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Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care

Gilchrist, Siobhan JD, MPH; Sloan, Arielle A. JD, MPH; Bhuiya, Aunima R. BSc; Taylor, Lauren N. MPH; Shantharam, Sharada S. MPH; Barbero, Colleen PhD, MPPA; Fulmer, Erika B. MHA

Author Information
Journal of Public Health Management and Practice: March/April 2020 - Volume 26 - Issue - p S19-S28
doi: 10.1097/PHH.0000000000001126


With approximately 800 000 strokes occurring annually in the United States, including almost 180 000 among working-age adults, there is an ongoing need for time-sensitive access to lifesaving treatments.1,2 Intravenous administration of a thrombolytic agent and endovascular therapy are recommended to treat ischemic stroke, the most common type, within only a few hours of onset. However, not all hospitals have the capacity to effectively diagnose and treat stroke. The American Stroke Association and the Brain Attack Coalition (BAC) began publishing policy recommendations in 2000, supporting state policies that incorporate stroke centers into a continuum of care.3–7 The continuum spans prehospital, in-hospital, and posthospital care.3 Prehospital care involves dispatching emergency medical services system (EMSS) providers to assess, triage, and transport a patient with suspected stroke to a stroke center with the appropriate level of care in a timely manner. In addition, EMSS providers transport patients with stroke needing more advanced care from one hospital to a higher-level stroke center. With respect to in-hospital care, a hierarchy of stroke center certification evolved since 2000, starting with hospitals certified as Primary Stroke Centers (PSCs) by accrediting organizations (eg, The Joint Commission, Healthcare Facilities Accreditation Program, Det Norske Veritas) and state agencies.8 PSCs are specifically staffed and equipped to diagnose, treat, and initiate rehabilitation for most patients with stroke.8 By 2009, 14 states had enacted legislation recognizing PSCs. Accrediting organizations began certifying hospitals as Comprehensive Stroke Centers (CSCs) around 2012.9 CSCs provide a broader array of neurological services to treat more complex strokes. The BAC proposed certification of Acute Stroke Ready Hospitals (ASRH) in 2013 to encourage rural or smaller facilities to diagnose and initiate stroke treatment using telemedicine.4 Certification for Thrombectomy Capable Stroke Centers to address severe stroke became effective in 2018.3 To date, more than 1500 hospitals have become certified as stroke centers.3 Posthospital care includes secondary prevention and rehabilitation services to reduce the likelihood of functional impairment, long-term disability, and stroke recurrence.3

The integration between the EMSS and stroke centers is vital to ensure timely access to treatment.10 Local and state public health agencies can facilitate this formally through rule making or informally through guidance, recommendations, and resources. These activities may include convening stakeholder committees; developing coordinated patient care plans such as prenotifying a hospital when a patient with stroke is en route; and developing standardized protocols authorizing ground and air ambulances to bypass a nearby non-stroke-certified hospital for a certified stroke center.10 In addition, because EMSS infrastructure is complex and often fragmented across the local, regional, and state levels, a regionalized approach has been proposed to coordinate care across networks of hospitals and emergency medical services (EMS) providers through collaboration, communication, and Continuous Quality Improvement (CQI) performance monitoring.10–13 Public health agencies also engage stakeholders in CQI monitoring through data collection and sharing.14 For example, state health departments participating in the Paul Coverdell National Acute Stroke Program (PCNASP) offer support to hospitals and EMS providers to collect and analyze performance metrics of stroke care provided.14,15

Few studies have examined the relationship between state law and prehospital and in-hospital stroke care. One study described the uptake of state and local EMS policies from 2000 to 2010 authorizing direct transport to certified stroke centers. The authors reported that by 2010, more than half of the US population lived in a jurisdiction with a stroke transport policy.16 A study assessing the impact of legislation on the number and distribution of certified PSCs found that a larger percentage of hospitals were certified as PSCs between 2009 and 2013 in states that had previously enacted stroke legislation compared with states that had not.17 This study used the presence or absence of legislation as one factor but did not determine how the states were regulating specific aspects of the stroke care continuum, particularly around prehospital and in-hospital care delivery.

The United States has experienced stagnation in the 40-year declining trend in stroke death rates. A Centers for Disease Control and Prevention (CDC) report found that stroke death rates in 38 states from 2013 to 2015 have “slowed, stalled, or reversed.”18 For example, 6 states in the southeastern stroke belt experienced increases in stroke mortality rates, although at least 3 of these states had enacted stroke-related legislation prior to 2013.17 While numerous factors may be attributed to these changes, an understanding of state stroke system statutory and regulatory infrastructures may assist health care authorities in developing strategies to deliver more effective and efficient stroke care.

