December 12-13, 2002
Paul E. Pepe, M.D., M.P.H.
Steering Committee Co-Chair
University of Texas Southwestern Medical Center at Dallas
For months prior to the December 12-13, 2002 symposium, "Improving the Chain of Recovery for Acute Stroke in Your Community,"
the National Institute of Neurological Disorders and Stroke (NINDS) convened several diverse steering committee and task force
subgroup meetings to begin thoughtful formulation of proposed task force reports and recommendations. Not only were these
proposals debated, edited, and re-debated long before the culminating symposium, they were also cumulatively reviewed and
ardently discussed during the symposium itself in several rotating panels.
In these multiple rotating panels, the majority of participants had the opportunity to provide feedback, input, and active
involvement in the final recommendation process for all of the topics covered. The deliberations and proceedings were formally
recorded and summary reports were articulated in plenary sessions. Most impressively, the group was interdisciplinary, diverse,
talented, knowledgeable, and highly motivated by the quest for improved public health and strong patient advocacy. Whether
the participants were neurologists, stroke rehabilitation nurses, emergency specialists, professional group representatives,
paramedics, medical educators, or hospital system administrators (just to name a few of the participant groups), they eventually
came together in unison to effect these recommendations.
At the risk of oversimplifying the results of the extensive work and many countless hours of effort provided by the individual
task forces, their leaders, and the general participants, the principal recommendations detailed in the ensuing chapters can
be summarized as follows:
Regarding the issue of Increasing Public Recognition and Rapid Response to Stroke:
- For a variety of reasons, stroke patients, their families, and the public at large generally do not recognize and immediately
act following the onset of stroke symptoms.
- To date, there is limited experience with interventions to reduce delays, but it is believed that key messages about stroke
need to be succinct, intense, and sustained. They should also include motivational components to ensure immediate response
- Therefore, multi-level interventions, targeted at high-risk individuals and their families as well as special populations
and the public at large, must be researched, sponsored, implemented, and measured for cost-effectiveness and sustainability
through a collaborative effort of multiple community stakeholders.
Regarding the issue of Choosing Your Level of Care
- For a variety of reasons, the level of stroke care and access to acute stroke care interventions is diverse across the United
States and other countries.
- Recognizing that, today, excellence in stroke care involves more than thrombolytics and invasive interventions, all health
care institutions should evaluate their capabilities of stroke care using evidence-based practice guidelines and performance
- In turn, hospitals should explicitly state their round-the-clock stroke care capabilities and, through appropriate channels,
provide confirmatory data of these capabilities so that patients and providers of prehospital stroke care can make appropriate
decisions regarding the destination site for hospital care.
- All stakeholders in the community or health care region should join forces to set up mechanisms to assess available stroke
care resources and create stroke care networks to better match and optimize patient needs and available resources, including
designations of primary and comprehensive stroke care services.
Regarding the issue of Professional Education:
- For a variety of reasons, there have been shortcomings in the efforts to educate medical professionals regarding acute stroke
care, including methodologies and targeted audiences, and there has even been some confusion in the information delivered.
- Therefore, comprehensive, consistent, and consensus-based curricula regarding acute stroke care should be targeted at disciplines
involved in providing stroke care such as emergency medicine and neurological residencies and relevant nursing personnel.
- Also, on-going education of medical professionals, consistent with principles of multi-modal, interactive adult education,
needs to be funded for appropriate development, implementation, and evaluation of any respective educational interventions.
Regarding the issue of Templates for Organizing Stroke Triage:
- For a variety of reasons, including competitive proprietary interests, individual stroke care provider sustainability, or
omission of widespread community-based support, mechanisms for designating and verifying appropriate stroke care sites for
patient transport decisions are often lacking.
- Therefore, in addition to aggressive training of emergency medical services (EMS) personnel with appropriate tools to recognize
an acute stroke and provide appropriate advice to patients and families, stroke system organizers must also achieve buy-in
from all stakeholders-participating hospitals, neurologists, emergency medicine specialists, medical societies, local government,
professional organizations, and community groups.
- Also, if feasible, a neutral, non-proprietary community organization (ie, local stroke council) should be established to develop
and monitor EMS triage protocol compliance, and to monitor receiving facility capabilities and compliance through appropriate
and confidential quality-assurance audits.
Regarding the issue of Incentives for Enhancing Stroke Care:
- For a variety of reasons, there have been many disincentives for practitioners and facilities alike to provide optimal stroke
care, including perceived and actual considerations such as fear of liability, lack of appropriate reimbursement, and even
issues such as "off-hours" absence of support.
- Therefore, it is essential that the importance of aggressive stroke care be widely accepted and rewarded in a community by
developing strategies such as those involving education, practitioner support mechanisms, and a coordinated stroke reimbursement
plan involving stroke advocates and professional organizations.
- An appropriate forum for discussion should be provided to facilitate: 1) community consensus regarding new therapies and best
practices; 2) constructive dialogue between emergency and neurological specialists, nursing personnel, EMS personnel, and
hospital administrations; and feedback on outcomes, research, and individual patient care successes.
Regarding the issue of Provider Support Systems for Acute Stroke Care:
- For a variety of reasons, many practitioners have avoided active participation in acute stroke care, and a central theme for
these practitioners has been the sense of isolation and a lack of back-up support systems.
- Therefore, it is first recommended that many of the previous topic suggestions be rapidly implemented, particularly those
involving incentives, education, community-wide support, and consensus for stroke care and public education.
- Mechanisms for real-time back-up support should be considered. These range from standard telephone advice and teleradiology
to sophisticated automated image interpretation.
- Stroke care credentialing and hospital "stroke drills" are other options to consider for improving practitioner implementation
of acute stroke care.
In closing, it should be emphasized that these bulleted recommendations serve only to summarize and highlight some of the
very detailed and comprehensive text provided in the following chapters by the six task forces and the hundreds of dedicated
2002 symposium participants. It must be recognized that these recommendations generally focus on the limited subject of acute
stroke care and specific strategies for getting more acute stroke patients into the health care system for the earliest possible
treatment. While the recommendations still may not be as comprehensive or as complete as some might like, they are a wonderful
step in the right direction toward achieving further improvements in our nation's management of this major cause of death
and disability. Therefore, the NINDS and the other supporting organizations must be strongly commended and appreciated for
sponsoring and facilitating this symposium and for publishing these proceedings. We strongly believe that they can lead to
clear improvements in the chain of recovery for stroke in your community.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892