Stroke is a leading cause of morbidity and mortality in the United States. The Center for Disease Control and Prevention (CDC) reports that over 795,000 people in the United States suffer a stroke each year and that approximately 140,000 of these are fatal. The annual cost of health care services, medicines, and missed days of work in the United States due to stroke is $34 billion. Yet despite these alarming figures, studies have shown that many patients suffering a stroke are not treated in accordance with recommended stroke treatment guidelines. The creation of stroke centers, and a corresponding stroke center certification, aims to improve access to and quality of stroke care nationwide.
Stroke treatment has been an area of rapid development and progress over the past 2 to 3 decades, and recent studies continue to shape our management practices. The mainstay of acute ischemic stroke (AIS) treatment has been thrombolytic therapy with intravenous (IV) recombinant tissue plasminogen activator (tPA) since the approval of alteplase by the Food and Drug Administration in 1996. This treatment has been especially effective in treating strokes due to small vessel occlusions, but much less effective in treating strokes due to large vessel occlusions (LVO). Unfortunately, LVO strokes are traditionally the most devastating in terms of morbidity and mortality. Recently, however, studies published since 2015 have shown significant benefit for LVO strokes with specialized endovascular therapies including mechanical thrombectomy. These exciting new therapies have revolutionized modern stroke care for LVO and made mechanical thrombectomy a new standard of care. This paradigm-changing intervention makes provider understanding of stroke center certification levels and capabilities of the utmost importance. 
The more time brain tissue remains ischemic, the worse the patient’s neurological outcome. This concept is known as “time is brain.” To improve outcomes, IV tPA should be administered as soon as possible from the onset of stroke. Early administration of IV tPA is associated with improved functional outcomes, decreased hemorrhagic conversion, and decreased in-hospital death. Every 15-minute delay in initiating tPA is associated with patients having 4% worse odds of walking independently at hospital discharge, 3% worse odds of being discharged to home (versus rehabilitation facility or institution), 4% greater odds of death before discharge, and 4% greater odds of experiencing symptomatic hemorrhagic transformation of the infarct. For LVO, the importance of early intervention is also critical in patients undergoing mechanical thrombectomy. Each 1-hour delay in mechanical thrombectomy reperfusion is associated with increased disability and decreased functional independence.
The American Heart Association (AHA) and American Stroke Association (ASA) 2018 guidelines recommend IV tPA be administered to all eligible patients as early as possible and within 3 hours of last known normal with an extended window of 4.5 hours in a more selective group of patients. Mechanical thrombectomy is also recommended as early as possible to eligible patients with LVO within 6 to16 hours of last known normal. Mechanical thrombectomy is considered reasonable in select patients within 6 to 24 hours of last known normal. Given these recommendations, it is critical for healthcare providers to have an understanding of stroke center certification levels and capabilities so that timely and appropriate treatment is initiated.
The Brain Attack Coalition (BAC) popularized the concept of stroke centers with a consensus statement in the Journal of the American Medical Association in 2000. The BAC was formed as a leading national group of professional stroke societies and regulatory agencies in the years before the publication. As treatment has evolved, further consensus statements have been published describing both the need for and capabilities of different levels of stroke centers and their corresponding levels of treatment. Overall, the purpose of stroke center certification and development is to improve quality and organization of stroke care.
In accordance with BAC recommendations, national certifying organizations have designated facilities as stroke centers of various levels. These certifying organizations include The Joint Commission (TJC), DNV GL Healthcare, and Healthcare Facilities Accreditation Program (HFAP). These certifying bodies ensure compliance with BAC recommendations but may have slightly different performance measures, patient volume requirements, healthcare provider experience criteria, research requirements, and site survey frequency.
The most basic stroke center certification level is the acute stroke-ready hospital (ASRH). These hospitals should be capable of performing rapid stroke assessment, stabilization, and administration of IV tPA. ASRHs provide acute stroke care in areas without nearby primary or comprehensive stroke centers. Following initial evaluation and IV tPA (if indicated), patient protocol dictates transferring to a higher-level stroke center for admission and ongoing care. ASRHs increase the availability of initial stroke care in areas with fewer resources and allow patients to be rapidly integrated into the greater stroke system.
The next higher level of stroke certification above ASRHs is the primary stroke center (PSC). PSCs have additional resources and capabilities compared to ASRHs including dedicated acute stroke teams, cerebral and cerebrovascular imaging, and an inpatient stroke unit. These facilities can provide acute care and admit most patients with AIS.
Recent advances in stroke care, especially mechanical thrombectomy lead to the development of Thrombectomy - capable stroke centers. The main requirements are the ability to perform mechanical thrombectomy 24/7 and to have dedicated ICU beds for critically ill stroke patients. These centers have to perform minimum mechanical thrombectomies per year.
The highest level of stroke center certification is the comprehensive stroke center (CSC). These hospitals provide the highest level of stroke care inclusive of neurosurgery, vascular surgery, interventional/endovascular therapy, advanced imaging (CT scan angiography and perfusion, magnetic resonance imaging with diffusion, magnetic resonance angiography), and complete hemorrhagic stroke care. CSCs can care for patients with complex strokes, hemorrhagic strokes, or strokes requiring endovascular intervention including mechanical thrombectomy.
