Mobile Stroke Unit News News magazine of the PRE-hospital Stroke Treatment Organization Volume 3, No. 2

Turning Point for Efficacy in Prehospital Stroke Care BEST-MSU Results Reported at International Stroke Conference

By Jim Grotta, MD President For me, the past few months have been momentous. From the global perspective, the rollout of COVID vacc- ination has allowed us to turn the corner on this pandemic and look forward to a return to life as we knew it where in- person human interaction can once again occur outside the home or hospital. Personally, as a 75 yo “first-responder”, I was fortunate to be one of the first to be vaccinated at my hospital. I am hopeful that by summer we can put the COVID pandemic in the rear-view mirror of our continued on p. 5 BEST-MSU results reported at ISC: Modified Rankin Scale score distribution at 90 days Berlin B_PROUD Mobile Stroke Outcome Findings Published

By Heinrich J. Audebert, MD Mobile Stroke Units (MSU; in Berlin: STEMO for Stroke Emergency Mobiles) have been serving Berlin for ten years. The specialized stroke emergency response vehicles allow physicians to start treating stroke patients before they reach hospital. B_Proud: Modified Rankin Scale score distribution at 3 months, unadjusted only for patients1 For the first time, it has been shown that the dispatch of mobile stroke units is linked Audebert and Martin Ebinger (Center to improved clinical outcomes. These to survive without long-term disability, have been published in JAMA1. for Stroke Research Berlin and Charité’s findings, which show that patients to Department of Neurology) set itself the whom STEMO were sent were more likely Ten years ago, a team led by Heinrich continued on p. 6

Overcoming the Tyranny of Distance in Reimbursement a Significant Persisting Australia – The “Stroke Golden Hour” Hurdle for Mobile Stroke Care Paradigm Major government support for air ambulance. Story, p. 4 U.S. National MSU Reimbursement Survey. Story, p. 3 Mobile Stroke Unit News April 2021

Note From the Editor Emergency Mobiles). Prof. Audebert was Mobile Stroke Principal Investigator on the B_PROUD trial and is the incoming By Robert G. Kowalski, MD, MS President. Unit News This issue of the PRESTO newsletter comes at a The newsletter also features an update on critical and arguably hist- a major commitment by the Australian Semi-Annual Newsletter oric juncture for the government to support pre-hospital of the organization, for Mobile stroke care, including delivery to far-flung PRE-hospital Stroke Stroke, for pre-hospital reaches of the continent via aircraft. Stephen Davis, MD and Geoffrey Donnan, Treatment Organization stroke care, and for stroke in general. On the first AO, MBBS, MD, of the University of (PRESTO) page, we are privileged to reproduce Melbourne and Co-Chairs of the

eponymous “Grotta bars” with new results Australian Stroke Alliance, describe the April 2021 from two large studies of outcomes in initiative. The effort includes devel- Volume 3 – Number 2 mobile stroke, the BEST-MSU study in the opment of light-weight CT scanning

U.S., and the B_PROUD study in Germany. technology for use on helicopters and Editor airplanes. Robert G. Kowalski, MD, MS These studies represent years of concerted Aurora, CO research involving one of the most Despite the positive results of BEST-MSU important new approaches in stroke care and B_PROUD, the field of mobile stroke Editorial Board since the advent of tPA and endovascular care is not without significant ongoing Heinrich J. Audebert, MD therapy for ischemic stroke – mobile challenges. Foremost among these is cost Berlin, Germany stroke. The BEST-MSU results were reimbursement, which Anne Alexandrov, Anne W. Alexandrov, PhD, RN presented last month at the International PhD, RN, explains in an article detailing Memphis, TN Stroke Conference by PRESTO President results of the U.S. National MSU Andrei V. Alexandrov, MD Jim Grotta, MD (after whom the modified Reimbursement Survey, presented at ISC. Memphis, TN Rankin Scale results graphic display is We look forward to the 13th World Skye Coote, MSN, RN named), and the B_PROUD results were Stroke Organization Congress, to be held Melbourne, Australia published by Prof. Heinrich J. Audebert virtually, Oct. 28-29, 2021. As the Stephen Davis, MD and colleagues in JAMA in February of this newsletter continues to chronicle devel- Melbourne, Australia year. Although the term is used cautiously, opments and advances in the field of Martin Ebinger, MD, PhD it is fair to say both are landmark studies in mobile stroke and pre-hospital stroke Berlin, Germany the field of stroke. care, we welcome any ideas and Klaus Fassbender, MD In his column, Dr. Grotta describes the contributions for future issues of the Homburg, Germany culmination of the BEST-MSU study and Mobile Stroke Unit News. James C. Grotta, MD does so in the context of his long and Robert G. Kowalski, MD, MS is Clinical Houston, TX storied career and the recent COVID Research Instructor at the University of William J. Jones, MD pandemic. With this, Dr. Grotta’s tenure as Colorado School of Medicine, Departments of Aurora, CO PRESTO President comes to a close, but Neurology and Neurosurgery, and is leading certainly not his work in the mobile stroke research on the university’s Mobile Stroke Eric M. Nyberg, MD Unit. Aurora, CO world. Compilation and analysis of

