Recommendations for the Establishment of Stroke Systems of Care

Schwamm, Lee H.; Pancioli, Arthur; Acker, Joe; Goldstein, Larry B.; Zorowitz, Richard D.; Shephard, Timothy J.; Moyer, Peter; Gorman, Mark; Johnston, S. Claiborne; Duncan, Pamela W.; Gorelick, Phil; Frank, Jeffery; Stranne, Steven K.; Smith, Renee; Federspiel, William J.; Horton, Katie; Magnis, Ellen; Adams, Robert J.

doi:10.1161/01.str.0000158165.42884.4f

Cited by 299 publications

(82 citation statements)

References 155 publications

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“…4,12,25 Although variation in this complex process is inevitable, some delays may be preventable through organizational change to effect timely triage, diagnosis, decision making, and treatment of patients with ischemic stroke. In this large national survey of hospitals regarding their strategies to reduce DTN time, we found that the speed of tPA treatment in many surveyed hospitals was significantly longer than the recommended national target of ≤60 minutes.…”

Section: Discussionmentioning

confidence: 99%

“…[11][12][13][14][15][16][17][18][19][20][21][22][23][24] However, the extent to which hospitals are using these strategies has not been well studied. More importantly, it is not clear which strategies are most effective.…”

Section: May 2014mentioning

confidence: 99%

“…Approximately 50% of hospitals had an ischemic stroke volume of >150 patients per year (median, 163; IQR, 106-247). The median tPA volume was 10 patients (IQR, [6][7][8][9][10][11][12][13][14][15][16][17] per year. Compared with GWTG-Stroke hospitals that did not participate in the Target: Stroke survey during the study period, Target: Stroke survey hospitals were more frequently larger, academic hospitals, primary stroke centers, with higher ischemic stroke volume, shorter baseline DTN times, and more experience with tPA administration (Table II in The strategies least frequently used included advance hospital notification by EMS (52.3%), rapid triage protocol with stroke team notification (68.8%), single-call activation system all of the time (62.5%), trainees involved in the stroke team all of the time (26.0%), routine premixing of tPA (16.1%), and storing tPA in the ED (62.2%).…”

Section: Study Samplesmentioning

confidence: 99%

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Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Xian

Smith

Zhao

et al. 2014

Stroke

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Background and Purpose— The benefits of intravenous tissue-type plasminogen activator in acute ischemic stroke are time dependent, and several strategies have been reported to be associated with more rapid door-to-needle (DTN) times. However, the extent to which hospitals are using these strategies and their association with DTN times have not been well studied. Methods— We surveyed 304 Get With The Guidelines-Stroke hospitals joining Target: Stroke regarding their baseline use of strategies to reduce DTN times in the January 2008 to December 2009 time frame before the initiation of Target: Stroke and determined the association between hospital strategies and DTN times. Results— Among 5460 patients receiving tissue-type plasminogen activator within 3 hours of symptom onset in surveyed hospitals, the median DTN time was 72 minutes (interquartile range, 55–94). Reported use of the different strategies varied considerably. Of 11 hospital strategies analyzed individually by multivariable analysis, 3 strategies were independently associated with shorter DTN times. These included rapid triage/stroke team notification (209/304 [69%] hospitals, 8.1-minute reduction in DTN time), single-call activation system (190/304 [63%] hospitals, 4.3 minutes), and tissue-type plasminogen activator stored in the emergency department (189/304 [62%] hospitals, 3.5 minutes). When analyzed incrementally, hospitals that used a greater number of strategies had shorter DTN times with 1.3 minutes (adjusted mean difference) saved for each strategy implemented (14 minutes if all strategies were used). Conclusions— Although the majority of participating hospitals reported using some strategy to reduce delays in tissue-type plasminogen activator administration for acute ischemic stroke, the strategies applied vary considerably and those most strongly associated with shorter DTN times were applied relatively less frequently.

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Section: Discussionmentioning

confidence: 99%

Section: May 2014mentioning

confidence: 99%

Section: Study Samplesmentioning

confidence: 99%

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Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Xian

Smith

Zhao

et al. 2014

Stroke

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“…[1] Presence of local protocols and pathways, adequate health care resources (including staff), regular quality assessments, and discharge planning appear to positively impact care. However, wide variations have been reported in acute stroke care processes, costs and outcomes worldwide.…”

Section: -Introductionmentioning

confidence: 99%

Regional variation in acute stroke care organisation

Venturelli

Robinson

Lavados

et al. 2016

Journal of the Neurological Sciences

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“…The development of stroke systems of care (Schwamm et al. 2005), EMS systems of prehospital care (Acker et al. 2007), and protocols for EMS bypass of hospitals not capable of stroke care was recommended (Adams et al.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of regionalized systems for stroke and myocardial infarction

et al. 2015

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BackgroundAcute ischemic stroke (AIS) and ST‐segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI.MethodsLiterature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non‐ or pre‐regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking “regionalization” and “myocardial infarction” or citation as a model system by any American Heart Association statement.ResultsFor AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre‐ or nonregionalized state. The final yield was nine papers from six systems.ConclusionAlthough regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.

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Recommendations for the Establishment of Stroke Systems of Care

Cited by 299 publications

References 155 publications

Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Strategies Used by Hospitals to Improve Speed of Tissue-Type Plasminogen Activator Treatment in Acute Ischemic Stroke

Regional variation in acute stroke care organisation

Effectiveness of regionalized systems for stroke and myocardial infarction

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