A public health systems and services research approach that applies legal epidemiology methods could illuminate weak or strong links within state systems. A 2011 Institute of Medicine report recommended strengthening the evidence base for policy making and using the best available evidence to formulate policy if strong evidence is lacking.19 To date, there are no empirical studies evaluating the impact of laws addressing specific aspects of the stroke systems of care. Given this lack of direct evidence, an examination of the best available evidence associated with the “key elements” of law that are likely to have the “greatest public health impact” could contribute to policy deliberations and build the evidence base for effective stroke policy.20 This descriptive study provides the first step. It links the results of an early evidence assessment of stroke policy interventions to a rigorous policy surveillance analysis of enacted state law and determines the extent to which state law reflects the evidence bases and expert recommendations for policies to improve stroke outcomes.


Two researchers with legal training jointly developed and tested a coding protocol designed to quantify provisions identified in state law that establish the legal authorities and infrastructure regulating the implementation of the prehospital and in-hospital stroke systems of care. A subset of variables in the protocol was used to align with the findings from 2 evidence assessments of the best available evidence for 16 types of stroke policy interventions using the Quality and Impact of Component (QuIC).21–24 Next, the researchers independently developed and ran multiple search strings using the Westlaw search engine* to collect the body of relevant law (statutes, regulations, and acts) for each of the 50 states and Washington, District of Columbia (collectively referred to as “states”) in effect on January 1, 2018.

Both researchers independently reviewed and redundantly coded each state's body of law (hereinafter referred to as “law”) according to the level of authority codified (eg, required, required with exceptions, authorized, or prohibited) for each variable. The researchers compared all state law records, discussed and resolved all divergences, and recoded to the agreed-upon response. Since only 1 state had a law addressing the QuIC posthospital policy intervention that had an emerging evidence base, this article focuses on the prehospital and in-hospital policy interventions and relevant variables that add contextual information. This research did not involve human subjects.


As of January 1, 2018, 39 states addressed 1 or more aspects of prehospital or in-hospital stroke care in law; 36 recognized at least 1 tier of stroke care. No state prohibited any policy intervention. The following subsections describe the prevalence of states with law addressing stroke systems of care legal authorities and organizational framework; prehospital and in-hospital policy interventions; and the degree of integration between prehospital and in-hospital stroke care. The prehospital results are presented in an order reflecting real-world practices, from EMS education on the use of a standardized stroke assessment protocol to transporting the patient and prenotifying the hospital a potential patient with stroke is en route, then transporting the patient to a higher stroke center level if warranted, and CQI to evaluate the EMSS cycle. Similarly, in-hospital results are ordered with PSCs as the foundation of the tiered system, then CSCs and ASRHs, followed by telemedicine, a feature associated with ASRHs, and finally CQI to assess the system.

Legal authorities and organizational framework

While the details of each state's law vary, most states used their legal authorities to develop and implement the stroke system through task forces, state regulatory agencies, and regional entities (Table 1).

  • Task forces: Twenty states required or authorized establishing a task force or similar entity to oversee or advise on stroke care coordination. Three of these states authorized a committee to develop recommendations for further consideration by the legislature or an executive agency. As of this analysis, these 3 states adopted no prehospital and in-hospital stroke laws.
  • Regulatory bodies: Twenty-one states authorized and 7 states required state agencies (eg, Department of Public Health, Office of Emergency Medical Services) to use rule-making authority to implement the stroke system.
  • Statewide and/or regional approach: Thirty states expressly established a state-level or centralized approach to stroke care coordination. Eighteen states also established a decentralized approach at regional or local levels.