additional results of the BEST-MSU study, Stephanie Parker, BSN, RN including economic aspects of this Houston, TX paradigm, is underway. Brandi Schimpf, BSN, RN Aurora, CO Dr. Audebert, Professor of Neurology at Silke Walter, MD Charité University, in Berlin, Germany, Homburg, Germany describes the published results of the Henry Zhao, MBBS B_PROUD study, which compared stroke Melbourne, Australia care in a conventional ambulance with care in an MSU (in Berlin called STEMO, or

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Mobile Stroke Unit News April 2021

Reimbursement-- a Continuing Challenge for Mobile Stroke

By Anne W. Alexandrov, PhD, RN the CT scan, although we also found physician, not the MSU,” said that some programs include vascular Reichenbach.

Patients treated on neurologists as the on-board expert. Reimbursement limitations are sign- Mobile Stroke Units The daily personnel expenses alone for ificant deterrents to USA program (MSU) are diagnosed these practitioners exceeds the reimb- development and challenge ongoing significantly faster, ursement that is provided.” Additionally, operations for existing programs. and those treated because MSUs are not recognized as a “Although we know MSUs are an with systemic throm- place of service for neuroimaging by important evidence-based tool to bolytic agents achieve payers, the non-contrast CT scans along improve acute stroke outcomes, we significantly better 3- with the CTAs that most USA MSUs are found during distribution of our survey month functional out- now completing are not recognized as that one program had already ceased comes, with many more treated within the reimbursable despite not having to operations in large part because of first 60-minutes of stroke onset. Despite repeat most imaging at the hospital. delivery of high-quality care, MSUs negative financial performance,” said struggle with suboptimal reimbursement Reichenbach. Only one program that Kenneth W. Reichenbach that challenges their growth worldwide. responded to the survey stated that they Jr., CRNP, MSN, program were financially viable because they had The PRESTO Reimbursement Committee director of the Mobile Stroke Unit at Lehigh been designated as an outpatient clinic, recently presented the results of a U.S. Valley Health Network in whereas all other respondents were National MSU Reimbursement Survey that Pennsylvania forced to rely on grants, philanthropy, or was presented at the American Heart institutional support for program Association/American Stroke Association sustainment. According to Reichenbach, International Stroke Conference in March Medications including alteplase, prothr- “It’s time that MSUs become recognized 2021. According to lead author, Ken ombin complex concentrates, and as appropriate places of services for Reichenbach, MSN, “We found that 100% continuous antihypertensive infusions acute stroke diagnosis and treatment, so of all U.S. MSUs are highly dependent on are also not reimbursable since these that their important services can be charitable donations or grants to cover are not recognized as drugs that should appropriately reimbursed, and more operational expenses.” Although the be given outside a hospital. “Presently, programs can be developed in the USA.” authors limited their study to programs in insurance payers are providing some the USA, reports from MSU programs Anne W. Alexandrov, PhD, RN is a Professor reimbursement for use of telemedicine and Mobile Stroke Unit Chief Nurse outside the USA show similar results. Op- on an MSU, but these payments are Practitioner, University of Tennessee Health erational costs for MSU programs consist minor and go only to the hospital-based Science Center, Memphis, TN. of a number of items that drive expenses considerably beyond that of regular ambulances, yet billing a regular ambulance charge is the only billing option that can bring in revenue. “Our study found that on average USA MSUs have 4 providers on board. Most commonly, these include paramedics which are required by most States to maintain patient contact throughout the transport if the MSU is classified as an ambulance, emergency medical technicians who serve as drivers and assist with medical procedures, nurses that are either experienced with providing care for stroke or stroke nurse practitioners who can prescribe management, and CT technologists who manage all aspects of Page 3

