Article In Brief
The last 20 years have seen stroke treatment improve by leaps and bounds. But the quality of stroke services and systems of care is inconsistent across the US, with challenges in staffing, leadership, and resources affecting hospitals' abilities to deliver high-quality care.
As acute stroke treatments such as endovascular thrombectomy (EVT) continue to expand and evolve, the need to focus on improving stroke systems of care in both institutions and the community is more pronounced than ever, according to experts in the field and two new publications.
Stroke care has undergone a revolution in the past few decades, from the US Food and Drug Administration approval of tissue plasminogen activator (tPA) in 1996 to the introduction of EVT starting in the early 2000s to the establishment of EVT as the standard of care for large artery blockage types of strokes (ischemic strokes).
Both therapies require a complex, time-sensitive system aimed at getting patients to the level of stroke care needed for their particular circumstances so therapy can begin while there is an opportunity to spare or limit brain damage.
But more than 20 years later, the quality of services and systems is inconsistent across the country. Even with stroke certification in place, a hospital might still have gaps in staffing, leadership, and resources that could impact its ability to deliver the highest quality of stroke care, wrote the authors of a scientific statement the American Heart Association (AHA) published online Feb. 7 in the journal Stroke.
Additionally, a March 8 paper in Circulation noted that EVT, a procedure considered to be one of the most important developments in acute stroke care in decades, remains unavailable to many patients in the US and other countries.
“Unfortunately stroke systems worldwide are not keeping up with the increasing indications for thrombectomy and the needs of an aging population that has an increased risk for stroke,” said Dileep R. Yavagal, MD, FAAN, professor of clinical neurology and neurosurgery and director of interventional neurology at University of Miami and Jackson Memorial Hospital, who is the corresponding author of the paper on worldwide EVT inequities.
Nicole Gonzales, MD, professor of neurology at University of Colorado Anschutz Medical Campus and co-author of the AHA's scientific statement, said that practices and resources among stroke centers vary significantly, even among those that have earned the same designated level of stroke care.
Stroke programs, particularly those that offer time-dependent treatments such as thrombolysis and EVT, need to be “a well-oiled machine,” and meeting important accreditation standards shouldn't be the end of achieving that goal, Dr. Gonzales said.
“Although stroke certification standards provide guidance on stroke center process elements, lack of guidance on structural components such as workforce, staffing, and unit operations has resulted in heterogeneous services among hospitals credentialed at the same stroke center level,” explained the statement in Stroke. The paper noted, for instance, that many certified stroke centers don't have dedicated stroke units or even dedicated beds for acute stroke admissions, even though research has shown that such units help reduce death, disability, and long-term care needs of stroke patients.
The statement also pointed out that the US is “one of the only countries that consistently overuses critical care for admission of noncritical care patients receiving tissue-type plasminogen activator; this is driven largely by failure to institute specialty stroke units, resulting in unnecessary costs and limiting bed access to patients with actual critical care needs.”
Dr. Gonzales said stroke units are among the evidence-based components of stroke care that “for some reason we don't seem to be able to translate into practice everywhere.”
Despite advances in both stroke treatment and prevention, stroke is the second leading cause of death worldwide and a leading cause of disability. In the US alone, stroke affects an estimated nearly 800,000 people annually, typically occurring at age 55 and older but with a growing incidence among people younger than 50.
Another Tool for Improved Outcomes
The AHA scientific statement noted that certifying and regulatory bodies recognize four levels of stroke centers: acute stroke-ready hospitals, primary stroke centers, thrombectomy-capable stroke centers, and comprehensive stroke centers.
Dr. Gonzales acknowledged that several accreditation organizations—including the Joint Commission, DNV Healthcare, and the Accreditation Commission for Health Care as well as various state agencies—do outline the scope of care and standards of practice for each designated level. But she said the AHA statement is intended to serve as an added tool to help stroke centers assess whether they are organized and staffed in a way that they can provide the best possible continuum of care. Having the added guidance as a reference should help reduce inconsistencies in how stroke centers function, Dr. Gonzales said.
People expect that a comprehensive stroke center is so designated because it provides treatments that have improved outcomes for patients, Dr. Gonzales said. “The reality, however, is that there can be personnel gaps, and hospitals are short on resources. For example, in some centers, the stroke coordinator role can be variable: shared between other disciplines or service lines.”
When a stroke coordinator “wears too many hats, that can detract focus from comprehensive stroke care and transitioning patients back into the community,” she said.
The statement underscores the importance of having corporate leaders committed to the value of running a well-staffed and resourced stroke center as part of the hospital's overall strategic plan. In addition to detailing the roles of stroke program medical director, stroke coordinator, vascular neurologists, and neurointerventionalists, the statement also noted the important role that nurse practitioners, physician assistants, and clinical nurse specialists play as members of the stroke team.
“Advanced practice providers play an increasingly important role in stroke center operations given the vascular neurology shortage,” the statement said.
