in Acute Stroke Care: Stroke Centers
This presentation addresses
some of the systems that could be used to optimize the care of patients
with acute cerebrovascular accidents. Several areas will be discussed,
1) Emergency medical services
2) Emergency Department
3) Acute stroke teams
4) Stroke protocols
5) Stroke units
6) Neurological services
7) Neuroimaging and laboratory
8) CQI efforts
9) Educational programs
institutional support for stroke care
in Acute Stroke Care: Stroke Centers
In 1996, the National
Institute of Neurological Disorders and Stroke (NINDS) sponsored a
National symposium on the "Rapid Identification and Treatment
of Acute Stroke".(1) The
symposium brought together a multidisciplinary group of experts representing
more than fifty organizations interested in the care of stroke patients.
Five panels were assembled that reviewed and made recommendations
on how to reduce disability and improve the quality of life for stroke
victims, see Table 1. The
panel presentations emphasized the pivotal role played by prehospital
providers and emergency physicians in acute stroke care.
The Executive Summary of the symposium recommended that: "Emergency
departments must have specialized protocols in place for identifying
candidates for therapy and treating those that require therapy within
a narrow therapeutic time window" and "Hospitals must develop
comprehensive acute stroke plans that define the specialized roles
of nursing staff, diagnostic units, stroke teams, and other treatment
services . . .".
Studies on acute
stroke management released since the seminal NINDS trial in 1995 have
borne out the imperative of organized systems necessary for acute
stroke care.(2,3) There is a narrow therapeutic window that mandates
rapid identification, transport, diagnosis, and treatment; any weak
link in this "chain of survival" undermines the system and
the quality of care available to the acute stroke patient.
Only 1% to 3% of ischemic stroke patients are being treated
with tPA, primarily as the result of delays in disease recognition
and arrival to the emergency department (ED).(4,5)
In addition to timely arrival to the ED,
physician acceptance of tPA and institutional attitudes and
capabilities have impeded the widespread use of tPA.
In one study, only 10% of eligible patients with an acute ischemic
stroke received tPA.(2)
in the ED, expedient triage, diagnostic testing and interpretation
must be accomplished to assess eligibility for thrombolytic therapy.
When used properly, tissue plasminogen activator (tPA) has
been clearly demonstrated to be beneficial.(4,5)
The Brain Attack Coalition (BAC) was formed under the sponsorship
of the NINDS to pursue and promote the agenda established by the 1996
Symposium. Members of
this multidisciplinary group are listed in Table 2.
Recognizing the importance of adhering to the acute stroke
management and treatment guidelines as defined by the NINDS, American
Stroke Association, and the American Academy of Neurology (4, 6, 7
), the BAC developed recommendations for the creation of stroke centers.(8)
The BAC proposed the creation of two levels of stroke centers;
primary stroke centers and comprehensive centers.
Eleven elements were identified as necessary to qualify as
a primary stroke center, see Table 3. These recommendations were not intended to be guidelines per
se, though the release of the recommendations have stimulated a debate
on the need to credential services provided by hospitals.
Emergency Medical Services
EMS is the link
between the community and the hospital.
EMTs and paramedics interface with the community at multiple
levels, providing services that range from onsite education in the
community, to triage decisions regarding whether to transport a patient,
to transport decision regarding level of transport, speed of transport,
and destination of transport.
Consequently, a stroke center cannot exist without full integration
In the 1995 NINDS
symposium, it was emphasized that EMS training curricula were significantly
deficient in the areas of cerebrovascular disease.
Dispatchers and prehospital care providers had limited instruction
on stroke diagnosis and management which contributed to the small
numbers of acute stroke patients arriving in the ED within the therapeutic
window. Since that time there has been significant effort in upgrading
training though there is limited data to demonstrate impact at this
time. EMS is the vital
link and a successful stroke center must be involved in the EMS quality
assurance program, EMS training, and EMS continuing education.
Those EDs receiving
acute stroke patients must have systems in place to expeditiously
triage them and to initiate diagnostic and therapeutic management.
Issues in acute stroke care have taken on an important role in emergency
resident education, while the recent emergency medicine literature
has actively published on topics related to stroke.(13, 14)
Emergency physicians are ideal coordinators of acute stroke
response since they are the medical directors for EMS, are experts
in stabilization and resuscitation, and intimately familiar with resource
utilization and system operations at their respective hospitals.(11)
Acute Stroke Teams
concept of an acute stroke team is modeled after that of the trauma
team, ie, designated personnel experienced in the diagnosis and management
of a specific problem type.
In the case of stroke, effective management depends on a comprehensive
neurologic examination, proper laboratory testing and neuroimaging
with proper result interpretation, familiarity with thrombolytic administration,
and ability to recognize and manage the complications of the stroke
or the thrombolytic therapy.
There are many potential scenarios that vary depending on the
institution that demonstrate the advantages of a stroke team: these
scenarios range from the busy ED that does not have the resources
to support the continuous care required by the acute stroke patient,
to the low volume ED that does not see acute stroke frequently enough
to be familiar with the stroke guidelines.
A stroke team is
composed of at least one physician and one other health care provider,
i.e., a nurse or physician
extender. The physician
can be a neurologist, emergency physician, or other specialist, but
must have interest and expertise in acute stroke care.