Mobile Stroke Unit News April 2021 Major Investment: Overcoming the Tyranny of Distance in Australia

It treats 10 times as many patients in The “Stroke Golden Hour” Program the first ‘Golden Hour’ after stroke, enabling a rapid diagnosis and By Stephen Davis, MD and Geoffrey thrombolytic treatment to be deliver- Donnan, AO, MBBS, MD (Co-Chairs ed faster than a traditional transfer to Australian Stroke Alliance); Damien hospital. An independent economic Easton and Amanda Place, on behalf of review showed that the MSU was cost the Australian Stroke Alliance effective, due to a combination of faster thrombolysis and facilitation of More Australians will have rapid access endovascular thrombectomy, with to time-critical stroke care following bypass of primary stroke centres to an the funding of the Australian Stroke Stephen Davis, MD Geoffrey Donnan, AO, endovascular-equipped comprehens- Alliance’s “Stroke Golden Hour” MBBS, MD ive stroke centre. program by the Australian Gover- nment’s Frontier Health and Medical The major research aim is to create Research initiative. The funding by this innovative light, portable brain program is designed to support scanners to be embedded in road, researchers to push the boundaries, to helicopter and fixed-wing ambulances develop big, new ideas to revolutionise to access regional Australia. These health care and to create new scanners will be essential for the rapid industries. The Alliance brings together diagnosis and appropriate treatment of stroke. more than 30 national organisations committed to transforming stroke Damien Easton Amanda Place Conventional CT scanners, typically response times and treatment. weighing three tons, are located in As reported in the last edition of PRESTO’s major city centres, providing little Our 5-year, $40 million program aims newsletter, Ambulance Victoria operates hope for many Australians who live in to reduce the risk of death and the vehicle within a 20km radius of the the “outback” of our country. The disability from stroke for many Royal Melbourne Hospital and has seen Australians, but particularly for the some impressive results. continued on p. 7 one third of our national population, who live in rural or remote locations. Stroke patients living outside of major metropolitan centres have little access to modern stroke care and have significantly worse clinical outcomes. This inequity is even greater for Indigenous Australians in remote communities who suffer stroke around a decade earlier with poorer out- comes. Program co-chief investigators and PRESTO members, Profs Stephen Davis and Geoffrey Donnan, are building on the success of Australia’s first mobile stroke ambulance which serves metropolitan Melbourne. The Melbourne Mobile Stroke Unit is the The Royal Flying Doctor Service treating a patient in the Australian outback. We first MSU in Australia and only one of aim to fit out aircraft with lightweight novel brain scanners to enable on-site two in the Southern Hemisphere. stroke diagnosis and treatment.

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Mobile Stroke Unit News April 2021

BEST-MSU, and a PRESTO Motto: From “efficacy” to “effectiveness”

Continued from Grotta, p. 1 BEST-MSU: Time from LKN to tPA bolus vs Percentage with 90d mRS 0-1; MSU + SM

