8/27/2013

The Future of Primary and Comprehensive Stroke

Centers

Mark J. Alberts, MD, FAHA

Chief, Division of Stroke and Cerebrovascular Disease Northwestern

University

Department of Neurology Chicago, IL

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Disclosures

Consultant and speaker for Genentech

Unpaid consultant to The Joint Commission

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Golden Era of Stroke Care

1.Advent of improved non-invasive brain and vessel
imaging with CT, CTA, MRI, MRA---greatly improved our
ability to diagnose stroke and understand the vascular
mechanisms that caused the stroke
•The recognition that stroke is indeed a medical emergency
that requires rapid diagnosis and treatment

1.The validation that IV TPA can be given rapidly after

stroke onset and improves outcomes

2.The proliferation of Primary Stroke Centers (and soon

Comprehensive Stroke Centers and Acute Stroke Ready
Hospitals)
5. Endovascular treatment of that will provide a network for acute stroke care
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aneurysms/AVMs
©2010, American Heart Association

8/27/2013 throughout the nation

Characteristics of Different Stroke Centers

Academic Medical Center Tertiary Care facility

WideComprehensive
range of hospitals;
Stroke Center
standard stroke care; stroke unit; use TPA

Rural hospitals; basic care; drip and ship;

use tele-technologies

Acute Stroke Ready Hospital

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Numbers of Various Types of Stroke Centers

75 to 200 total

Final count 1000-1200

Comprehensive Stroke Center

Perhaps 1200-1800
Primary Stroke Center

Acute Stroke Ready Hospital

> 5000 total acute care hospitals in the U.S.

What do we know about PSCs and CSCs?

•PSCs and CSCs save lives; there are very few medical
interventions that save lives!!!

•PSCs increase the use of IV TPA; this is still the only FDA-approved
medical intervention that has been shown to improve recovery after a
stroke

•Patients cared for at a PSC or CSC have improved outcomes

•Patients cared for at a PSCs are more likely to be treated according

to current guidelines; this will reduce the risk of complications and
recurrent strokes
•t
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Outcomes at a CSC: Finland Study

Meretoja et al, Stroke, 2010

Other Functions of a CSC

•Act as the “Hub” hospital to coordinate:

– Emergent communications (telemedicine,telestroke, teleradiology,

robots)
– Emergent transfers (helicopter, ambulances)

– Consultations, assistance, advice

•Act as a resource hospital or leader for various activities:

– Research programs and studies

– Educational programs for professional staff and lay public

•Act as a partner and advocate for:

– Local and regional resources (money, ambulances, etc.)

– Regional and state regulatory and legislative initiatives

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Potential Challenges of Becoming a CSC

•The major care elements must all be available on a 24/7 basis

– Some hospitals that think of themselves as a CSC do not do this

– Unclear if some hospitals can meet this requirement

1.EMS diversion or triage to CSCs may be a challenge

1. Cannot easily determine in ambulance type of stroke

2. May be able to assess stroke severity

3. Political, legal, local challenges

2.Financial issues
– Some procedures done at a CSC may not be well reimbursed in the future
– Unclear what the costs of CSC certification will be
– These issues can be overcome by increased marketing, patient volume, and
procedures

Stroke Centers in a Care Network

CSC

PS PS
C C

ASRH ASRH ASRH

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Challenges with a Stroke Center Network

1.Get the patient into EMS system as soon as possible
•Get the patient proper emergent care ASAP

•Use tele-medicine and tele-radiology to import expertise

•Use EMS and helicopters to export the patient

•Do a better job of field triage

•By-pass lower care facilities in favor of higher care if needed

1.Can this be done by changing regulations? Will new laws be

needed?

Distribution of Stroke Centers in Texas

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Stroke Centers and Referral Areas

PSCs and CSCs in a Network

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Stroke Patient Transportation to Hospital

Ambulance
Picks up stroke
leaves home
patient
base
T1
T2
T
Ambulance Transports
returns to home
3 patient to
base nearest hospital

Stroke Patient Transportation to Hospital

Ambulance Picks up stroke

leaves home patient
base T1 T2
Ambulance returns
T3
Transpo
to home base rts
patient
T4 T to
Send Ambulance
Call another 5 to Hospital
nearest
hospital
ambulance Number 1 T
Transport patient to T Pick up patient at 6
PSC or CSC hospital number
7 1

T Ambulance returns
to base
8

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Time Used for Ambulance and Patient Care Delays

•Ambulance time used: T1+T2+T3+T5+T6+T7+T8

•PATIENTS DELAYS: T1+T2+T3+T4+T5+T6+T7

•Neuronal death = 1.9 million per minute (Saver, Stroke, 2006)

•Assume each delay epoch = 15 minutes for transportation;

45 minutes at first hospital
•Taking patient to inappropriate hospital = 256.5 million
neurons lost

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Providing the Next Generation of Stroke Care

•The American Heart Association/American Stroke Association and The
Joint Commission have enhanced their long standing relationship (since
2003 for Primary Stroke) and are pleased to announce that beginning
February 1, 2012, certified Primary Stroke Centers (and Advanced Disease
Specific Certification for Heart Failure programs) will be able to use the
designated seal and heart check mark to signify that they are providing the
“next generation of stroke or heart failure care.”
•Our enhanced alliance combines the considerable expertise,
knowledge, and experience of both the American Heart
Association/American Stroke Association and The Joint Commission

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Downloadable art files of the seal and heart check mark that hospitals will be able to
use to promote their advanced certification are now available on

the TJC extranet (as of February 1st) .

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The Future of this Relationship

•Discussions continue with TJC on the intent of the two
organizations (AHA/TJC) to co-brand Comprehensive Stroke
Centers (CSC).
•TJC has initiated a Technical Advisory Panel that the AHA
Hospital Accreditation Science Committee has been actively
involved with to develop the Comprehensive Stroke Center
model.
•A tentative launch date for CSC certification has been set for
July 2012

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This is the Future of Stroke Centers

The number and CSC certification THE OUTCOMES
quality of PSCs begins and
increase accelerates

 900 PSCs and • Dozens of CSCs • More patients

counting certified in 2012 receive care in
 Increased • Quality metrics Stroke Centers and
adherence with are collected have improved
GWTG and and modified outcomes
other national • Laws are passed • CMS rewards Stroke
quality mandating Centers with higher
measures transfer of some reimbursements
 Similar patients to CSCs ©2010, American Heart Association 22
developments
around the world
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Conclusions
1.Stroke Centers improve outcomes not just by using TPA
and other high-tech tools, but by providing good medical and
nursing care to all patients on a 24/7 basis

2.Stroke centers provide an excellent venue through which to

conduct cutting edge stroke research

3.Stroke Centers will lead the way for many types of quality
improvement and outcome programs

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