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<3 hours ago to a PSC or a CSC has been implemented or is in the process of implementation in 7 states, covering >25% of the US population. The states of Florida, New Jersey, Maryland, Massachusetts, New Mexico, New York, and Texas have laws or policies mandating that acute stroke patients be taken to the nearest stroke center. In other states, the limited number of such centers makes preferential routing logistically infeasible. Stroke centers in rural areas often use helicopter transportation or telemedicine technologies to provide rapid transportation and expertise to expedite treatment at outlying hospitals.33,53 However, this is clearly an area that will evolve as the number of stroke centers increases, their geographic distribution expands, and the concept is embraced by the medical community. Stroke centers should not be viewed in isolation. Rather, they should be part of a larger support network sometimes referred to as a stroke system of care. Such a system would encompass issues such as prevention, education, acute care, rehabilitation, and quality improvement.59 In addition, as the number of stroke centers increases, such facilities may form a network of hospitals that would be useful for testing new therapies for acute stroke.B. Conclusions and Recommendations Robust data demonstrate the efficacy of specialized stroke services in improving outcomes of patients with stroke. Thus, there is a strong impetus to develop such specialized stroke services across the United States. Both primary (PSC) and comprehensive (CSC) centers are needed. At present, the process of identification of PSCs is ahead of that used to develop CSCs. The details of the organization of such services may vary among institutions or in different parts of the country to reflect demographic or geographic variables. Statewide or regional programs are being developed. A method to designate stroke centers, such as the JCAHO program, is being used to ensure that centers have the expertise and resources to provide modern stroke care. Plans for EMS to bypass institutions that do not have the capability to provide modern stroke care need to be developed. The following recommendations were not included in the prior stroke guidelines. Class I Recommendations 1. The creation of PSCs is strongly recommended (Class I, Level of Evidence B). The organization of such resources will depend on local variables. The design of several community-based PSCs that provide emergency care and that are closely associated with a CSC, which provides more extensive care, has considerable appeal. 2. The development of CSC is recommended (Class I, Level of Evidence C). 3. Certification of stroke centers by an external body, such as JCAHO, is encouraged (Class I, Level of Evidence B). The panel encourages additional medical centers to seek such certification.4. For patients with suspected stroke, EMS should bypass hospitals that do not have resources to treat stroke and go to the closest facility capable of treating acute stroke (Class I, Level of Evidence B). III. EMERGENCY EVALUATION AND DIAGNOSIS OF ACUTE ISCHEMIC STROKE Given the narrow therapeutic windows for treatment of acute ischemic stroke, timely evaluation and diagnosis of ischemic stroke are paramount.60 Hospitals that maintain an ED must create efficient pathways and processes to rapidly identify and evaluate potential stroke patients. The physician’s evaluation, diagnostic testing, including neuroimaging, and contact with a physician with stroke expertise should be performed concurrently. A consensus panel convened by the National Institute of Neurological Disorders and Stroke (NINDS) established goals for time frames in these steps in the evaluation of stroke patients in the ED.25,61 At this same symposium, the “Stroke Chain of Survival” was promoted as a template for identifying critical events in the ED identification, evaluation, and treatment of stroke patients (Table 2).61 By using this template and the time goals, hospitals and EDs can create effective systems for optimizing stroke patient care.62 All patients with suspected acute stroke should be triaged with the same priority as patients with acute myocardial infarction or serious trauma, regardless of the
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