MSUs and write books, movies, and stories for our grandchildren about how we survived the great pandemic. It has been a momentous time for the world of mobile stroke units as well. When Jose-Miguel Yamal, the PI of our Data Core revealed the unequivocally positive results of the BEST-MSU study in a “private showing” to our Project Manager Stephanie Parker and me, we were overwhelmed by emotion. I was transported back to Airlie Virginia in 1994 when Barbara Tilley, the PI of the NINDS tPA Trial Data Core, evoked the same and the reason that PRESTO as an MSU systems to better identify and gasps from the investigators when she organization was envisioned in the first treat stroke patients at the first flashed up the slide showing p< .01 for 90 place. Here is my “laundry list” of moments after symptom onset? This day mRS 0,1. History repeats itself! Time priorities from the immediate to the will require a focus on increasing stroke is brain, time is clot, and MSUs provide a long range for what PRESTO as an alerts, improved dispatch accuracy, and new definition of “time”. It is not 6 hrs, organization should strive to achieve in complete regional integration and or 3 hrs; it is 60 minutes or less. the next decade: coordination between MSU and EMS systems. I want to personally thank my co- 1. How can we fine-tune our existing continued on p. 8 investigators in the BEST-MSU study at our sites in Memphis, Colorado, New International Stroke Conference Summary York, Indianapolis, Los Angeles and Burlingame who believed in carrying out BEST-MSU and Mobile Stroke Results for Clot Lysis in LVO a rigorous clinical trial, and after raising funds for their MSUs, were willing to The Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared allocate 50% of its time to Standard to Standard Management by Emergency Medical Services (BEST-MSU) Study Management rather than having their (NCT 02190500) is a prospective, multicenter, alternating-week, cluster- MSU in operation full time. That required controlled trial at 7 U.S. sites (Yamal YM, Rajan SS, Parker SA, et al. Benefits of a sacrifice, and a commitment to research stroke treatment delivered using a mobile stroke unit trial. Int J Stroke 2017 that I believe the results have validated. doi:10.1177/1747493017711950reference). Results were presented at the And of course I want to tip my hat to my colleagues in Germany, Drs. Fassbender 2021 International Stroke Conference and have been submitted for publication. and Audebert, who are the true fathers of 1,047 tPA-eligible patients were analyzed; tPA treatment was significantly more the MSU concept and whose efforts we frequent and faster on the MSU, with one-third treated within the first “golden have built upon. hour”. Outcomes measured at 90 days using a utility-weighted Rankin scale And congratulations to our Australian were significantly better in MSU patients and there were no safety concerns. colleagues, Drs. Davis and Donnan who Longer term follow up for cost-effectiveness is ongoing. At the same meeting, have received a transformative grant Alexandra Czap MD presented data on 69 MSU patients who had a LVO from their government to develop an air- demonstrated either by CTA or a dense MCA on plain CT and who received tPA MSU to serve the remote and indigenous at a median of 68 minutes after stroke symptom onset. Twenty eight percent communities of that continent. of these patients had LVO clot lysis on repeat imaging on average one hour later, Now we need to translate these positive and this was associated with substantial clinical improvement, providing trial results into clinical reality. From biological proof of the powerful thrombolytic effect of tPA when given in the “efficacy” to “effectiveness”. That should first hour. be the motto of PRESTO going forward, Page 5

Mobile Stroke Unit News April 2021 Summary of the B_PROUD study results and 10 years MSU service

Continued from Audebert, p. 1

aim of further reducing time to treatment by bringing the necessary Berlin currently has diagnostic and treatment procedures to three STEMOs, the patient rather than the other way mobile stroke units around. Berlin’s first purpose-built which help reduce mobile stroke unit was launched in time to treatment. February 2011. Following years of research, the team was able to confirm Photo: S. Haase / that STEMO-based stroke treatment is Berliner Feuerwehr safe2 and, more importantly, reduces time to treatment3. Nowadays, the

Berlin Fire Department operates three STEMO vehicles. As part of a collaboration with three participating Not only did a greater number of MSU The odds of patients with MSU dispatch hospital owners, these vehicles cover patients receive thrombolysis (60 for having significant disabilities 3 most of the Berlin area. Data from the percent vs 48 percent in the control months after stroke was 29 percent recently published B_PROUD study1 group), they received this treatment on lower compared to patients with show that dispatch of mobile stroke average 20 minutes earlier than conventional ambulance care. MSU units is associated with improved controls. After 3 months, approximately dispatch therefore results in significantly outcomes in patients with stroke. 7 percent of patients in the MSU more stroke patients returning to an dispatch group died. This figure com- independent life after stroke. The study evaluated patients with acute pared with 9 percent in the conventional The health economic analysis looking at cerebral ischemia between February ambulance group. Similarly, while cost-effectiveness and cost-utility is 2017 and May 2019. Whether a MSU approximately 51 percent of patients in currently underway. was dispatched or not was effectively the MSU group reported no stroke- decided by chance: if one was available related impairments in day-to-day Prof. Heinrich J. Audebert, M.D. is Professor within the relevant area, it was functioning, the corresponding figure in of Neurology at Charité Universitätsmedizin, dispatched at the same time as the the control group was only 42 percent. Berlin, Germany. conventional ambulance, enabling the patient to receive treatment before B_PROUD Co-Primary Outcome Results: Dichotomized mRS1 their arrival in hospital. A mobile stroke unit was dispatched in 749 of a total of 1,543 cases analyzed as part of the study (49 percent). If no MSU was available at the time of the emergency call, only a conventional ambulance was dispatched to ensure transport to a specialist hospital. In 794 of these cases, patients were cared for within the conventional emergency medical system. Using a standardized protocol, the researchers then determined survival at three months post-stroke and the extent of References any neurological impairment affecting 1. Ebinger M, B. S, Kunz A, et al. Association between Dispatch of Mobile Stroke Units and Functional Outcomes among Patients with Acute Ischemic Stroke in Berlin. JAMA. 2021. the patients. Functional outcome was 2. Weber JE, Ebinger M, Rozanski M, et al. Prehospital thrombolysis in acute stroke: results of the measured with the modified Rankin PHANTOM-S pilot study. Neurology. 2013;80(2):163-168. Scale (mRS) ranging from ‘0’ (no 3. Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on neurological deficit) to ‘6’ (death) and time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA. rated by blinded certified raters. 2014;311(16):1622-1631.

