Systems in Acute Stroke Care: Stroke Centers - CiteSeerX

Systems in Acute Stroke Care: Stroke Centers Andy Jagoda, MD, FACEP Kevin Baumlin, MD, FACEP

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, including: 1. Emergency medical services 2. Emergency Department care 3. Acute stroke teams 4. Stroke protocols 5. Stroke units 6. Neurological services 7. Neuroimaging and laboratory services 8. CQI efforts 9. Educational programs 10. Overall institutional support for stroke care

Systems in Acute Stroke Care: Stroke Centers Andy Jagoda, MD

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Systems in Acute Stroke Care: Stroke Centers Introduction 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) Once 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


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regarding level of transport, speed of transport, and destination of transport. Consequently, a stroke center cannot exist without full integration with EMS. 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. Emergency Department 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 The 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.


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Written Care Protocols Thrombolytic use 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 use.(2) 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 process.(11, 12) Stroke Unit 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. Neurosurgical Services Neurosurgical intervention 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 Hospitals choosing 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.


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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 longterm outcomes. Education Programs Stroke diagnosis 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) Conclusions In conclusion, 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.

Systems in Acute Stroke Care: Stroke Centers Andy Jagoda, MD Table 1: Panels at the NINDS symposium on stroke Prehospital Emergency Medical Care Systems Panel Emergency Department Panel Acute Hospital Care Panel Health Care Systems Panel Public Education Panel Table 2: Members of the Brain Attack Coalition American Academy of Neurology American Association of Neurological 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 Stroke Belt consortium

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Systems in Acute Stroke Care: Stroke Centers Andy Jagoda, MD 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 Emergency medical services integrated into the acute stroke team operations Emergency department integrated into the acute stroke team Stroke unit Neurosurgical services available within 2 hours Commitment from the institution Neuroimaging performed and interpreted within 45 minutes of patient arrival Laboratory services with rapid turn around of tests Quality improvement program including a database or registry Continuing education program

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Systems in Acute Stroke Care: Stroke Centers Reference List 1. Marler J, Jones P, Emr M. (Eds). Proceeding of a National Symposium on Rapid Identification and Treatment of Acute Stroke. [NIH publication No. 97-4239] 1996, Bethesda, MD. 1997. 2. Katzan I, Furlan A, Lloyd L, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 2000; 282:1151-1158. 3. Tanne D, Bates V, Verro P, et al. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: A multicenter survey. The t-PA Stroke Survey Group. Neurology 1999; 53:424-427. 4. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581-1587. 5. Albers G, Bates V, Clark W, et al. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000; 283:1145-1150. 6. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Practice advisory: thrombolytic therapy for acute ischemic stroke - summary statement. Neurology. 1996; 47:835-839. 7. Adams H, Brott T, Furlan A, et al. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. Circulation. 1996; 94:1167-1174. 8. Alberts M, Hademenos G, Latchaw R, et al. Recommendations for the establishment of primary stroke centers. JAMA 2000; 283:3102-3109. 9. Chiu D, Krieger D, Villar-Cordova C, et al. Intravenous tissue plasminogen activator for acute ischemic stroke: Feasibility, safety, and efficacy in the first year of clinical practice. Stroke 1998; 29:18-22. 10. Goldstein L. North Carolina stroke prevention and treatment facilities survey. Stroke 2000; 31:66-70. 11. Akins P, Delemos C, Wentworth D, et al. Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke. Neurology 2000; 55:1801-1805.


