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NINDS: Stroke Proceedings: Grotta Panel


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

Acute Hospital Care: Resource Utilization

James C. Grotta, M.D.
University of Texas Medical School, Houston

What constitutes the minimal and maximal resources needed for acute stroke care? How should "primary" and "comprehensive" stroke centers be defined, and is there something in between?

To help hospitals begin to develop stroke plans appropriate for local needs, we have subdivided stroke resource components into nursing, diagnostic, stroke team, and therapy.

A primary stroke center would have the following minimal facilities needed to carry out medical acute stroke therapy, including intravenous thrombolysis:

Nursing: a receiving area with the ability to monitor vital signs and cardiac function, suction, give intravenous hydration, and initiate intubation and ventilation.

Diagnostic: CT completed within 25 minutes and read within 45 minutes (might employ teleradiology), electrocardiogram, and laboratory for basic hematology, chemistry, and coagulation tests.

Stroke team: a neurologist or other physician with stroke expertise on call within 15 minutes, either on site or by telemedicine. Neurosurgical availability on site or by transport within 2 hours. Radiologic expertise to interpret CT scan.

Therapy: pharmacy, monitoring capabilities for vital signs, oximetry, and neurological status as per published guidelines. For eligible patients, a door-to-drug time of 60 minutes.

In addition to the above, a comprehensive stroke center would have complete facilities and expertise available for all aspects of stroke therapy, diagnosis, and secondary prevention.

Nursing: all of the above with one dedicated nurse for the patient during treatment, a designated space for acute stroke treatment, oximetry, and the ability to assess the patient within 10 minutes of emergency department (ED) arrival.

Diagnostic: all of the above with CT scan completed and read within 30 minutes, magnetic resonance imaging and angiography (MRI/MRA), carotid ultrasound, and transesophageal echocardiography. Cerebral catheter arteriography with endovascular team available to have patient catheterized within 45 minutes of ED arrival. Optional newer techniques such as CT angiography, diffusion and perfusion MRI, single photon emission computed tomography, and transcranial Doppler.

Stroke team: multidisciplinary team available within 15 minutes, 24 hours a day, 7 days a week; should include a neurologist, neurosurgeon, endovascular neuroradiologist, and stroke nurse. Communication system established between stroke team, ED, and prehospital emergency medical services (EMS) for early identification and prioritization of appropriate patients for acute stroke therapies. A backup system established for communication breakdowns. Establishment of critical pathways and standing orders for stroke patients in the ED and after admission. Flow-charting and other techniques for speeding patient triage, diagnosis, and treatment in the ED. Maintenance of a registry of stroke patients, treatment, and diagnosis.

Therapy: pharmacy response within 15 minutes. Critical care or stroke unit beds available with no more than four patients per nurse and 24-hour physician availability. Operating room and staff familiar with cerebral aneurysm and carotid artery surgery.

Rehabilitation facilities: physical, occupational, nutritional, and speech therapy available within 24 hours of patient admission.

Comprehensive stroke centers are typically involved in clinical and basic stroke research. They may have stroke fellowship programs and are active in stroke continuing medical education.

Intermediate stroke centers would incorporate some, but not all, of the features of a comprehensive center and would provide more skilled services than a primary stroke center. For example, emergency cerebral angiography and uncomplicated cerebrovascular surgery may be available, but 24-hour endovascular neuroradiology services, complex cerebrovascular surgery, dedicated stroke intensive care units, or new imaging technologies such as diffusion weighted MRI may not be available.

There are many arguments for and against the concept of stratification of stroke centers. Arguments in favor of some form of stratification include:

  1. It would reinforce the concept that stroke treatment in the 21st century requires revised planning and allocation of resources for all health care providers including acute care hospitals.
  2. It would provide an impetus for centers interested in stroke care to organize themselves and select the level of care appropriate to their particular site.
  3. It would enable health care networks to optimize resource utilization and standardize care across the network.
  4. It would help EMS professionals and referring physicians identify where stroke patients should go to receive optimal care.
  5. It would foster outcomes assessment and quality improvement.

Arguments against stratification include:

  1. A system of "haves" and "have-nots" would be created which would discourage the "have-nots" from developing a program of care for acute stroke patients, and perhaps discourage future innovation among the "haves."
  2. Most stroke patients presently do not qualify for acute stroke therapies because they do not arrive quickly enough at a hospital where the expertise is available. Since available stroke therapies (intravenous t-PA) and those under development (neuroprotective agents) can be given at most hospitals with minimal facilities (i.e., primary stroke centers), establishing a rigidly stratified system might restrict patient access to rapid treatment.
  3. Establishing and monitoring a rigidly stratified system would require a complex administrative suprastructure.
  4. A rigidly stratified system may have undesirable political, regulatory, and medicolegal consequences.

The goal of any stratification system should be to increase patient access to high-quality stroke care. Hence, all systems should be flexible, voluntary, and based on a hospital's ability to meet key guidelines established through national consensus. There was little support for mandatory certification of stroke centers. The purpose of such stratification would be to include as many hospitals as possible in the care of acute stroke patients at a level commensurate with their resources.

Lastly, the measure of efficacy of any acute stroke center, regardless of care level, should be outcomes based. Time targets can be used to measure system efficiencies, e.g., percentage of patients treated within 60 minutes of arrival. Centers should also be able to compare costs, length of stay, and (most importantly) mortality and morbidity outcomes with those from centers that have similar levels of care and with national benchmarks. Optimal stroke outcome will also require prevention of secondary complications of stroke, optimal specialized nursing care, rehabilitation, and secondary stroke prevention.

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

Last updated May 17, 2011