Primary stroke center: basic components and recommendations.

Abstract: Stroke is the leading cause of disability and the third leading cause of death in the United States. The brain attack coalition (BAC), whose members belong to several professional medical societies, formed a working group to explore the factors and elements that are associated with better clinical outcome after acute stroke. In the year 2000, the BAC published the recommendations for primary stroke centers (PSC). The primary goals for the PSC are to improve and to standardize stroke care. Convinced by the compelling data on the PSC, the Joint Commission on Accreditation of Healthcare Organization adopted the BAC recommendations and started certifying hospitals as designated PSCs. Many hospitals are already certified and numerous others are currently seeking certification. The BAC is now working on the recommendations for a comprehensive stroke center. The nihilism which dominated the stroke field has finally been replaced by remarkable progress and better understanding of stroke and stroke treatment.

Key Words: primary stroke center, acute stroke team, stoke unit

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Both common and treacherous, stroke has an enormous impact on society. It is the leading cause of long-term disability in adults and second only to heart diseases in causing death worldwide. (1) Its incidence is on the rise as the population ages. Currently in the United States, there are around 750,000 new or recurrent strokes every year. This results in approximately 150,000 annual deaths. (2) In recent years, the nihilism toward the care of stroke patients has been replaced by a remarkable understanding of the underlying stroke mechanism leading to significant improvement in its management. Stroke has changed from being a cerebrovascular insult to an infarct with specific causality, which can be acutely treated.

In 1995, a study funded by the National Institute of Health (NIH) showed a significant improvement in the outcome of patients who received intravenous (IV) tissue plasminogen activator (tPA) within three hours from the onset of stroke symptoms. (3) Based on the results of the trial, the Food and Drug Administration (FDA) approved IV administration of tPA within three hours of stroke onset. This was the first and only FDA-approved treatment for acute ischemic stroke. However, despite its proven efficacy and FDA approval, currently only 3 to 5% of acute stroke patients receive this treatment. One of the main reasons cited for this paucity of tPA utilization is its narrow time-window of treatment. Another important reason cited is a lack of training in the use of tPA in patients with ischemic stroke injury who arrive at the hospital within 3 hours of stroke onset. This has led to both underutilization of the therapy and sometimes violation in following the strict criteria in its administration.

In the last ten years, several clinical studies were conducted to explore factors that led to a more favorable outcome after an ischemic insult on the brain. Stroke units and acute stroke teams were the most extensively evaluated factors. Numerous meta-analysis studies, including the one performed by the Cochrane Collaboration, (4) found a reduced rate of death and in-hospital stay for patients admitted to stroke units, as opposed to regular wards. In 1995, Webb et al (5) published a study showing that a multidisciplinary approach to stroke care may reduce length of stay (LOS) and morbidity. In a study published in 1996, Wentworth and Atkinson (6) demonstrated that implementing an acute stroke program in a community hospital decreases hospitalization costs and LOS. A highly functioning acute stroke program requires a multidisciplinary team comprised of a medical director, a stroke unit, a 24-hour acute stroke team, along with a critical path care plan and standing orders for stroke, as well as ongoing research projects. Ronning et al (7) and Jorgensen et al (8) showed that acute stroke units save lives and reduce the frequency of discharge into nursing homes.

The brain attack coalition (BAC) is a team comprised of members of the American Academy of Neurology, American Association of Neurologic Surgeons, American Association of Neurosciences Nurses, American College of Emergency Physicians, American Heart Association, American Society of Neuroradiology, National Institute of Neurologic Disorders and Stroke, National Stroke Association, and the Stroke Belt Consortium. The positive data on the efficacy of certain factors on the outcome of ischemic stroke inspired the BAC to establish recommendations for a stroke center. Two of the major goals for a stroke center were to improve the level of care provided to stroke patients and to standardize certain aspects of acute care. Two types of stroke centers were postulated: 1) A primary stroke center (PSC) to stabilize and provide emergency care to stroke patients; and 2) a comprehensive stroke center (CSC) to provide extensive care for more complicated cases. Because most patients are first seen and cared for in a setting most consistent with a PSC, the group initially worked on the recommendations for a PSC.

In the year 2000, members of the BAC published the recommendations for the establishment of a PSC. (9) Recommendations were based, in part, on an extensive literature review, which included more than 600 articles of both randomized clinical trials and observational studies. Recommendations were also based on consultation with experts in the area of stroke (Table).

The recommendations to establish a PSC are as follows:

Patient Care Area:

* Acute Stroke Team: There is impressive data to support the importance of this team in acute stroke care. The team should include both physicians and health care professionals, and it is recommended that the team be led by a neurologist. The team should be available 24 hours a day, within a 15-minute time frame. There should also be a specific and well-organized system such as dedicated pagers to activate the team.

