ARTICLE IN BRIEF
The Brain Attack Coalition has updated and revised its recommendations for primary stroke centers.
Technology, research, and experience have changed the course of stroke treatment in the last decade and these advances are reflected in a set of new recommendations published in the Aug. 25 online issue of Stroke.
The new guidelines were developed by the Brain Attack Coalition, a group of stroke experts who pored through the recent literature to update the evidence-based recommendations for establishing primary stroke centers initially published in 2000.
“There have been a number of advances in medical knowledge and treatment for stroke” since the initial recommendations were published, said Mark J. Alberts, MD, the lead author of the new paper.
Dr. Alberts, professor of neurology at Northwestern University and director of the stroke program at Northwestern Memorial Hospital, noted that there was a big push a decade ago to increase awareness of stroke and open specialized hospital-based stroke centers that could offer state-of-the-art emergency treatment. This effort came on the heels of the 1996 federal approval of intravenous tissue plasminogen activator (tPA) for acute ischemic stroke.
Since then, he said, about 800 primary stroke centers have been certified by the Joint Commission and the American Heart Association AHA), to guarantee that centers have standards of care and keep detailed outcome data. Still, about 150 stroke facilities, which have identified themselves as stroke centers, have not been through a certification process, said Dr. Alberts.
The updated recommendations stress the importance of acute stroke teams; implementation of telemetry monitoring; imaging with MRI and diffusion weighted sequences; MR angiography or CT angiography to image the cerebral vasculature; cardiac imaging; programs in place for early rehabilitation; and certification by independent organizations such as the AHA and Joint Commission. [For more detail, see “Key Revisions to Primary Stroke Center Recommendations.”]
“Improved care for patients with acute stroke will have significant public health and financial implications,” said Dr. Alberts. “More patients are surviving stroke with reduced disability and going home sooner in large part because of these primary stroke centers. The new guidelines will ensure better outcomes for more acute stroke patients.”
The new recommendations also pave the way for the next level of stroke center that is being established that would provide more advanced and interventional treatments to patients with more severe strokes. These comprehensive stroke centers will be set up to offer care to patients with large or complex strokes, hemorrhagic strokes or those who require endovascular surgery, said Dr. Alberts.
“Many of the new recommendations will have a substantial impact on patient care,” said Jeffrey Saver, MD, professor of neurology at the David Geffen School of Medicine at UCLA and director of the UCLA Stroke Center. For example, the new guidelines suggest that emergency medical services can now direct ambulances straight to primary stroke centers — unless there are concomitant medical conditions that require transport to the nearest emergency department — which cover about 50 percent of the population throughout the country, he said. And telemedicine services by the primary stroke center to support such services are highly recommended.
The new recommendations would require that hospitals use a formal stroke registry, such as the Get With the Guidelines Stroke Registry, to monitor performance. Centers must record how often they give tPA; how fast they implement the IV treatment; whether patients developed complications and if so, what.
“The first set of recommendations was revolutionary in 2000,” said Pierre Fayad, MD, the Reynolds Centennial professor, chairman of the department of neurological sciences and director of the Stroke Center at the Nebraska Medical Center. “These new guidelines are evolutionary. They substantiate what we are now doing and expand further the options.”
The coalition also recommended that primary stroke centers expand telemedicine capabilities that would help doctors in rural areas make quick stroke assessments and deliver acute stroke treatments. The use of the air ambulance was also added to the latest recommendations.
James Grotta, MD, professor and chairman of the department of neurology at the University of Texas in Houston, and a member of the Neurology Today editorial board, said: “These recommendations raise the bar to reflect what should be the management of the stroke patient in 2011.”
He added that the guidelines stopped short of providing a direction for the field with the expansion of comprehensive stroke centers. “We need to address triage and not just in the time it takes to get patients to a stroke center but in the delivery of care based on the severity of the stroke,” said Dr. Grotta.
Harold Adams, MD, professor of neurology and director of the Division of Cerebrovascular Disorders and the University of Iowa Stroke Center and Carver College of Medicine, said that the new criteria for primary stroke centers seem to overlap with many of the recommendations that are included for comprehensive stroke centers.
ìSome of the new recommendations, which are aimed at the non-emergency evaluation and management of patients with recent stroke, may cause problems for smaller community hospitals that may not have some of the technology and physician expertise that are included in the new guidelines,S he said.
KEY REVISIONS TO PRIMARY STROKE CENTER RECOMMENDATIONS
- Acute Stroke Team: A member of the acute stroke team should be at the patient's bedside within 15 minutes.
- EMS: The EMS team must transport patients to the nearest primary stroke center (PSC) — Class 1, Level B — unless there is another concomitant imminent life-threatening condition that would necessitate EMS transport to the nearest appropriate emergency department (ED). Telemedicine/telestroke/teleradiology technologies— Class 1, Level A — can be used by PSCs to support hospitals or other facilities in need of such support. Use of air ambulances is a class IIa, Level B recommendation.
- Emergency Department (ED): PSCs should have a well-trained and staffed ED (class 1, level B) able to monitor protocols — viral signs and neurological status — of patients.
- Stroke Units: Stroke units should include continuous multichannel telemetry capable of monitoring blood pressure, pulse, respiration, oxygenation and clinical monitoring protocols that include how changes in a patient's status are detected, how they are documented, and how medical staff are notified of such changes.
- Imaging: MRI, MRA, or CTA, and cardiac imaging should be available Class 1, level B — though the imaging is not required for all patients and is not meant to be performed in the hyperacute setting. The inclusion of transthoracic echocardiography or transesophageal echocardiography, — (Class 1, Level A) as is or cardiac MRI is recommended (Class 1, II B, Level C).
- Laboratory Services: Electrocardiogram is recommended (Class 1, Level A); as is testing for HIV (Class 1, Level B); drug toxicology, chest x-ray, and pregnancy testing (Class IIa, level C).
- Rehabilitation Services: The recommendation for rehabilitation assessment and early initiation of basic rehabilitation services is supported by multiple studies with different classes of evidence — ranging from Class 1 to Class IIa, Level B to C evidence.
- Administrative Support: Medical staff with neurological expertise improves outcomes and is an important element of a PSC (Class I, Level B); having a PSC director with training and expertise in cerebrovascular disease is also a key element for a PSC (Class IIA, Level C). The concepts of having pay for call and neurohospitalists are new and require further data before formal recommendations can be made.
- Outcomes and Quality Improvement: Stroke centers should include a stroke registry, database, or similar monitoring program, and include at least two relevant patient-care parameters for benchmarking (both Class 1, Level A).
- Certification: Specific recommendations for certification (Class I, Level B) include these criteria: the certifying body should be administratively and financially independent of the hospital; the program should include an assessment of infrastructure, personnel, protocols, and programs; a site visit should be performed at least every two years; and well-defined and quantifiable disease performance measures should be assessed on a regular basis.