TABLE 1 - Stroke Systems of Care Policy Interventions by Evidence Rating and Number of States With Relevant Law as of January 1, 2018
Policy Intervention Evidence Rating Number of States
Legal authorities and organizational framework
Stroke Systems of Care Task Force (Task forces) N/A 20
State Agency Rule-Making Authority (Regulatory bodies) N/A 28
Statewide Systems of Care (Statewide approach) N/A 30
Regional Systems of Care (Regional approach) N/A 18
Any legal authorities and organizational framework law 37
Prehospital care
Continuing Education on Stroke for EMS Providers (EMS education) Emerging 11
Standardized Stroke Screening Tool Use by EMS Providers (Standardized screening)a Promising quality 13
EMS Triage and Ground Transport to Most Appropriate Stroke Facility (Triage and transport) Best 20
Air Medical Triage and Transport to Most Appropriate Stroke Facility (Triage and transport) Best 3
Stroke Prenotification of Receiving Facility by EMS Providers (Prenotification) Best 6
Interfacility Transfer to Most Appropriate Stroke Facility (Interfacility transfer) Best 18
Continuous Quality Improvement of EMSS for Stroke (EMSS CQI) Emerging 11
Any prehospital evidence-supported law 30
In-hospital care
Primary Stroke Centers (PSCs)b,c
Nationally Certified Primary Stroke Centers (PSC)b Best 32
State Standards for Primary Stroke Centers (PSC)b Best 5
Comprehensive Stroke Centers (CSC)b,d
Nationally Certified Comprehensive Stroke Centers (CSC)b Promising quality 30
State Standards for Comprehensive Stroke Centers (CSC)b Promising quality 5
Acute Stroke Ready Hospitals (ASRH)b,e
Nationally Certified Acute Stroke Ready Hospitals (ASRH)b Promising quality 22
State Standards for Acute Stroke Ready Hospitals (ASRH)b Emerging 8
Other stroke centersb NA 10
Telemedicine to Initiate Treatment On-site (Telemedicine) Best 10
State-level Continuous Quality Improvement Registry (CQI)f Best 15
Any in-hospital evidence-supported law 36
Any stroke systems of care law 39
Abbreviations: ASRH, Acute Stroke Ready Hospital; CQI, Continuous Quality Improvement; CSC, Comprehensive Stroke Center; EMS, emergency medical services; EMSS, emergency medical services system; N/A, not applicable; PSC, Primary Stroke Center.
aTwenty-three states authorized use of a stroke prehospital assessment protocol, but only 13 expressly mentioned a standardized or validated tool.
bStroke center data are not mutually exclusive—for example, there are 8 states with state ASRH standards but 5 of these also recognize national standards, so those 5 states are part of the total in the Nationally Certified Acute Stroke Ready Hospitals row.
cThirty-three states recognized PSCs.
dThirty-one states recognized CSCs.
eTwenty-five states recognized ASRHs.
fTwenty-four states had a provision for stroke centers and hospitals to participate in or use a CQI data system or standards.

Prehospital care

Thirty states addressed prehospital policy interventions in law (Table 1; see Table, Supplemental Digital Content 1, available at, that lists each state and the prehospital and in-hospital evidence-supported policy interventions addressed in law).

  • EMS education: Education or training to ensure EMS providers can evaluate a patient using stroke screening tools is supported by emerging evidence. Eleven states authorized stroke education for EMS providers, of which 3 also had an emergency medical dispatch stroke education law. One state required EMS provider training at the regional level, 8 used a statewide approach, and 2 authorized statewide and regional approaches.
  • Standardized screening: EMS use of a standardized or validated stroke screening tool (eg, Cincinnati Prehospital Stroke Scale) to assess stroke is supported by promising quality evidence. Twenty-three states authorized use of a stroke prehospital assessment protocol in law; however, only 13 states expressly required (n = 12) or authorized (n = 1) use of a standardized tool. Two of the 13 expressly required use of a validated tool.
  • Triage and transport: EMS ground transport and air transport laws directly routing a patient with suspected stroke to a designated stroke center are supported by best evidence. Six states' law authorized and 14 required triage and ground transport bypass to a stroke facility. One state had a ground transport law that did not address patient triage. Six states required statewide protocols, 6 required regional protocols, and 2 required statewide and regional protocols for triage and transport. Three states authorized air transport (by airplane or helicopter) for a patient with stroke, of which 2 also authorized ground transport.
  • Prenotification: Best evidence supports EMS alerting a receiving facility that a patient with suspected stroke is en route. Six states expressly required or authorized prenotification; 4 also had a stroke transport law.
  • Interfacility transfer: Best evidence supports hospitals entering into agreements to transfer a patient to a higher-level stroke center. Fifteen states required and 3 authorized some or all stroke center levels, hospitals, or freestanding emergency clinics and receiving facilities to execute interfacility transfer agreements.
  • EMSS CQI: CQI to evaluate EMS stroke care is supported by emerging evidence. Eleven states authorized an approach that expressly addressed EMSS CQI, including 2 with statewide and regional, 6 with statewide, and 3 with regional CQI approaches.