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Mobile Stroke Unit News April 2021

Major Government Commitment to Air Mobile Stroke in Australia

Continued from Davis et al, p. 4 Ceretom CT scanner in the current Melbourne Mobile Stroke Unit still weighs over half a ton. Our aim is to develop scanners weighing around 100kg or even lighter! The “Stroke Golden Hour” program brings together academic aeromedical and materials engineers, with commercial partners. The aim is to produce two scanners, weighing between 100kg and as little as 30kg. One of these is using a microwave technique, which can detect changes in the electrical properties of brain tissue due to change in blood flow, water A concept diagram for the Micro X ring device. This will be a lightweight CT scanner content and temperature with a high using novel nanotube technology. Developed by Micro X, Adelaide, Australia sensitivity. In early clinical tests, there is encouraging ability of microwaves to differentiate haemorrhagic stroke from nosis and treatment to the scene of the disability. “We are bringing together ischaemic stroke. Another approach patient’s stroke. It’s all about time and aeromedical and material engineers, uses ultra- lightweight CT scanning using the need to administer thrombolysis stroke physicians, Indigenous medical novel, non-thermionic nanotube tech- within 4.5 hours of stroke onset – but professionals, specialist nurses and par- nology. This allows miniaturization of ideally within stroke’s ‘Golden Hour’. amedics, as part of our team,” he says. the scanner and has no moving parts. And with new data showing a significant The Golden Hour research program also The early prototypes have already increase in younger Australians exp- includes a novel stroke patient app provided images that show promise, eriencing stroke, this will have which will use a digital telehealth although a huge amount of devel- enormous implications for the nation,” platform to transfer and receive real- opmental work and clinical validation says neurologist, Prof. Geoffrey Donnan. studies lie ahead in our 5-year program. time patient and audio com- Prof. Davis pointed out that patients in munication with a city-based stroke The aim is for paramedics to travel with remote part of Australia are twice as physician, 24-hours a day, transforming one of the scanners, effectively taking likely as city stroke survivors to be left the support of health careers out in the the emergency department to the with a serious, lifelong disability. “And field. It is underpinned by an educational patient. The scanners would be only 3% of rural and remote patients program and an economic evaluation. embedded in standard road ambulances receive care in a specialist stroke unit, and aircraft. For those relying on the compared with 77 % of people in metro Stephen Davis, MD is Professor of Trans- nation’s ambulance helicopters or the areas”. Providing acute stroke care to lational Neuroscience at the University of Royal Flying Doctor Service’s jets, the remote indigenous communities will be Melbourne, Director of the Melbourne Brain Centre at the Royal Melbourne Hospital and standard of care will be transformative. a major aim. Indigenous Australians Co-Chair of the Australian Stroke Alliance. Treating clinicians at the remote suffer stroke around 10 years younger Geoffrey Donnan, AO, MBBS, MD is location will be linked to stroke experts with poorer outcomes. This program by a national tele-stroke system. The Professor of Neurology, University of aims to help bridge that gap. Melbourne, and Co-Chair of the Australian Royal Flying Doctor Service coordinates “One in four Australians will have a Stroke Alliance. Damien Easton is CEO of the the world’s largest fleet of air Australian Stroke Alliance. Amanda Place is ambulances, with more than 80 aircraft. stroke sometime in their lives. While 1,000 Australians die from stroke every Director of Communications of the Australian Stroke Alliance. “Fundamentally, we are taking the diag- month, very few survive without some

