Embedded Files
expert stroke care to patients located in rural areas (Class IIa, Level of Evidence B). Additional research and experience on the usefulness of telemedicine are encouraged. II. DESIGNATION OF STROKE CENTERS In an attempt to improve the organization and delivery of care to stroke patients, the Brain Attack Coalition published 2 sets of recommendations, one for primary stroke centers (PSCs) and, more recently, one for comprehensive stroke centers (CSCs).44,45 A PSC has the personnel, programs, expertise, and infrastructure to care for many patients with uncomplicated strokes, uses many acute therapies (such as intravenous rtPA), and admits such patients into a stroke unit. The CSC is designed to care for patients with complicated types of strokes, patients with intracerebral hemorrhage or subarachnoid hemorrhage, and those requiring specific interventions (eg, surgery or endovascular procedures) or an intensive care unit type of setting. The specific elements of a PSC and a CSC will not bereviewed in the present document because they are well covered in the articles cited above. Many of the elements in a PSC or a CSC, including stroke units, written care protocols, availability of physicians with neurological expertise, and neurosurgical volumes, are associated with improved outcomes among patients treated for stroke.44,45 Since the publication of the PSC article in 2000,44 numerous published studies have demonstrated the utility and effectiveness of such centers.22,46–51 One study found that a PSC increased the use of intravenous rtPA from 1.5% to 10.2% in 2 years.46 Another study found that 7 of the 11 elements of a PSC were associated with increased use of intravenous tPA.47 Additional areas of disease performance that may be added include performance of a lipid profile, dysphagia screening, and the presence of a rehabilitation plan. The utility of a CSC is beginning to emerge. Studies show that a CSC increases the use of lytic agents and that a CSC may improve overall care and outcomes.52,53 In-hospital death rates were reduced by almost 50% in hospitals with a vascular neurologist and were reduced by 24% in those with a stroke team.54 Such centers have acted as a regional resource for stroke care with good results and will be pivotal for further advancements in acute stroke care, stroke prevention, and rehabilitation.38,55,56 A. Stroke Center Certification The certification or designation of some hospitals as PSCs or CSCs is progressing rapidly. The American Stroke Association convened an expert panel to study this issue for PSCs, with the conclusion that a variety of certification processes might be developed and lead to improved care and outcomes.57 Another panel is currently meeting to evaluate various options for CSC certification. One study showed that self-certification was likely to lead to a significant overestimation of a hospital’s compliance with published recommendations for a PSC.58 Thus, these data and anecdotal experience suggest that outside independent evaluations of hospitals as stroke centers should lead to more accurate assessment of a facility’s true capabilities. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) began a formal process for the certification of PSCs in February 2004 As of February 2006, ≈200 hospitals in the United States had been certified as PSCs by the JCAHO. The JCAHO certification process includes a detailed evaluation of a hospital’s staffing, education, disease management programs, outcomes, and infrastructure (see www.JCAHO.org for details). Several states have developed or are exploring a state-based certification process for PSCs, primarily using the state health department or a related government agency as the certifier. At this time the American Stroke Association and JCAHO have taken preliminary steps that may lead to a formal certification process for CSCs. Standardized Measures for Stroke: JCAHO Primary Stroke Centers The preferential routing of acute stroke patients to a PSC has been demonstrated to increase the proportion of patients cared for at stroke-capable centers and to increase the proportion of patients treated with thrombolytic therapy to >10%.48 Direct routing of stroke patients whose symptoms started
Report abuse