Giving clot busters within three hours of symptom onset can reduce disability from stroke. But many of today's health systems don't have the stroke response system in place to quickly recognize, diagnose and provide therapy to patients who suffer stroke. As a result, only 2 percent to 3 percent of eligible patients receive the approved clot-busting therapy, called tissue plasminogen activator (tPA).
In the first study, Toby Gropen, M.D., chairman of the department of neurology, Long Island College Hospital, Brooklyn, N.Y., and chair of the New York City Operation Stroke, and colleagues studied 32 hospitals in Brooklyn and Queens, New York City.
Fourteen of the hospitals were designated as Brain Attack Coalition Primary Stroke Centers, a model that requires that centers meet the Brain Attack Coalition (BAC) guidelines that include acute stroke teams available to respond 24 hours a day, seven days a week; a specialized unit dedicated to stroke care; appropriate laboratory services; and an experienced staff, which undergoes regular continuing medical education.
The BAC is a group of professional, voluntary and government organizations – including the American Stroke Association. In 2000, the coalition published guidelines on establishing primary stroke centers to improve care of stroke patients and standardize some aspects of acute stroke care.
From March to May 2002, researchers examined data from 763 ischemic stroke patients at the start of the study, before the hospitals received designation, and re-measured the data for 725 ischemic stroke patients after the hospitals were designated.
All time-to-treatment improvements were greater at stroke centers between baseline and remeasurement. Importantly, tPA use increased from 2.4 percent at baseline (18 of 763 patients), to 5.2 percent overall in the hospitals (38 of 725 patients) and 7.7 percent (32 of 416 patients) at stroke centers.
"I think this model should motivate other communities to look at doing something very similar," Gropen said.
In a separate study, Maureen Connors Potter, B.S., M.S., and colleagues investigated stroke care at hospitals around the United States that have achieved the Joint Commission Primary Stroke Center certification. The Joint Commission's guidelines for stroke centers are also based, in part, on BAC recommendations.
"We have three basic requirements: compliance with our standards, which really assures a quality process of care delivery; use of evidence-based clinical practice guidelines; and accountability through performance measurement for quality improvement," said Potter, who is executive director for international accreditation at the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook, Ill.
While there were varying rates of compliance with sub-components of the criteria, tPA administration rates at certified hospitals have doubled, increasing from a range of 1 percent to 5 percent before certification – to 10 percent or more after designation.
It seems that people who live near certified stroke centers are more aware of stroke and its symptoms, she said. Hospitals that become designated as stroke centers have media campaigns educating the public about how to recognize strokes and get immediate help.
"The success of this system depends greatly on people's ability to recognize signs and symptoms of a brain attack, or a stroke, and getting to the hospital, fast," Potter said.
The authors also report reduced complications at certified stroke centers.
"The concept behind designated stroke centers is to reduce mortality and complications and improve clinical outcomes so more people that experience stroke can go home to resume the rest of their lives, instead of having to go to long-term care or extensive rehabilitation," Potter said.
According to Potter, by mid 2005, there should be more than 100 hospitals nationwide with Joint Commission Primary Stroke Center certifications, and people should become educated about where these stroke centers are located.
For a list of certified stroke centers, visit http://www.jcaho.org/dscc/psc/index.htm.
Gropen's co-authors are Patricia J. Gagliano, M.D.; Cathy A. Blake, B.A.; Ralph L. Sacco, M.D.; Thomas Kwiatkowski, M.D.; Neal J. Richmond, M.D.; Dana Leifer, M.D.; Richard Libman, M.D.; and Salman Azhar, M.D. The study was supported by the New York State Department of Health.
Potter's co-authors are Anne W. Wojner, Ph.D.; Mark J. Alberts, M.D.; and Robert J. Adams, M.D. Statements and conclusions of study authors that are published in the American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
Abstracts 92 and 57
NR05-1005 (ISC05/Gropen, Potter)
Note: Abstract 57 will be presented at 2 p.m., CST, Thursday, Feb. 3, 2005. Abstract 92 will be presented at 9:50 a.m. CST, Friday, Feb. 4, 2005.