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Mobile Stroke Unit News April 2021

Vision for the Future of Mobile Stroke and PRESTO We already have subcommittees add- ressing the first two—dispatch and Continued from Grotta, p. 5 1. Do we want to sponsor our own reimbursement—but they need to be 2. How can we increase the number of congresses apart from AHA, ESOC, SVIN strengthened and broadened, and other

MSUs so they transition from a etc, or should we integrate with one of subcommittees need to be formed. those to have a yearly satellite meeting? “demonstration” project to a public 4. Should we grow our “newsletter” into health solution? This will require better 2. How can we raise awareness, make a regular publication? Something to reimbursement and a business model. ourselves known as an organization, think about. 3. How can we speed and increase increase membership, make member- Our positive results have created a new thrombectomy as well as tPA? This will ship more attractive? opportunity for PRESTO. require on-board CTA or other new technology to identify LVOs quickly and 3. How can PRESTO act as an organ- Carpe diem! achieve the “direct to angio” paradigm. ization to achieve each of the goals I James C. Grotta, MD, is Director of Stroke have listed, and others that members Research and Director, Mobile Stroke Unit 4. How can we improve other aspects of may identify? I suggest we have working Consortium, Memorial Hermann-Texas stroke treatment using our MSU subcommittees to address each one. Medical Center, Houston, TX. platform? This will require clinical trials of hemostatic agents for ICH such as FASTEST, TNK or other new thrombolytics, anti-thrombotic drugs to Mobile Stroke Presentations at ISC 2021 amplify the effect of tPA, revisiting cytoprotective therapies given within Oral Presentations Poster Presentations the first hour, etc.

5. How can we reach rural and under- Benefits of Stroke Treatment Delivered by a Mobile Interventional Stroke Teams Lead to served communities that are not Mobile Stroke Unit Compared to Standard Improved Outcomes in the Early Time Window Management by Emergency Medical Services for LVO Stroke amenable to a centrally based (BEST-MSU Study) Jacob Morey, MBA distribution? This will require air-MSUs James C. Grotta, MD such as soon-to-be implemented in Immediate Recanalization of Large Vessel Association of Anemia with Functional Australia and Norway, and perhaps Occlusions by tPA on the Mobile Stroke Unit Outcomes in Patients with Mechanical “roving” ground-based MSUs serving a Alexandra Czap MD Thrombectomy defined underserved geographic area. Taha Nisar, MD

6. How can we leverage what we have Low Frequency Vibrations Enhance Reimbursement of Mobile Stroke Units in the learned with ischemic stroke Thrombolytic Therapy and Improve Stroke United States: A Survey by the Prehospital Outcomes Stroke Treatment Organization (PRESTO) management to other emergent cond- Nirav Dhanesha, PhD Kenneth W. Reichenbach Jr., CRNP, MSN itions? MSU AIS management can be the “footprint on the moon” for other Going the Distance for Thrombectomy: The Hemorrhage Enlargement in the First Two conditions; for instance ECMO for Ultra Long-Distance Transport Hours: A Mobile Stroke Unit Study Carlos Garcia-Esperon, MD Ritvij Bowry, MD cardiac arrest, and enhanced resusc- itation after head trauma. The Mobile Interventional Team: Coming to a Successful Conduct of an Acute Stroke Clinical Hospital Near You Trial During COVID From the organizational standpoint, Johanna T. Fifi, MD James C. Grotta, MD PRESTO must have the mission to make these goals a reality. We will hopefully Virtual Care via Mobile Application Using a Comparing Process, Performance Measures and Patient Electronic Health Record Portal is Clinical Outcome Between Mobile Stroke Unit see an increase in membership as MSUs Feasible and Increases Stroke Patient and Usual Care in Underserved Areas proliferate. We need to be prepared. Engagement - A Pilot Study Yongchai Nilanont, MD What is our identity? What should we Leslie Pope, RN

do as an organization? We have already Propelling Prehospital Stroke Care: Stroke Care, Pitfalls of Mobile Stroke Treatment Unit - A begun by forming membership and re- Transport Trials, and Telestroke Helicopter Single Center Review search committees, but now we have to Enrique C. Leira, MD, MS Mangala Gopal, DO think bigger.

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