Having a data collection and review staff focused on quality metrics for stroke (such as door-to-CT time and door-to-needle time) enables centers to “demonstrate the need for performance improvement and development of new care standards,” the statement said. It said centers should strive to collect data on 100 percent of patients “to prevent bias in case selection and to provide the clearest picture of program quality.”
Dr. Gonzales said data findings should be seen not as a negative but as a prompt to specifically identify how to adjust the system of care. “If we are not meeting our door-to-needle target fast enough, we need to understand why,” she said.
The paper on EVT was published as part of a global campaign called Mission Thrombectomy to increase the availability of mechanical thrombectomy, which since 2015 has become a first-line therapy for large-vessel occlusion. A survey of 75 countries by the group between November 2020 and February 2021 found vast disparities (460-fold) between the availability of the procedures, with the lowest-income countries lagging far behind high-income countries. The paper estimated that only 2.79 percent of patients potentially eligible for EVT worldwide get the procedure.
Dr. Yavagal is the founder and global chair of Mission Thrombectomy and former president of the Society of Vascular and Interventional Neurology, which sponsors the initiative. He said that about 20 to 30 percent of all ischemic stroke patients could benefit from EVT based on the location and severity of their stroke, but even in the US, the numbers fall far below that, with only about 30 percent of eligible patients getting the procedure.
Rapid access to thrombectomy-capable stroke centers is essential to avoiding permanent disability from large artery blockage stroke since earlier EVT treatment leads to better outcomes, Dr. Yavagal explained, noting that EVT is only approved to be done within 24 hours of stroke symptoms.
A 2020 study of the distribution of thrombectomy-capable stroke centers in the US found that 19.8 percent of the population has direct EVT access within 15 minutes and just under 31 percent has EVT access within 30 minutes, with people in less densely populated areas less likely to have ready access to the therapy.
Dr. Yavagal said it is not surprising that EVT has not been more widely adopted into stroke systems of care, noting that new technologies in general can take decades to go from a novelty to standard practice. Part of the challenge with EVT is a shortage of physicians (neurologists, radiologists, and neurosurgeons) trained in the procedure. Other parts of the stroke system, from emergency medical responders to neuroimaging teams, also have to adapt to the time demands involved in EVT.
For instance, the ideal hospital door-to-puncture time for EVT is 60 minutes, and once the groin is punctured, the artery needs to be opened ideally within 30 minutes by removal of the clot blocking the artery (EVT procedure), Dr. Yavagal said.
His program at University of Miami Health/Jackson Memorial has steadily increased the number of EVT it does, from approximately 150 in 2020 to more than 200 in 2022.
Dr. Yavagal said part of the program's stroke system of care involves pre-notification of the emergency department by EMS when they suspect a large artery stroke in the field. “We also have a continuous monitoring and group review of our door-to-EVT start and finish time durations on a quarterly basis. This allows for fine-tuning of the stroke team rapid response to continually try to shorten our door-to-EVT times,” he said.
The Big Picture
Amy K. Guzik, MD, FAAN, stroke program director at Atrium Health Wake Forest Baptist, a North Carolina health care system that operates a 21-hospital telestroke network, said she believes the new AHA guidance will be a useful reference for stroke center directors and coordinators to assess how their programs stack up. Also, the added information on ideal levels of staffing and resources could be helpful for lobbying hospital administrators on the need to fill positions or raise budgets.
“Administrators may not understand the full scope of stroke care,” which involves a team effort from multiple departments and disciplines, Dr. Guzik said. In addition to hands-on roles, having sufficient staff to conduct robust data collection and analysis is essential to the goal of “continuous quality assessment.”
“A well-functioning stroke system of care provides the infrastructure and support to ensure patients are cared for at the right place at the right time, balancing the needs of high-acuity patients to access specialized care and the needs of the health system with limited bed availability,” said Dr. Guzik, who also directs her system's telestroke program.
She said stroke systems need some built-in flexibility to address unexpected challenges or obstacles to care. For example, “during the pandemic, our system was able to flex up the capabilities of our community hospitals to care for higher-acuity stroke patients with remote telemedicine support from our Comprehensive Stroke Center, preserving beds at our CSC for the sickest patients,” she said.
Victor C. Urrutia, MD, director of the Johns Hopkins Hospital Comprehensive Stroke Center, said getting more EVT centers in the community and away from urban centers is a laudable goal, but “there is a tension between having the procedure readily available and having enough volume to ensure quality. Just adding more centers may not be the full answer.”
Dr. Urrutia said every community—whether at a city level, regionally, or statewide—must determine the most logical way for them to organize a stroke system of care based on their geography, population, emergency response resources, and other factors.
“Often, the stroke centers are the drivers of that organization,” he said, noting that as a stroke program director, he works closely with emergency medical personnel and state agencies. He said stroke centers cannot be static organizations given that treatments continue to advance.
“Stroke center accreditation programs and guidance papers like the latest statement from the AHA should help foster a stroke care environment that is ready to “respond to changes in the evidence,” Dr. Urrutia said.