Overview: Acute Hospital Care Panel
Hospital Care of Acute Stroke
Anthony J. Furlan, M.D. (Session Chair)
The Cleveland Clinic Foundation
Delivery systems for acute stroke hospital care are relatively primitive compared to systems for state-of-the-art emergency cardiac care. In part, this reflects the nihilistic attitude toward acute stroke care fostered by years of providing only supportive therapy (1). The recent approval of intravenous t-PA for selected patients with ischemic stroke of less than 3 hours' duration has exposed these deficiencies and mandates changes in the hospital care system. Importantly, although the immediate impetus stems from thrombolysis and brain ischemia, these long-delayed changes in hospital stroke care will also benefit patients with subarachnoid and intracerebral hemorrhage.
Pertinent to acute stroke intervention are aggressive stroke teams with a paging and response algorithm modeled after the "Code Blue" concept used in acute myocardial infarction (AMI) (2,3). Pilot studies using stroke teams have been conducted in tertiary centers, usually related to clinical trials, with dramatic reductions in diagnostic and treatment delays (4-6). However, it probably will not be feasible to develop comprehensive acute stroke teams in many community hospitals. Some hospitals may not be equipped to care for more severe or complex stroke patients, for example those with intracerebral or subarachnoid hemorrhage. Availability of neurologists, neurosurgeons, interventional neuroradiologists, and other specialists may be limited in outlying regions.
Comprehensive regional stroke centers for patients with complex, resource-intensive cerebrovascular disorders should be identified and linked to outlying community hospitals via stroke networks. The National Stroke Association has developed guidelines for the identification of comprehensive stroke centers. However, transfer of acute stroke patients to a regional stroke center would preclude treatment in many patients. Even when 911 is called, the mean time to emergency department (ED) arrival for acute stroke patients is 2.6 hours (4-6). If the system is accessed through the family doctor or by family transport to the ED, the mean arrival time exceeds 5 hours. Hence, therapy is precluded in many stroke patients simply because of late arrival at the hospital.
To address these concerns, minimal qualifications must be established for physicians and hospitals treating patients with acute stroke. The recommended target for intravenous t-PA in acute ischemic stroke is a door-to-drug time of less than 60 minutes, which is close to the average time for starting thrombolysis after AMI (7,8). To achieve this ambitious goal, hospitals should develop an acute stroke plan designed to reduce management delays to a minimum. The National Stroke Association's Emergency Response System Organization at Sites (ERSOS) guidelines provide a detailed template for implementing a comprehensive acute stroke hospital care delivery system (9). Using templates, hospital stroke plans can be tailored to fit local needs but should include four basic elements outlined in the following sections.
As the hospital entry point for both ambulance patients and walk-ins, the ED is the common denominator for most acute stroke patients. On-site and en route communication with emergency medical services (EMS) by telemetry, radio, or telephone permits mobilization of the stroke team preferably through a dedicated beeper. An accurate prehospital diagnosis of stroke by EMS personnel using a simplified stroke scale is feasible although less precise than a diagnosis of AMI since there is no simple test like the electrocardiogram for confirmation (10,11).
Preprinted ED stroke order sheets and prepackaged specimen tubes ensure that all necessary chemistries and tests are done before treatment is started. Coagulation studies are essential. The ED should be able to test the activated clotting time (ACT), activated partial thromboplastin time (APTT), and international normalization ratio (INR) on-site and have STAT laboratory access. A 12-lead electrocardiogram machine and electrocardiogram technician should be immediately available. Training the ED nursing staff to perform a 12-lead electrocardiogram and establishing a critical pathway protocol that includes an electrocardiogram as part of the initial evaluation of vital signs in patients with possible stroke will minimize diagnostic delays.
The essential imaging technology for acute stroke is CT. Although more than 90% of hospitals with at least 200 beds have CT scanners (12), personnel and transportation delays consume 1 hour or more between ED and CT in most hospitals. Some hospitals with active stroke programs have a CT scanner in the ED. CT results should be available to the treating physician within 45 minutes of patient arrival at the ED. This can only be accomplished if there is effective integration between the ED, radiology services, and patient transport.
Diagnostic emergency cerebral angiography is required in selected stroke patients and should be available within 60 minutes of presentation to the ED. Neurointerventional procedures such as aneurysm coiling, angioplasty, and intraarterial thrombolysis require special expertise and imaging technology and should be performed at regional comprehensive stroke centers. Intraoperative angiography, stereotactic devices, and microneurosurgical equipment are necessary at comprehensive centers performing complex aneurysm and vascular malformation surgery.
