, but to have a successful interventional program, you also need to have the right equipment, the right personnel, technologists, the proper ICU post-care, and nurses who have dealt with these patients time in and time out. If you’re flying to different parts of your region to offer thrombectomy, those places will not necessarily have those components necessary for a comprehensive program.” Safety is also a concern when flying in a helicopter for the interventionalist, he added.
The region outside Portland, Bozorgchami pointed out, is quite rural, and driving patients less than 60 miles away into their comprehensive stroke center by ambulance appears to be the fastest and most cost-effective approach.
Hui acknowledged that the helicopter approach is not the best option everywhere. In some dense urban centers, he said, the subway might be preferable to helicopter transport. Mount Sinai Hospital in New York uses such a system, he noted.
Source:
Hui FK, El Mekabaty A, Schultz J, et al. Helistroke: neurointerventionalist helicopter transport for interventional stroke treatment: proof of concept and rationale. J NeuroInterv Surg. 2017;Epub ahead of print.
Disclosures:
- Hui reports no relevant conflicts of interest.
- Bozorgchami reports being a paid consultant for Neuravi.
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