Article In Brief
The American Stroke Association has published an upset set of recommendations for stroke systems, suggesting four different tiers of care.
A new policy statement from the American Stroke Association aims to help hospitals, doctors, and policy makers address advances in stroke care and challenges in providing both treatment and education to the public. Neurologists said the suggestions were timely and appropriate, but they also worried about how certain recommendations would be funded, particularly in rural and poorer areas.
The statement, published in the May 20 online edition of Stroke, updated guidelines from 2005 and 2013, particularly focusing on telestroke, mobile stroke units, and improvements in neurocritical care.
Among the main recommendations were those focused on improving stroke education designed to reach diverse populations, as only 50 to 60 percent of hospitalized stroke patients arrive via emergency medical services (EMS), and racial and ethnic minorities are less likely to use EMS; extra transportation times to reach a facility capable of endovascular thrombectomy, noting that bypassing an acute stroke-ready hospital or primary stroke center without thrombectomy capability should be limited to no more than 15 minutes in patients with a prehospital stroke severity scale score suggestive of large vessel occlusion; and protocols that include pre-arrival notification by EMS that a stroke patient is en route should be used in all cases. In addition, the update policy statement called for more research into the effectiveness of mobile stroke units—CT-equipped ambulances staffed with a nurse and paramedic and often supported by a physician via telemedicine.
Karin Nystrom, APRN, is the stroke program manager at the comprehensive stroke center at Yale New Haven Hospital and one of the statement authors. She said part of the challenge in developing new recommendations is the increasingly wide variety of stroke treatment centers and options.
Four Tiers of Care
Now there are four tiers of care—acute stroke care hospitals, primary care centers, thrombectomy-capable centers, and comprehensive stroke centers, not including mobile stroke units. That sometimes makes it confusing for hospital systems, patients, and EMS to figure out the right choice, she said.
“This is when all the elements of care should flow in an integrated system—in a small, rural, 60-bed hospital with telemedicine capabilities, the emergency department providers can connect with a stroke specialist to assess whether to give tissue plasminogen activator and then ship the patient to the nearest thrombectomy-capable or comprehensive center for a higher level of care.”
The challenge is to optimize care while not duplicating resources, she said, and the new guidelines strongly recommend that all the stakeholders, from community centers providing stroke awareness classes to the four stroke-care tiers, work together.
Sarah Y. Song, MD, MPH, FAAN, associate professor of neurology at Rush University in Chicago, said the new inclusion of the 15 minute-rule seems practical, and she appreciated the discussion of the mobile stroke units.
“These guidelines reflect the newest data and the idea that since some strokes, such as the most devastating and disabling strokes—large vessel occlusions—can be treated very effectively with additional catheter-based therapies, getting the right patient to the right hospital can be the difference between being dependent on others for the rest of your life or walking out of the hospital with little to no disability.”
Dr. Song said she was particularly interested in the evolving role of thrombectomy-capable centers, because how these centers will fit in the paradigm will be interesting, but likely more definition, quality and outcome measures, are needed.
In an editorial accompanying the statement, Robert A. Harrington, MD, chair of the department of medicine at the Stanford University, wrote that it might be a challenge for local and regional communities to define how to create a stroke system of care specific to their needs. He also pointed out that there is a concern that comprehensive stroke centers may not advocate for thrombectomy-capable centers for fear that they may take patients away.
“These interventions are highly effective for patients, but they are also highly remunerative for hospitals, so hospitals want to do these procedures and it's definitely good for patients at the same time,” said David Tirschwell, MD, medical director of Comprehensive Stroke Care at the UW Medicine Stroke Center at Harborview in Washington. “But it creates issues: If someone has a stroke in town X, the question becomes, do we take them to a closer place even if they can't do a thrombectomy or drive further (to a hospital that can). If we bypass the non-thrombectomy hospital, then the smaller place gets mad because they don't want to lose the patient.
“Then at the intermediate (thrombectomy-capable) level, they may be able to do thrombectomy, but no one does it frequently, and you have to perform this regularly to be good at it. The complexities continue.... and in an urban level like Seattle, which has numerous comprehensive stroke centers, adding in thrombectomy-capable centers dilutes the experience at the high level centers.”
When it comes to prehospital triage policies, “no one knows what the right answer is, and more research is needed,” Dr. Tirschwell said. “I think some natural experiments are happening now where different communities are using different approaches and we'll see what works best, but one size will not fit all.”
Often EMS are put in the middle, having to make a decision about where to take patients, while there is competition among hospitals.
Dr. Song said that by utilizing a multidisciplinary approach and involving stakeholders at many levels—from communities to hospitals to emergency medical services, and data analysts—the entire system is meant to unify, direct, and streamline stroke care, make sure that the system continues to improve over time, and ensure that each patient receives the best stroke care possible.
Victor C. Urrutia, MD, medical director of the stroke service at The Johns Hopkins Hospital, said that Maryland has a history of a cooperative approach to the stroke system of care and has implemented or is working on fulfilling most of the recommendations in the guidelines. The state has a state stroke quality improvement committee within the Maryland Institute for Emergency Medical Services Systems, he explained, and the committee has implemented inter-hospital transfer guidelines that has helped expedite door-in, door-out time in community hospitals as well as transfer times for patients.
Dr. Urrutia said one of the things he appreciated about the new guidelines was that the paper emphasized that all the stakeholders in the community should be involved in creating a stroke system of care from the start, because every community is going to be a little different. But it's important to have a central organizing body and that can be achieved through legislation and funding, to help support those partnerships and community outreach.
The updated guidelines noted the challenges of reaching out to diverse communities, and that social media might be a good way to get the word out about stroke education. As part of Joint Commission certification, stroke centers are raising to the challenge of educating the community. There is a mandate at all levels of certification to educate.
“Primary stroke centers that are accredited are mandated to demonstrate that they are out in the community teaching about stroke risk factors and recognition. When you move to the next level, a comprehensive stroke center, is required to organize CME activities in addition to community outreach. But education is not just about being certified, it's also our mission.”
Nystrom, from Yale New Haven Hospital, said that 20 years ago, if a loved one had a stroke, there wasn't much that could be done. But the pendulum has swung the other way, dramatically, and it's up to both medical centers, their communities, and its health care providers to get the message out.