A number of diagnostic technologies are available at comprehensive stroke centers but, although desirable, are not mandatory for all patients with acute stroke. These technologies include emergency carotid ultrasound and transcranial Doppler, magnetic resonance imaging (MRI, MR angiography, diffusion and perfusion MRI, echo planar MRI), single photon emission computer tomography, positron emission tomography, and transesophageal echocardiography.
After the physician has written an order for a thrombolytic drug to be administered, the agent must be obtained, properly reconstituted, and administered. Stocking the thrombolytic drug in the ED instead of in a central pharmacy significantly decreases the delay to therapy. Use of a thrombolytic drug cart, kit, or tackle box to stock the drug, checklists, standing orders, flow sheets, and adjunctive equipment including intravenous tubing, needles, blood tubes, and tape is one of the most efficient ways to organize the ED team.
A number of novel concepts have recently been developed to focus the attention and efforts of hospital ED staff on treating patients with chest pain in an expedited fashion. The most popular of these ideas is the chest pain center. Most hospitals that have developed chest pain centers have dedicated one or more monitored beds in the ED to the rapid evaluation and treatment of patients with suspected AMI. Some hospitals have dedicated a section of the ED as a clinical decision unit, where patients can be observed for up to 24 hours. This approach can reduce the cost of ruling out an AMI by up to 80% by not admitting all patients to the coronary care unit. A similar approach could potentially reduce acute stroke admissions and costs.
Hospitals lacking any intensive care capabilities should not manage patients with acute stroke. Hemorrhagic stroke often requires management in an intensive care unit (ICU) with neurosurgical input. High-risk therapies like thrombolysis and complications such as cerebral edema also necessitate that many ischemic stroke patients have access to intensive care. The utility of stroke units has been demonstrated through shortened length of stay and lower mortality, but not consistently by a better neurological outcome (13,14). However, dedicated stroke units, or even neurological intensive care units, may not be cost-effective in all hospital settings. Hospitals can adapt medical or surgical intensive care beds for acute stroke. Also, many acute stroke patients require only intermediate level neurological monitoring that can be accomplished in stepped units with lower staffing levels than an ICU (e.g., nurse:patient ratio of 1:4 versus 1:2).
New approaches and attitudes toward stroke will require neurological retraining beginning with residency programs. Physicians treating acute stroke must have some neurological experience and must learn the selection criteria for thrombolysis, including the NIH Stroke Scale (NIHSS) (15). The ability to read CT scans, recognize the early signs of brain ischemia, and distinguish hemorrhagic from nonhemorrhagic stroke is essential. Minimum stroke training and continuing medical education (CME) requirements for neurologists, neurosurgeons, family practitioners, internists, emergency medicine physicians, and radiologists must be established by the appropriate national organizations.
A comprehensive stroke team incorporates 24-hour access to a neurologist, neurosurgeon, and interventional neuroradiologist capable of diagnosing and managing any cerebrovascular problem. Subarachnoid and intracerebral hemorrhage require neurosurgical expertise. In outlying hospitals, access to neurological and neurosurgical expertise may require networked telecommunication and transportation links.
In the majority of cases of AMI, the ED physician makes the decision to administer thrombolytic therapy without further consultation. It is typically faster to treat with thrombolytic agents in the ED than to transfer the patient to an ICU. A minority of hospitals require the ED physician to consult with a cardiologist or the patient's primary care physician before administering a thrombolytic drug. Consultation remains essential in patients with relative contraindications or in whom the diagnosis is unclear, but in the majority of cases of AMI consultation only delays the administration of thrombolytic therapy. An analogous situation could pertain to the treatment of acute ischemic stroke, but first there must be improved neurological training for nurses, ED physicians, internists, and family practitioners as well as some standardization of stroke diagnostic and treatment protocols.
Experienced ED physicians can interpret electrocardiograms of patients with chest pain with nearly the same level of accuracy as cardiologists; however, cardiologists are more likely to be correct in the evaluation of difficult electrocardiograms (16). By contrast, many ED physicians receive no formal training in brain CT interpretation. Early signs of infarction on CT have been linked to an increased risk of hemorrhage complicating thrombolysis but are easily missed even by experienced radiologists (17). CT misdiagnosis is an infrequent problem in full-service hospitals with 24-hour access to radiologists, but could be a major problem in outlying community hospitals.
Transmission of an electrocardiogram to a cardiologist by a facsimile machine can provide backup interpretive assistance for the ED physician in difficult cases without significantly delaying care. Teleradiology links could provide similar services for interpreting CT scans in the ED. However, unlike the electrocardiogram in AMI, CT is normal in most patients with early ischemic stroke and the diagnosis ultimately rests on clinical neurological expertise. ED physicians, internists, and family practitioners must therefore receive sufficient neurological training during residency and through CME to be able to diagnose and treat acute stroke.