The stroke team must be able to respond within 15 minutes and
available 24 hours a day. There must be a system in place for rapid mobilization of the
team, communication between various services, ideally including communication
with EMS prior to patient arrival.
The stroke team must document its activities and have in place
a mechanism to evaluate its performance and patient outcomes.
Written Care Protocols
in acute stroke has been shown to be an effective treatment when guidelines
are carefully followed. (4, 5, 9)
Failure to adhere to time limits and to exclusion criteria
has been associated with unacceptable morbidity.(2)
In one study, tPA was associated with a 15.7% intracranial
hemorrhage rate which was almost three times that reported in the
NINDS trial; this unacceptably high rate of hemorrhage was linked
to failure to closely adhere to accepted guidelines in thrombolytic
One study from
North Carolina documented that 66% of hospitals surveyed did not have
an acute stroke protocol and that 88% did not have an established
mechanism for rapid triage of the acute stroke patient.(10) Written
protocols are a valuable tool in the provision of quality care.
Protocols for the acute stroke patient must include both prehospital
and ED management and be comprehensive in their scope.
Protocol deviations can be minimized with an ongoing education
Studies have shown
that morbidity and mortality from acute stroke can be decreased when
patients are cared for by providers familiar with issues related to
the post-stroke period. These
issues include care strategies to prevent aspiration, deep vein thrombosis,
pneumonia; and strategies to promote mental and physical rehabilitation.(15
) Not all hospitals can
provide these services, therefore, it is reasonable that once a patient
is stabilized that they are transferred to a facility that can.
is rare in acute stroke yet a distinct possibility. (4) In the NINDS
trial, only one of 22 patients with an intracranial hemorrhage required
a neurosurgical intervention.
Hospitals caring for the acute stroke patient must have mechanisms
in place to access neurosurgical support.
This can entail either having
a neurosurgeon on call and available for emergencies within
2 hours, or protocols to facilitate the transport of a patient to
a hospital with neurosurgical capabilities.
Commitment and Support of the Medical Organization
to accept acute stroke patients must have an administration that is
committed to ensuring the services necessary for quality care are
in place. Such a commitment entails allocated funding toward maintaining
the infrastructure necessary for ongoing acute stroke care.
This infrastructure includes 24 hours a day / 7 days a week
services, continuing education, and a medical director for the stroke
team who understands the requirements for maintaining a stroke center.
Neuroimaging and laboratory services
Acute stroke protocols
require that a neuroimaging study be performed within 25 minutes of
being ordered and read within 20 minutes of study completion.
The study must be read by someone experienced in interpreting
the images in the context of acute stroke since risk stratification
can be performed based on findings. (5)
It has been recommended
that laboratory study results be available within 45 minutes of being
ordered. In general,
the acute stroke patient needs a complete blood cell count, blood
chemistries, and coagulation studies.
In addition, cardiac enzymes may be necessary in select patients.
The BAC recommends that, due to the importance of these studies,
that the Director of Laboratory Services provide a written letter
of support towards ensuring the timely availability of testing results.
Outcome and quality improvement
Tracking of the
care provided to all acute patients is essential to any continuous
quality improvement (CQI) program.
Studies have demonstrated the value of CQI in stroke care.(16,
17). The BAC recommends
that hospitals providing acute stroke care have systems in place for
tracking patients treated including the timing of therapies, complications,
short-term and long-term outcomes.
and management is continually evolving, mandating the need for ongoing
continuing education. Neuroimaging technologies are rapidly changing and new therapies
are on the horizon. The
BAC identifies the importance of education not only for the health
care provider but also for the community at large since effective
stroke care and activations of the stroke care system must begin with
recognition of the problem by the patient.(18)
effective management of the acute stroke patient requires intact systems
that facilitate diagnostic and therapeutic decision making.
At the present time, tPA is the only drug readily available
for treating an acute stroke and its therapeutic window is small.
Those hospitals accepting these patients must be prepared to
mobilize the appropriate resources to ensure a timely diagnosis, and
must be prepared to manage consequent complications.
When treatment protocols are carefully followed, symptomatic
intracranial hemorrhage can be reduced to levels even below that reported
in the NINDS trial.(5) Conversely,
when systems are not in place, an unacceptably high complication rate
results not only from thrombolytics but from the complications of
the stroke itself.
Table 1: Panels at the NINDS symposium on stroke
Medical Care Systems Panel
Health Care Systems
Table 2: Members of the
Brain Attack Coalition
of Neurological Surgeons
of Neurosciences Nurses
of Emergency Physicians
of Neurologic Disorders and Stroke
Stroke Belt consortium
Table 3: The 11 elements
necessary for a hospital to provide acute stroke care
Acute stroke team
available 24 hours a day
Written care protocols
to ensure rapid recognition, diagnosis, and treatment
services integrated into the acute stroke team operations
integrated into the acute stroke team
available within 2 hours
and interpreted within 45 minutes of patient arrival
with rapid turn around of tests
program including a database or registry
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Katzan I, Furlan A, Lloyd L, et al. Use of tissue-type plasminogen
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Tanne D, Bates V, Verro P, et al . Initial clinical experience
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