NEW ORLEANS – The number of certified stroke centers in the United States continues to rapidly increase, complemented by state mandates that require emergency medical services to take patients with acute strokes to designated stroke centers.
“It's a brush fire. System changes at the state level are rapidly growing,” Lee H. Schwamm, M.D. said during a press conference at the 30th International Stroke Conference.
Another step toward creating more expedited and integrated systems for managing stroke patients was taken in early February, when the American Stroke Association's Task Force on the Development of Stroke Systems published online their recommendation on establishing stroke systems of care. A print version of the guidelines appears in the March 1 issues of both Stroke and Circulation.
“There is a wide variability in the delivery of stroke care” in the United States today, said Dr. Schwamm, associate director of the acute stroke service at Massachusetts General Hospital in Boston and chairman of the task force. But “communities can identify the centers that do the right stroke care, and can preferentially send stroke patients to those centers.”
The new recommendations from the task force outline “a way to build and implement a [stroke care] system that has all of the components working together,” said Joe E. Acker III, executive director of the Birmingham (Ala.) Emergency Medical Services System and a task force member. “A state can take this document [the task force's recommendation] and create a stroke system; it's that easy,” Mr. Acker said.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began certifying hospitals as primary stroke centers in February 2004, and exactly 12 months later it had certified 88 hospitals in 28 states, said Maureen Connors Potter, executive director for international accreditation at JCAHO in Oakbrook, Ill. By last month, JCAHO was reviewing 15 hospitals each month for certification as primary stroke centers. Out of the 4,900 hospitals in the United States, 1,200 had self-reported to JCAHO their intent to eventually file applications for certification, said Ms. Potter, who presented a first-year report on the process at the conference. JCAHO review of all 1,200 hospitals could probably be completed in 2 years, once all of the formal applications are filed, she estimated.
Once a significant number of stroke centers exist within a region, another key step is to make sure that acute stroke patients are preferentially brought to the centers by emergency medical technicians. Several states–Alabama, Florida, Maryland, Massachusetts, New York, and certain counties in California–already have programs or legislation in place that mandate this approach, although some of these programs are just now becoming implemented.
Documentation of the impact that can occur from designated stroke centers and an integrated emergency medicine response plan was presented at the conference by Toby I. Gropen, M.D., chairman of the department of neurology at Long Island College Hospital in Brooklyn, N.Y. He reported on the pilot phase experience of the New York State program, which began with 14 designated stroke centers in Brooklyn and Queens in May 2003.
During 3 months prior to the start of this program, 2.4% of all patients with acute stroke who were seen at hospitals in Brooklyn and Queens were treated with tissue plasminogen activator (TPA). During the 3 months shortly after the program was in place, the overall rate of TPA use had more than doubled, rising to 5.2% of all acute stroke patients. And among patients arriving at the 14 designated stroke centers, TPA was used on 7.7% of all acute stroke patients, said Dr. Gropen at the meeting, sponsored by the American Stroke Association.
The initial experience in Brooklyn and Queens also showed other signs of improved patient care.
The average time elapsed before a stroke patient underwent a CT examination at the 14 participating hospitals was cut in half, compared with the delay before the program started. And the number of patients who were admitted to stroke units, the next step beyond the emergency department, rose from 15% just before the program began to 38% in the first months after it was in place.
Dr. Gropen was also optimistic that these numbers are still improving. “We had a rapid deployment. The more experience people have, the better treatment will get,” he said.