AHA/ASA Statement: Toward a Modern Stroke Care System

Megan Brooks

August 29, 2013

In a policy statement released today, the American Heart Association/American Stroke Association (AHA/ASA) outline key concepts and components of a modern stroke system of care in the United States.

"In the US and some parts of Europe and the world, various cities, states, and regions are developing multitiered systems of care for patients with acute stroke," Randall Higashida, MD, co-chair of the writing group, told Medscape Medical News.

"This document serves to put forth concepts and elements intended to optimize patient care and management procedures. [They] are practical to implement, supported by existing clinical data and expert consensus opinion, all to improve overall patient outcomes," he said.

Dr. Higashida is chief of neurointerventional radiology and clinical professor of radiology, neurological surgery, neurology, & anesthesiology, University of California San Francisco Medical Center.

The statement is published online August 29 and will appear in the October issue of Stroke.

Building a Modern Stroke System

"As stroke awareness is increasing worldwide, more patients are being rapidly assessed and triaged to hospitals for emergency therapies. However, few hospitals are certified to deliver expeditious assessment and rapid, expert care for delivering intravenous thrombolytics for acute ischemic stroke within 3-4.5 hours from symptom onset, or to treat acute causes of cerebral hemorrhage," Dr. Higashida said.

"A fully functional 'stroke system of care' that reduces stroke-related deaths by just 2% to 3% annually would translate into 20,000 fewer deaths in the US alone and approximately 400,000 fewer deaths worldwide," he noted.

"Post-stroke disability would also be reduced, which would improve the quality of life, result in the more efficient use of healthcare resources, and reduce the financial burden on patients and their families, third-party payers, and governments," Dr. Higashida explained.

The "Interactions Within Stroke Systems of Care" policy statement includes several key recommendations:

  • Developing public education programs to improve awareness of stroke symptoms and the need to call 9-1-1 to get to the hospital quickly for treatment;

  • Ensuring emergency medical service (EMS) personnel can quickly assess patients with stroke and get them to the hospital with appropriate care within 15 to 20 minutes;

  • Establishing protocols to optimize the transfer of patients between hospitals offering different levels of care and within the different departments of a hospital;

  • Supporting the certification of stroke centers that follow treatment guidelines designed to improve patient care and outcomes; and

  • Using telemedicine, especially in rural areas, to ensure patients have 24/7 access to consultation and care.

In addition, the AHA/ASA says patients must have access to post-stroke care, including rehabilitation and nursing services, regardless of their financial status or socioeconomic background. The statement also addresses issues related to adequate reimbursement for stroke treatment and care and the need for quality improvement and public reporting initiatives.

In the United States, there are now more than 1000 primary stroke centers, about 40 to 50 comprehensive stroke centers, and an unknown number of acute stroke-ready hospitals, writing group co-chair Mark Alberts, MD, clinical vice chair, Department of Neurology, University of Texas Southwestern Medical Center at Dallas, told Medscape Medical News.

"As the number of stroke centers in the US continues to grow, there is a pressing need to integrate and coordinate EMS and hospital-based care among these various groups," he said. "Already we are receiving questions almost every day from various hospitals, EMS providers, cities, and regional agencies about how to determine which patients should be triaged to which hospital."

The new policy recommendations "provide some guiding principles and approaches to assist providers and policy makers in all areas with these important decisions," Dr. Alberts said. "While these issues have been largely solved for the different levels of trauma centers, we are beginning to address similar concerns for patients with an acute stroke.  Considering the scope of stroke as a public health problem (the WHO [World Health Organization] recently announced that stroke is the second leading cause of global death), now is an ideal time to begin to organize such systems of care."

Time to Get Off the Fence

Shyam Prabhakaran, MD, MS, associate professor, Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, wasn't involved in developing the policy statement but reviewed it for Medscape Medical News.

"I believe this is an important statement that will assist regions and states that are currently operating or considering an organized stroke system of care," he said.

"As with trauma, there is evidence that care at stroke centers improves outcomes. Therefore, it is crucial that all regions develop triage and transport policies that are consistent with these guidelines and specific to their population needs," Dr. Prabhakaran added.

He said a system implemented recently in Chicago that includes triaging patients suspected of stroke to primary stroke centers has been successful, according to a report published in JAMA Neurology in July and reported by Medscape Medical News at that time.

"I hope these data and statements encourage systems that have been on the fence to step up and make policy changes," Dr. Prabhakaran said.

Stroke. Published online August 29, 2013. Full text

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