In-hospital care

Thirty-six states established a tiered approach for acute stroke treatment in law. Thirty-three of these states required or authorized hospitals to be certified by a national accrediting body or to meet state criteria to be recognized or designated as a stroke center. They appear less concentrated across the east-north-central census division (Figure 1). The legal process by which states designated stroke centers varied substantially. Many (n = 26) required hospitals to submit to a formal state designation process for some or all levels. Three recognized hospitals that submitted an attestation of accreditation to a state agency for recognition or to be listed as stroke centers on the agency Web site. One state recognized stroke centers through its certificate of need regulatory program. Nine states developed state designation criteria that hospitals could meet in lieu of national accreditation. Ten recognized other stroke center designations, such as thrombectomy-capable centers. Four states recognized out-of-state stroke centers. In addition, most states adopted 1 or more evidence-supported in-hospital policy intervention, described later (Table 1 and Figure 1; see Table, Supplemental Digital Content 1, available at

  • PSC: Best evidence supports recognizing PSCs certified by a national accrediting body or through state-developed criteria. A total of 33 states recognized PSCs in law. Of these, 2 only recognized PSCs, 6 recognized both PSCs and CSCs, and 25 recognized PSCs, CSCs, and ASRHs. All but one state recognized nationally accredited PSCs. Five states recognized PSCs accredited using state-developed criteria, of which 4 provided hospitals the option to be nationally certified or to meet state-developed criteria.
  • CSC: Promising evidence supports recognizing CSCs certified by a national body or through state-developed criteria. Thirty-one states' law recognized certified CSCs (6 also recognized PSCs, and 25 recognized PSCs and ASRHs); 30 recognized CSCs certified by national accrediting bodies. Five (5/31) recognized state-developed criteria to designate CSCs, of which 4 (4/5) also provided hospitals the option to be nationally certified whereas 1 did not recognize national certification.
  • ASRH: Twenty-five states' law recognized nationally or state-certified ASRHs. Twenty-two (22/25) recognized nationally certified ASRHs. Eight (8/25) recognized state-developed ASRH standards, of which 5 also provided hospitals the option to be nationally certified or to meet state-developed criteria. ASRH recognition by a nationally accredited body and state-developed criteria are supported by promising and emerging evidence respectively.
  • Telemedicine: Telemedicine for stroke treatment is supported by best evidence. Ten states authorized the use of telemedicine for stroke care, of which 9 (9/10) also recognized certified ASRHs.
  • CQI reporting: Best evidence supports a statewide CQI program that includes a state-level stroke data system to track nationally recognized stroke performance metrics. Twenty-four states' law included a provision for stroke centers and hospitals to participate in or use a CQI data system or standards. Twenty mandated reporting by all (n = 13) or by some (n = 7) stroke center tiers. CQI reporting was voluntary in 4 states. However, only 15 of the 24 states established a statewide CQI approach for stroke centers to report (voluntarily or as required) stroke CQI data into a statewide data system. The reporting laws addressed 3 broad categories of stroke data systems: state specific, such as the Delaware Stroke System Registry and Quality Improvement Program (n = 5); a nationally recognized data platform (eg, “Get With The Guidelines-Stroke (GWTG)”) (n = 15); or an unspecified system (n = 4).

States With Law Authorizing Tiered Stroke Centers by Level, State-Developed Accreditation Criteria and Recognized Centers in Other States, in Effect January 1, 2018Abbreviations: ASRH, Acute Stroke Ready Hospital; CSC, Comprehensive Stroke Center; PSC, Primary Stroke Center.

Integration of Prehospital and In-hospital Care

Some combinations of policy interventions were more prevalent than other combinations, and few states authorized multiple prehospital and in-hospital policy interventions (Table 2 and Figure 2). States with EMS prenotification provisions were more likely to have telemedicine provisions (5/6) than states without prenotification (5/30). Of 15 states with a statewide CQI data system law for mandated or voluntary in-hospital reporting, 5 authorized at least 2 best evidence prehospital policy interventions and 3 of these 5 states authorized all best evidence in-hospital policy interventions. States with law designating the 3 levels of nationally and/or state certified stroke centers (PSC, CSC, and ASRHs) were more likely to have multiple prehospital policy interventions than states with fewer tiers. Of 25 states recognizing 3 tiers, 11 authorized the 2 most common prehospital interventions, ground transport and interfacility transfer, compared with 2 of 8 states that recognized CSCs and/or PSCs, and 6 of these 8 states authorized the 3 most common prehospital interventions (ground transport, interfacility transfer, and standardized screening tool). Five of 18 states that authorized interfacility transfer agreements also authorized telemedicine and recognized 3 tiers.