Identification and prioritization of patients with AMI or acute stroke are challenges in every busy ED. Only 4-5% of patients with chest pain who present to the ED are candidates for thrombolytic therapy (18,19). Similarly, recent stroke thrombolysis trials suggest that fewer than 5% of screened patients are eligible for therapy (15). Therefore, triage nurses may have to screen 25 patients to find one stroke patient who is eligible for urgent treatment. This low yield greatly reduces the incentive for nursing and medical staff to immediately evaluate every patient who arrives at the ED with suspected stroke symptoms. Ambulatory patients pose a particular problem, since their presentation to the ED may not be as dramatic as that of patients who arrive by ambulance. If registration is required for ambulatory patients prior to seeing a triage nurse, there is a further delay, particularly when the ED is busy and overcrowded.
Guidelines, algorithms, and critical pathways are important tools for minimizing delays and enhancing the triage of patients with acute stroke. Guidelines for the treatment of acute ischemic stroke have been published and recently were supplemented for thrombolysis (20,21). Similar guidelines have been published for subarachnoid and intracerebral hemorrhage (22,23). The thrombolysis guidelines set a promising new trend since they were jointly developed by the American Heart Association Stroke Council and the American Academy of Neurology. Guidelines improve the process of care although by themselves are insufficient to implement changes in physician behavior (24-27).
Critical pathways build on guidelines by identifying the optimal sequencing of medical management decisions and thereby enhance efficiency in the process of care (28). Integrated critical pathways have both area-specific (ED, angiography suite, ICU, regular nursing floor) and diagnosis-specific (ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage) components. Critical pathways are often implemented by nursing personnel as they assure the continuity of care in different locations and by different medical specialists. They are also important tools for quality assurance (29).
Algorithms are tools that physicians use to organize the process of making diagnostic and treatment decisions. Evidence-based algorithms for stroke have been developed but have not been widely adopted (30,31). Algorithms are controversial since they cannot take into account all of the variables and options involved in clinical decision-making and therefore run the risk of creating "cookbook" medicine. Algorithms should not be used as surrogates for neurological expertise but can provide some guidance in clinical decision-making.
The ultimate goal of any hospital acute stroke plan is to improve patient outcome. Therefore, quality improvement is an essential component of any hospital acute stroke plan, and is becoming even more important as hospitals and physicians seek to justify health care expenditures.
Community-based attempts to assess quality of care and outcomes in acute stroke have emphasized costs, length of stay, and in-hospital mortality rather than long-term disability or handicap. Available models rely heavily on coma and level of consciousness (LOC) to predict risk of death from stroke. Coma and LOC on admission are very important in predicting mortality after intracerebral hemorrhage and subarachnoid hemorrhage (32,33), but LOC alone is insufficient to predict mortality after brain infarction (34-36) and thrombolysis does not reduce ischemic stroke mortality.
Many stroke outcome models reflect the trend toward creating "minimal clinical data sets" by relying on a few easily extracted physiological variables that show statistical correlation but have no clear relevance to quality of care (37). Skepticism about outcomes research was highlighted by Iezzoni et al (38) who compared 11 different severity-adjusted models assessing stroke mortality and found that 25% of the hospitals were ranked differently, either "better" or "worse," depending on which particular model was used.
Previously there has been little pressure on physicians or hospitals to systematically change the way they examine stroke patients or record essential data (39). The omission by statistical models of stroke outcome variables validated in peer-reviewed medical literature reflects the fact that such data are not routinely collected by physicians and recorded in the medical record in a standardized format. Furthermore, measures of treatment efficacy used in clinical trials, such as stroke scales (NIHSS) and functional measures of stroke outcome at 90 days (Barthel index or modified Rankin scale), have not been the standard of care in the community setting.
It is doubtful whether short-term stroke mortality can be used to meaningfully compare quality of care between hospitals. Most of the variation in mortality between hospitals reflects not quality of care but systematic differences in unmeasured or unobserved patient characteristics, inadequacy of the fit of the model, and random error (40). Short-term mortality models cannot normalize for all of the known and unknown variables affecting outcome in different patient populations regardless of how much clinical information is available. Alternatives include process analysis, which could be linked with critical pathways, functional assessment, and patient satisfaction.
Attempts to work with neurological specialty societies to develop algorithms for stroke care have met with limited success (41). Problems included imprecise data collection and coding, and consensus difficulties due to lack of agreement over appropriate practice criteria. As expensive and dangerous new therapies like thrombolysis emerge, research on community-based stroke outcomes is urgently needed (42). A clinically relevant national stroke database created with community physician compliance in mind would greatly facilitate this effort.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last updated May 17, 2011