REVISED

RECOMMENDATIONS FOR

PRIMARY STROKE

CENTERS

Samuel Bierner, MD

Professor, PM&R

UT Southwestern Medical Center

Brain Attack Coalition report Stroke

2011;42:2651-2665

First Recommendations

•2000

Revised Recommendations

•2011

Burden of stroke

United States

• 795,000 persons per year

have a new or recurrent

stroke

Causes of death

• 4th Leading Cause of

Death (down from 3rd)

• Major cause of adult

disability

2 Levels of Stroke Centers

PSC (Primary Stroke Center)

• Provide acute care to

most patients with stroke

• Use some acute stroke

therapies;

• Admit the patient to a

stroke unit

CSC (Comprehensive Stroke Center)

• Large or complex stroke;

• Hemorrhagic stroke;

• Requiring specialized

treatments

(endovascular, surgery)

• Multi-system involvement

• Neurosurgical services

immediately available

Major Elements of a PSC

Patient Care

• Acute Stroke Team (AST)

• Written care Protocols

• Emergency medical services (EMS);

• Emergency Department;

• Stroke Unit;

• Neurosurgical Services;

• Imaging Services;

• Rehabilitation Services;

• Laboratory Services

Administrative/Support

• Institutional Support

• PSC Director, call reimbursement

• Stroke Registry with outcomes and QI components;

• Educational Programs for Public and Professionals

• Certification

• Participate in Stroke System of care

Acute Stroke

Team• At bedside within 15

MINUTES

• At least 2 members

• If a rapid response team from

outside hospital, must be

able to respond in less than

or = 15 minutes

Initiate diagnostic and

Immediate care

At least

1 Physician with

expertise in

cerebrovascular

disease;

1 other healthcare

provider (nurse, PA or

NP)

Available 24/7 basis

Class I A

Recom-

mendation

• Written Care Protocols

• Swallow evaluation before

feeding

• DVT prophylaxis

EMS

• “drip and ship”

protocols for use of

intravenous tPA;

• Inclusion of “air

ambulances” is a new

recommendation;

• New technologies:

telemedicine, telestrok

e/teleradiology

• Los Angeles Pre-

hospital Stroke Screen

• Establish time of

onset;

• Transport patient’s

medications with them

to hospital;

• Cooperative

educational activities 2

x per year

Emergency Department

• ED personnel must be

trained in diagnosis

and treatment of all

types of acute stroke

• -Use of tPA in acute

ischemic stroke

• Door-to-physician

assessment time of 15

minutes

• Key ED personnel

should participate in

educational activities

at least 2 times per

year;

• 8 hours CEU per year;

• Log of patients and

door to physician times

maintained

Stroke Unit

• Defined group of beds

• Step-down unit with nurse: patient ratio of 1:3.

• Written care protocols

• Nursing expertise in NIHSS and vital signs checked every 1-2 hrs.

• Multi-channel telemetry (BP, P, O2, Resp)

• Stroke Units reduced death by 17 to 28%;

• 7% increase in ability to live at home;

• 8% reduction in length of stay

Neurosurgical Services

• Ventricular drainage

catheter placement;

• Evacuation of a

hematoma;

• Decompressive

hemicraniectomy for

massive cerebral

infarction

• NSG care must be

available within 2

hours of the time it is

deemed clinically

necessary

Cerebral and Cerebrovascular Imaging

• Must be able to perform head CT within 25 minutes of the order being written;

• Physician can read scan within 20 minutes of its completion

• Brain MRI may be used in lieu of head CT if same time parameters can be met.

• Vascular imaging (MRA or CTA) should be available for those patients who might benefit from this testing

Cardiac Imaging

• Significant % of

ischemic strokes are

due to cardio-embolic

disease:

• Atrial fibrillation;

• Myocardial infarction;

• Valvular disease;

• Aortic Arch plaques;

• TTE

• TEE

• Cardiac MRI

• PSC should have at

least 1 modality

available to image the

heart for all admitted

patients with stroke.

Laboratory Services

• Blood chemistries

• Coagulation studies

• Pregnancy test (when

appropriate)

• Studies must be

completed within 45

minutes of being

ordered

• ECG

• Chest X-ray

• HIV test

• Pregnancy test

• Drug toxicology test

• All must be done

Rehabilitation Services

• TJC (Joint

Commission) has

included rehabilitation

consideration as a

disease performance

measure for PSC

• Early assessment of

needs (PT, OT, ST)

• Early assessment of

rehabilitation potential

• Early initiation of basic

rehabilitation activities

• Does not have to have

inpatient unit (IRF)

TJC Certification Program

• Launched in 2004

• More than 800 PSC’s in current network

• Must select 2 relevant patient-care parameters for benchmarking each year

• Quality Improvement –Stroke Registry or Database

• UTSW and Parkland are both certified