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12. The NINDS rt-PA Stroke Study Group: A systems approach to immediate evaluation and management of hyperacute stroke: Experience at 8 centers and implications for community practice and patient care. Stroke 1997; 28:1530-1540. 13. Lewandowski C, Barsan W. Treatment of acute ischemic stroke. Ann Emerg Med 2001; 37:202-216. 14. Osborn T, LaMonte M, Gaasch W. Intravenous thrombolytic therapy for stroke: A review of recent studies and controversies. Ann Emerg Med 1999; 34:244-255. 15. Stroke Unit Trialists' Collaboration. Collaborative systemic review of the randomized trials of organized inpatient (stroke unit) care after stroke. BMJ 1997; 314:1151-1159. 16. Tilley B, Lyden P, Brott T, et al. Total quality improvement methodology reduce delays between emergency department admission and treatment of acute ischemic stroke. Arch Neurol 1997;54:1466-1474. 17. Newell S, Englert J, Box-Taylor A, et al. Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998; 29:1145-1150. 18. Pancioli A, Broderick J, Kothari R, et al. Public perception of stroke warning signs and knowledge of potential risk factors. JAMA 1998; 279:1293-1297.


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Systems in Acute Stroke Care: Stroke Centers Annotated Bibliography 1.

Proceeding of a National Symposium on Rapid Identification and Treatment of Acute Stroke. [NIH publication No. 97-4239] 1996, Bethesda, MD. 1997. The proceeding from this symposium established the need for an organized, systems approach to acute stroke care. 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. The panel presentations emphasized the pivotal role played by prehospital providers and emergency physicians in acute stroke care.

2.

Alberts M, Hademenos G, Latchaw R, et al. Recommendations for the establishment of primary stroke centers. JAMA 2000; 283:3102-3109. This document reviewed the current literature regarding the need to establish designated centers for acute stroke care. The document recognizes the limited amount of outcome data to support strict guideline development, consequently, the recommendations made are primarily consensus based. The Brain Attack Coalition, which authored this paper, 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.


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Systems in Acute Stroke Care: Stroke Centers Questions 1. Approximately what percent of acute stroke patients are arriving to emergency departments within the therapeutic window for t-PA? a. b. c. d. e.

1-5% 20-25% 50-55% 70-75% 95-100%

2. Which of the following is not true regarding “Stroke Centers”? a. b. c. d. e.

Stroke Center designation is regulated by the NINDS Stroke Centers should be integrated with EMS systems Stroke Centers should have twenty-four hour a day, seven day a week, head CT availability Stroke Centers should have written protocols for triaging and treating acute stroke patients Stroke Centers should provide ongoing stroke education

3. Which of the following is true of “Stroke Teams” providing emergent stroke care at Primary Stroke Centers? a. Stroke teams should be led by a neurologist b. Stroke teams should have a neurosurgeon available in-house c. Stroke teams should be available within five hours of patient arrival in the emergency department d. Stroke teams should have a neuroradiologist reading a head CT before giving t-PA e. Stroke teams must be prepared to recognize and manage complications of thrombolytic therapy


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Systems in Acute Stroke Care: Stroke Centers Answers 1.

Answer a. The NINDS t-PA study and most subsequent studies have reported that less than 5% of acute stroke patients are candidates for thrombolytic therapy. Most acute stroke patients arrive in the ED outside of the three hours limits for t-PA eligibility. Reasons for the delay in arrival in the ED include failure of the patient to recognize that an acute stroke has occurred and delay in accessing transport to the ED.

2.

Answer a. The concept of a stroke center arose from the success of trauma centers and the recognized need for acute stroke patients to arrive in facilities capable of diagnosing and treating the stroke. Though the components of a stroke center have been delineated in a consensus documents supported by the NINDS, stroke center designation is not regulated at this time.

3.

Answer e. Stroke teams should be led by a physician with expertise in acute stroke diagnosis or management; the specialty training of the stroke team leader is not critical. Neurosurgeons should be available within two hours of need and thus a stroke center does not necessarily need an in-house neurosurgeon. Stroke teams must be mobilized upon the arrival of a patient in the emergency department; ideally, it should be mobilized via EMS notification before the patient arrives. Stroke teams must have someone with expertise in reading head CTs, however, this person does not necessarily have to be a neuroradiologist. The stroke team must be prepared to recognize and manage complications of thrombolytic therapy.