TABLE 2 - Number of States With Stroke Prehospital and In-hospital Policy Interventions, January 1, 2018 (Prehospital = Column and In-hospital = Row)
EMS Education Standardized Screening Ground Transport Air Medical Transport Prenotification Interfacility Transfer EMSS CQI Total
Primary Stroke Centers (any)a,b 9 13 20 3 5 18 11 33
Nationally Certified PSCa,b 9 13 20 3 5 17 11 32
State PSC Standardsa,b 2 1 3 2 2 3 3 5
Comprehensive Stroke Centers (any)a,c 8 12 19 3 5 17 10 31
Nationally Certified CSCa,c 8 12 19 3 5 16 10 30
State CSC Standardsa,c 2 1 3 2 2 3 3 5
Acute Stroke Ready Hospitalsa,d 8 12 18 3 5 14 9 25
Nationally Certified ASRHa,d 8 12 16 3 4 11 9 22
State ASRH Standardsa,d 3 2 6 2 3 6 3 8
Other Stroke Centersa 3 3 5 1 3 7 3 10
Telemedicine 3 4 5 2 5 5 4 10
State-Level CQI Registry 5 4 6 2 2 4 7 15
Total 11 13 20 3 6 18 11
Abbreviations: ASRH, Acute Stroke Ready Hospital; CQI, Continuous Quality Improvement; CSC, Comprehensive Stroke Center; EMSS, emergency medical services system; N/A, not applicable/not available; PSC, Primary Stroke Center.
aStroke center data are not mutually exclusive—for example, there are 8 states with state ASRH standards but 5 of these also recognize national standards, so those 5 states are part of the total in all 3 ASRH rows.
bPSC row counts include states that also recognized CSC and ASRH.
cCSC row counts include states that also recognized PSC and ASRH.
dASRH row counts include states that also recognized PSC and CSC.

States With Law Authorizing Tiered Stroke Centers by Level, EMS Standardized Assessment Tool, Ground Transport, and Interfacility Transfer, in Effect January 1, 2018Abbreviation: EMS, emergency medical services.

Four states authorized the most policy interventions (15, 11, and 10); 3 of these included all in-hospital policy interventions. Two states authorized all 4 best evidence prehospital policy interventions. Six authorized in-hospital but no prehospital policy interventions (see Table, Supplemental Digital Content 1, available at


From a national perspective, many states (n = 36) had taken legislative or regulatory action, largely supported by evidence, to recognize or designate stroke centers by 2018. Almost half of the states (n = 25) recognized the 3 levels of stroke centers supported by best available evidence as reported in 2 QuIC evidence assessments.23,24 These states were also more likely to have multiple prehospital policy interventions than states with fewer tiers. This suggests that policy makers are attentive to evidence-based interventions for stroke care.

A statewide regulatory infrastructure could provide the standardization needed to ensure that stroke care is well coordinated within regions and across the state.3 At least 3 states have developed an extensive regulatory approach integrating prehospital and in-hospital care at the state and regional levels. For example, Illinois regulates stroke care coordination through Department of Public Health oversight of stroke center designation and the State Stroke Advisory Subcommittee must work with Regional Stroke Advisory Subcommittees throughout the state to develop regional stroke triage and transport plans. To date, there are no detailed studies examining the impacts of different state statutory and regulatory approaches integrating stroke care across multiple state, regional, and local agencies, hospitals, EMS providers, and others. It is conceivable that complex regulatory approaches are time-consuming or resource-intensive to implement, particularly if state or substate-level agencies develop their own stroke center designations. Many states enacted enabling legislation authorizing public health agencies and committees to make recommendations and propose regulations to coordinate stroke systems of care; however, in some cases, regulations to implement the system had not been promulgated.

