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NINDS: Stroke Proceedings: Feldmann

Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Determining Acceptable Outcomes of Acute Stroke Care

Edward Feldmann, M.D. 
Brown University School of Medicine, Providence, Rhode Island

Quality improvement in our health care system is necessary and is being demanded by patients, payors, and health care providers. Stroke spans the continuum of health care, from prevention to long-term rehabilitation, and is an ideal model for the development of quality improvement indicators.

This chapter will serve as a first proposal for key indicators to assess acceptable outcomes of acute stroke care. These indicators may apply to small groups of patients at one particular institution or to a region that encompasses many institutions. The indicators are arranged according to the timing of particular events in the course of caring for an acute stroke patient (1,2), and will cover all four domains of measure: clinical, functional, patient and family satisfaction, and cost.

Key Indicators to Measure in the Prehospital Setting:

  • Presence of community education programs to inform the public and physicians about local prehospital systems available to expedite the treatment of acute stroke.
  • Recognition of stroke by patients and bystanders.
  • Use of emergency medical services (EMS) systems (911) by patients thought to have acute stroke.
  • Assignment of high priority (similar to that for myocardial infarction and serious trauma) to care of patients with possible acute stroke by EMS dispatchers and EMS personnel.
  • Presence of programs to train EMS personnel to recognize and respond to acute stroke.
  • Recognition of stroke and pre-notification of receiving emergency department (ED) by EMS personnel prior to arrival.


Key Indicators for Events Occurring in the ED:

  • A stroke system prepared for rapid response at all times--24 hours a day, 7 days a week.
  • An available protocol for acute stroke response and an ED staff practiced in all aspects of the stroke treatment algorithm.
  • Awareness by ED staff that stroke is an emergency as important as myocardial infarction and serious trauma.
  • Measurement of the time from arrival at the ED to the first ED evaluation by a physician.
  • Measurement of the time from patient arrival at ED until the acute stroke system is activated or until a stroke team receives notification.
  • Availability of CT scanning 24 hours a day.
  • Measurement of the time from patient arrival at ED to CT scan.
  • Rapid availability of the results of emergency tests required for the evaluation and treatment of acute stroke.
  • Measurement of the time from patient ED arrival until the first contact with acute stroke system personnel.
  • Presence in ED of physician with designated skills, experience, and training in treatment of acute stroke.
  • Presence of physician with training that meets established criteria for skills necessary to interpret head CT scans required prior to initiating treatment of patients with acute stroke.
  • Measurement of the annual number of patients with acute stroke treated in the ED.
  • Measurement of the annual number of patients with acute stroke for whom evaluation is completed within 3 hours of stroke onset.
  • Availability of pharmaceuticals for treatment of acute stroke on an emergency basis.


Key Indicators for Events Occurring in the Hospital:

  • Availability of stroke care guidelines and a dedicated acute stroke care unit.
  • Availability of expertise for treatment of intracerebral and subarachnoid hemorrhage.
  • Availability of acute stroke care unit or intensive care unit required for patients with subarachnoid hemorrhage or intracerebral hemorrhage, and for patients with acute ischemic stroke who have received thrombolytic therapy.
  • Presence of appropriate protocols for management of blood pressure.
  • Prophylaxis required to prevent deep vein thrombosis.
  • Initiation of established protocols and programs for secondary prevention of stroke within 24 hours of hospital admission.
  • Presence of procedures and diagnostic capability for accurate and complete reporting of treatment complications, including any intracerebral hemorrhage following initiation of thrombolytic therapy.
  • Measurement of stroke mortality rate.
  • Measurement of average length-of-stay for acute stroke patients.
  • Presence of procedures for prompt recording of data needed to document resource utilization.
  • Presence of procedures for accurately documenting the costs for acute stroke treatment.
  • Presence of procedures to record discharge status for acute stroke patients.
  • Presence of procedures to record measures of patient satisfaction.


Key Indicators for Events Occurring After the Patient is Discharged From the Hospital:

  • Availability of a full range of rehabilitation services to meet the diverse needs of recovering acute stroke patients.
  • Procedures to assure performance and recording of standard measures of functional capacity in a high proportion of acute stroke patients at the time of discharge.
  • Reports that include a standard measure of patient outcome available to all personnel involved in the entire chain of survival for treatment of acute stroke patients.
  • Presence of methods to analyze acute stroke patient outcome data and implement appropriate changes in the acute stroke care system required to improve the quality of care.


Key Indicators for System-Wide Issues:

  • Measurement of the number of designated stroke treatment centers.
  • Use of a protocol for coordination of patient referral and patient care among centers in a region.

A minimum set of key indicators would be less cumbersome to pursue and would serve to initiate the complex process of quality improvement. This minimum list should consider patient safety to be of paramount importance, and it should assess large impact issues and indicators for which reasonably reliable measurement tools exist. This minimum list might include:

  • Prehospital care:
    1. Adequate ability of public and medical professionals to identify stroke and activate the acute stroke care system.
    2. Appropriate use of EMS (911) acute stroke system.
  • ED care: Time from arrival to evaluation and treatment is appropriate.
  • Hospital care: Stroke care protocol is available and implemented for a large proportion of acute stroke patients.
  • Postdischarge care: Standard measures of patient function are recorded and analyzed.



1. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994;25:1901-1914.

2. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1996;94:1167-1174.


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Last Edited: July 01, 1999

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last Modified May 17, 2011