* Written Procedure/Care Protocols: Such protocols will preclude deviation from national treatment guidelines, thereby, reducing tPA-related complications. (10) They are also beneficial for stroke care in general. These protocols must be reviewed and updated at least once a year. An acute stroke treatment protocol designed by the Zeenat Qureshi Stroke Research Center at the New Jersey Medical School is shown (Fig. 1).

* Emergency Medical Services (EMS): EMS is an important component of a primary stroke center. EMS should assign acute stroke a high priority to ensure rapid evaluation and transport. Communication with the stroke center should be done effectively. On the other hand, the emergency department should efficiently receive and triage stroke patients arriving via EMS. The stroke center staff should support and participate in educational activities involving EMS personnel at least twice a year. Once the concept of PSC becomes more familiar, it is expected that EMS will transfer stroke patients only to hospitals with a designated primary stroke center.

* Emergency Department (ED): ED physicians should be trained in diagnosing and treating all types of acute stroke. There should be organized and well-established lines of communication with both the EMS and the Acute Stroke Team. More importantly, there should be written protocols for triage and treatment of patients with acute stroke. These protocols must include distinct sections related to the administration of IV tPA. The ED physicians and nurses must also pursue continuing education related to cerebrovascular diseases twice a year.

* Stroke Unit: The importance and efficacy of stroke units in the care of patients with acute stroke is supported by numerous studies. A collaborative systematic review of randomized trials on organized inpatient care after stroke showed that patients who received care in a stroke unit had a 17% reduction in death, a 7% increase in discharge to home and an 8% reduction in LOS. (4) However, the PSC requires the intention to provide care beyond the hyperacute phase of stroke. The Stroke Unit does not have to be a distinct hospital ward, but it must be staffed and directed by personnel with training and expertise in caring for patients with cerebrovascular diseases.

[FIGURE 1 OMITTED]

* Neurosurgical Services: This should be available within two hours of request. This means that either the patient can be transferred or the neurosurgeon on call is able to see the patient within 2 hours.

Support Services:

* Commitment and Support of the Medical Organization: This includes the facility, its administration, and personnel who are important to assure that the necessary training, organization, infrastructure and funding are available. The PSC must also have a designated medical director. The director does not have to be a neurologist but must have sufficient training and expertise in cerebrovascular diseases.

* Neuroimaging: Computed tomography (CT) scan or magnetic resonance imaging (MRI) should be performed within 45 minutes and interpreted within 20 minutes of patient arrival to the hospital. Interpretation of films can be done by neurology or radiology personnel or even via telemedicine.

* Laboratory Services: This should be available 24 hours a day. CBC and chemistry and coagulation profiles must be performed expediently. Chest x-ray and EKG should be performed within 45 minutes as well.

* Outcome and Quality Improvement: The center should utilize a registry to enter the various factors like outcome and type of treatment a patient receives. It should also use a specific benchmark for comparison. Each year the center should select two different benchmarks for comparison to assure standard quality of care.

* Educational Programs: The field of cerebrovascular diseases, including both diagnosis and management, is rapidly progressing. To keep up to date with the progress, members of the PSC are required to attain 8 hours of continuing medical education (CME) credits in stroke per year. Members of the PSC are also required to provide educational programs to both the public and professional staff twice a year.

After publishing the recommendations for the PSC, the BAC encouraged hospitals to develop designated PSCs based on these recommendations. In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) publicly announced their intention to implement a separate disease management program for several chronic illnesses (Disease-Specific Care Certification). The BAC sought to certify hospitals as designated PSCs based on their published recommendations. In November 2003, the JCAHO adopted the BAC recommendations and started certifying hospitals as designated PSCs. So far, 69 hospitals in United States have been certified as a designated PSC.

Conclusions

As mentioned above, the two major goals for the development of a PSC is to improve and standardize care for stroke patients. The necessity of a standardized protocol is demonstrated in two separate studies which show an increase in intracerebral hemorrhage complications from tPA when the strict administration criteria is violated. (9) A survey revealed that the majority of physicians involved in acute stroke care support the designation of a PSC. (11) After the recommendations for the institution of PSCs were published, studies were conducted to evaluate the efficacy of the PSC. One study (12) confirmed that implementing a PSC in a community hospital resulted in a 16% increase in the use of IV tPA. This, in turn, is reflected by a significant improvement in the patient's outcome, as well as in a reduction of patient care costs. Recently. Stavem and Ronning (13) demonstrated a 20% reduction in mortality in stroke patients treated in stroke units. Phillips et al (14) demonstrated that the institution of an acute stroke program, which utilizes an interdisciplinary approach, resulted in reduction in median LOS, reduction in DVT incidence by 68% and also, reduction in mortality and long-term disability. Moreover, there was also a high level of patient satisfaction. In a study evaluating the efficacy of the various elements recommended for a PSC, Gillum and Johnston (15) showed that centers with a vascular neurologist and those with written guidelines limiting tPA administration to a neurologist have lower rates of in-hospital mortality and shorter LOS and a nonsignificant increase in tPA administration.