EMS bypass, interfacility transfer, and hospital prenotification protocols have been shown to reduce the time to stroke treatment.25–27 EMS bypass and interfacility transfer were prevalent among states recognizing stroke centers; yet, 11 states recognizing stroke centers did not authorize either policy intervention and few required prenotification or air transport protocols. Few states' law addressed training EMS providers to screen for stroke using a standardized stroke assessment tool. A recent study found a significant improvement in EMS staff knowledge of the state's stroke triage and transport protocol after attending a state-sponsored stroke training curriculum that could serve as a model for other states.28

Because ASRH certification was developed for small or rural hospitals to treat and transfer patients with stroke, interfacility transfer and telemedicine laws were expected to be more common in states that designated ASRHs.4 Of 18 states with interfacility transfer law, 14 also recognized ASRHs of which 5 also addressed telestroke (5/18); however, only 14 of the 25 states recognizing ASRHs also authorized interfacility transfer and even fewer also addressed telestroke (5/25). It was unsurprising that few states' law addressed telestroke, given that a previous study found that 44 states' telemedicine laws could encompass telestroke even if the laws did not expressly address stroke.29

These results highlight the need to integrate EMS and hospital stroke CQI performance metrics to make it easier to identify areas for improvement. Only 15 states expressly required or authorized reporting to a statewide data system, and fewer states addressed data sharing between EMS and stroke centers; yet, almost half of the states requested stroke centers to report CQI data. In 2017, Orange County, California, was awarded a federal grant to pilot a bidirectional health information exchange system between EMS providers and receiving hospitals.30 Other states, such as Michigan, are considering applying probabilistic matching to link de-identified EMS and hospital stroke data.31 These avenues may benefit stroke systems and need further exploration.

A small fraction of patients with stroke (5%) receiving the recommended therapy has led to calls to reevaluate how stroke care is delivered.13 Concerns were raised that too many hospitals are being designated as stroke centers serving too few patients with stroke to maintain a high level of efficient quality of care.32 A regionalized approach has been proposed to ensure that patients are transported to the most appropriate level of care.13 Fifteen states' law did not recognize stroke centers; yet, stroke centers exist in all states.3 However, no state was found to expressly use its regulatory power to limit the number or distribution of stroke centers. Most states allowed or required a state agency to designate any hospital that applied for designation or, in some cases, to accept the hospital's written word attesting to its certification level. Some states, such as Mississippi, certify stroke centers through a certificate of need program that could affect the distribution of stroke centers. EMS stroke transport laws requiring bypass of nondesignated hospitals also impact stroke center numbers.16 Other factors, such as public and private insurers shifting from fee-for-service to value-based and other pay-for-performance payment models for cardiovascular care, may affect how stroke systems are redesigned.33


State laws varied in their legal requirements, and this analysis did not capture how policy interventions were implemented or enforced. This study did not address how states regulate stroke systems using broad legal authorities for EMSS or hospital accreditation, nor did it capture local bypass laws such as in California or laws addressing other domains of the stroke care continuum (eg, prevention).34 Some states are advancing stroke care through the PCNASP, and their uncodified efforts were not captured. For example, Georgia participates in the PCNASP and tracks stroke CQI performance metrics using a statewide database that is not expressly authorized in legislation; however, hospital CQI reporting is required by rule.


Policy surveillance of stroke systems of care laws revealed potential strengths and weaknesses in how stroke care delivery is regulated across the nation. Many states had a stroke regulatory infrastructure for in-hospital care that is supported by best available evidence. However, there are gaps in how state law integrates evidence-supported prehospital and in-hospital care that warrant further study. By allowing for comparisons across jurisdictions, this study will serve as a prelude to subsequent studies along the CDC's Division for Heart Disease and Stroke Prevention policy research continuum,35 such as a case study examining how state stroke systems of care laws are implemented, and a study examining temporal and geographic trends in stroke outcomes associated with changes in law over time.

Implications for Policy & Practice

  • Early evidence assessment of best available evidence for stroke prehospital and in-hospital policy interventions is a translation tool that policy makers can reference when developing or implementing state stroke systems of care laws.
  • Public health practitioners can use these policy surveillance results to determine which states have adopted evidence-supported stroke prehospital and in-hospital policy interventions.
  • These results can help decision makers identify areas where departments of public health and EMSS regulatory authorities could be strengthened, such as incorporating CQI processes into regional and statewide data systems linking prehospital and in-hospital stroke data.


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*Researchers used multiple search strategies. One researcher used the search string adv: stroke/p (hospital OR center OR EMS OR “emergency medical” OR system OR care OR tele!). Another researcher used: (stroke or “transient ischemic” or “brain attack”) % “heat stroke” or engine and adv: ((911 or 9-1-1 or telecommunication! or emergency or dispatch!)/p (stroke or “transient ischemic” or “brain attack”))

A table of legal authorities can be made available upon request.


law; legal epidemiology; policy; policy surveillance; stroke; stroke systems of care

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