The robust literature supporting the efficacy of mechanical thrombectomy was not available at the time of the most recent BAC stroke center certification recommendations in 2013. So while those guidelines focus on the 3 levels of stroke centers, some certifying organizations have recently introduced the concept of thrombectomy capable stroke centers (TSC). First certified by TJC in 2018, these facilities are PSCs with added capabilities to perform mechanical thrombectomy for LVO but do not meet all necessary criteria for CSC certification. TJC reports that nearly one-third of certified PSCs perform mechanical thrombectomy and meet TSC criteria. As stroke therapy continues to advance, stroke system will continue to evolve. The development of TSCs is an example of rapid adaptation within larger and more defined stroke center framework.
An area of active debate and research lies in the optimal prehospital strategy to transport stroke patients to the most appropriate stroke certified center. Since "time is brain," timely transport to definitive stroke centers must be made to minimize delays to IV tPA and mechanical thrombectomy. All stroke centers are capable of administering IV tPA, however only TSCs and CSCs are capable of mechanical thrombectomy. Consider a scenario where a patient determined to have a stroke by Emergency Medical Services (EMS) is 15 minutes from the closest ASRH or PSC, and 30 minutes from the closest TSC or CSC. Should hospital destination by EMS be to the ASRH/PSC for timely IV tPA or should the patient bypass the ASRH/PSC to the more distant TSC/CSC for possible mechanical thrombectomy? Currently, 2 basic routing strategies exist. They are known as "drip 'n ship" and "mothership."
"Drip 'n ship" refers to the strategy of transporting the patient to the nearest stroke center to initiate IV tPA before transfer to a TSC/CSC for mechanical thrombectomy if advanced imaging reveals LVO amenable to intervention. This strategy minimizes delay to IV tPA administration at the risk of delaying time to possible mechanical thrombectomy.
“Mothership” refers to the strategy of bypassing closer ASRHs/PSC stroke centers to go directly to a TSC or CSC for possible mechanical thrombectomy. This strategy minimizes delay to mechanical thrombectomy at the expense of delaying IV tPA.
Only patients suffering AIS due to LVO would be eligible for mechanical thrombectomy and thus the bypass strategy is more reasonable if EMS can recognize LVO in the field before hospital destination decision accurately. Numerous stroke scales are currently employed for EMS detection of possible LVO including the Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity Scale (CSTAT), Rapid Arterial Occlusion Evaluation (RACE), and Field Assessment Stroke Triage for Emergency Destination (FAST-ED). The selection of a particular screening tool is generally based on regional stroke system preferences.
The 2018 AHA/ASA guidelines state, "“It remains unknown whether it would be beneficial for emergency medical services to bypass a closer IV tPA-capable hospital for a thrombectomy-capable hospital." The AHA/ASA has proposed an EMS triage algorithm which recommends patients with suspected LVO and last known normal within 6 hours be transported directly to nearest TSC/CSC as long as bypass does not add more than 15 minutes to transport and does not preclude the use of IV tPA. Research investigating patient outcomes and assessment tools along with consideration of regional resources will likely guide future recommendations.
Other issues of concern include the training of emergency department and hospital-based healthcare providers to appreciate and understand the rapidly evolving stroke recommendations. Providers previously may have only evaluated an AIS patient for IV tPA eligibility. However, providers now must obtain advanced multimodal neurovascular imaging to identify possible LVO and transfer the appropriately triaged patient to a TSC/CSC certified stroke center for mechanical thrombectomy.
Stroke remains a leading cause of morbidity, mortality, and healthcare expense in the United States. However, stroke care is now in a stage of rapid therapeutic advancement for even the most devastating strokes. It is critical for providers to understand current stroke guidelines and corresponding stroke center certifications for appropriate patient care and destination protocols. Timely recognition is also critical as treatment delays lead to poorer outcomes, and may even take patients out of treatment windows for an outcome changing medication or intervention.
The lack of stroke center certification standardization is a potential area of future concern. As previously discussed, stroke centers are currently certified through independent organizations (e.g.-TJC, DNV GL, HFAP). There are government agencies that, in some jurisdictions, may give stroke center designation and some institutions even elect self-certification. The BAC strongly endorses independent certification as that has been demonstrated to be more accurate, rigorous, and comprehensive a process.
One study examining the quality of care and outcomes in PSCs taking part in Get With The Guidelines-Stroke data comparison found statistically significant differences between certification organizations. The rate of IV tPA use was found to be higher in TJC and DNV GL and lower in HFAP and state certified hospitals. Door-to-needle times were longer in HFAP hospitals, and state certified PSCs had higher in-hospital mortality. If this trend continues, changes in certification procedures may be necessary to ensure all designated stroke centers meet similar performance measures.
Optimal stroke care requires coordination and communication between providers at all healthcare levels. This starts from the initial patient contact by EMS to stroke team assessment upon hospital arrival (including clinicians, pharmacists, and nurses), to initial imaging interpretation by radiology, and finally to acute surgical or endovascular intervention with inpatient and outpatient rehabilitation. Hospital transfer may also be involved in any step of the process. As effective treatment modalities require prompt recognition and implementation, it is critical that all levels of the stroke network are operating efficiently as a team. Patient outcomes are improved when each component recognizes and effectively communicates to contribute to the overall stroke care system.
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