The second half of the last century saw enormous progress in the diagnosis and management of acute stroke. New therapies, including IV tPA, are now FDA approved for use in acute ischemic stroke. Care for acute stroke patients is now recommended in a designated PSC to improve and standardize care. Recommendations for the establishment of a comprehensive stroke center were published in 2005. (16) The JCAHO will probably adopt these recommendations and start certifying hospitals as designated CSCs in the near future.

References

1. World Health Organization. The World Health Report 1999. Geneva, WHO, 1999.

2. American Heart Association. Heart Disease and Stroke Statistics: 2005 Update. Dallas. TX. American Heart Association, 2005.

3. Anonymous. Tissue plasminogen activator for acute ischemic stroke: the National Institute of Neurological Disorders and Stroke rtPA Stroke Study Group. N Engl J Med 1995;333:1581-1587.

4. Unit Trialists' Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke 1997;28:2139-2144.

5. Webb DJ. Fayad PB, Wilbur C, et al. Effects of a specialized team on stroke care: the first two years of the Yale Stroke Program. Stroke 1995;26:1353-1357.

6. Wentworth DA. Atkinson RP. Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke 1996;27:1040-1043.

7. Ronning OM, Guldvog B, Stavem K. The benefit of an acute stroke unit in patients with intracranial haemorrhage: a controlled trial. J Neurol Neurosurg Psychiatry 2001;70:631-634.

8. Jorgensen HS. Nakayama H, Raaschou HO. et al. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost: a community-based study. Stroke 1995;26:1178-1182.

9. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers: Brain Attack Coalition. JAMA 2000;283:3102-3109.

10. Katzan IL, Furlan AJ, Lloyd LE, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 2000;283:1151-1158.

11. Kidwell CS, Shephard T, Tonn S, et al. Establishment of primary stroke centers: a survey of physician attitudes and hospital resources. Neurology 2003;60:1452-1456.

12. Lattimore SU. Chalela J, Davis L, et al. Impact of establishing a primary stroke center at a community hospital on the use of thrombolytic therapy: the NINDS Suburban Hospital Stroke Center experience. Stroke 2003:34:e55-e57.

13. Stavem K, Ronning OM. Survival of unselected stroke patients in a stroke unit compared with conventional care. QJM 2002:95:143-152.

14. Phillips SJ, Eskes GA, Gubitz GJ, et al. Description and evaluation of an acute stroke unit. CMAJ 2002;167:655-660.

15. Gillum LA, Johnston SC. Characteristics of academic medical centers and ischemic stroke outcomes. Stroke 2001;32:2137-2142.

16. Alberts MJ. Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. July 1. 2005 2005;36:1597-1616.

Yousef M. Mohammad, MD, MS, Afshin A. Divani, phD, Hoda Jradi, MPH, Haithm M. Hussein, MD, Amardeep Hoonjan, MS, and Adnan I. Qureshi, MD

From the Department of Neurology, Ohio State University Medical Center, Columbus, OH, and the Department of Neurology and Neurosciences. Zeenat Qureshi Stroke Research Center, New Jersey Medical School, Newark, NJ.

Reprint requests to Afshin A. Divani, PhD, Director, Zeenat Qureshi Stroke Research Center, UMDNJ, New Jersey Medical School. 185 South Orange Avenue, Medical Science Building, H506, Newark, NJ 07103. Email: [e-mail]

Accepted March 7, 2006.

RELATED ARTICLE: Key Points

* A primary stroke center is a well-studied and designed program to improve and standardize acute stroke care.

* An acute stroke team is led by a physician with expertise in stroke management, to provide acute stroke care.

* A stroke unit is an inpatient facility, equipped with both the personnel and medical equipment to provide best care for acute stroke patients.

Table. Components of a primary stroke center

Patient care
  * Acute stroke teams
  * Written care protocols and standing orders
  * mergency medical services
  * Emergency department
  * Stroke unit
  * Neurosurgical services

Support services
  * Commitment and support of the medical organization
  * Neuroimaging
  * Laboratory services
  * Outcomes and quality improvement
  * Educational programs