What is the status of stroke centers?
Stroke
care in the United States is changing rapidly…
This
change has been propelled by the realization that while stroke remains
common, costly, and tragic, it is now also preventable, treatable,
and modifiable. There is no other neurological disorder for which
we currently have such potential to make a positive impact. Yet we
are not living up to our potential. Our knowledge of what we should
be doing about stroke considerably exceeds the reality of what we actually
are doing.
Our failure to do our best has led to an examination of the way in which
stroke care is delivered. The conclusion is that the old system of stroke
care is inadequate. It is too sluggish, too fragmented, and too inconsistent
to treat stroke effectively. Stroke centers are seen as part of the
solution for this problem.
The
concept of stroke centers was first published in June of 2000(1).
In this document, the components of a Primary Stroke Center were set down
by the Brain Attack Coalition (BAC), a group representing many prestigious
organizational stakeholders across the country. Key elements of a Primary
Stroke Center were noted to include an integrated emergency response system,
acute stroke teams, readily available brain imaging and laboratory tests,
and stroke units.
In the BAC paper, the favorable experience of trauma centers was seen
as an inspiration for stroke, which—like trauma—requires
that a complex set of actions be rapidly performed by a diverse, but coordinated
group of health care providers. In the case of stroke, these actions
focus on the appropriate delivery of clot-busting medication to open up
a blocked artery that is causing a stroke.
While acute treatment was the centerpiece of the BAC paper, the Primary
Stroke Center was seen as more than an acute response system. Many simple
but easy-to-overlook procedures favorably impact stroke care beyond the
acute stage. To insure that these are not overlooked, written care
protocols for stroke were called for, along with systematic monitoring
of these procedures.
The BAC paper circulated widely for several years. Many hospitals looked
at the list of recommendations and reckoned themselves to meet all of
the specified criteria. Since no agency or organization was empowered
to certify whether hospitals actually did meet the criteria, hospitals
began calling themselves “stroke centers” via a questionable
system of self-designation. One report indicated that although 77%
believed that they met recommended criteria, only 7% actually did so(2).
It
was not until 2004…
that Primary Stroke Center designation began
to be provided by an independent organization. For a fee, paid by candidate
hospitals, the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) began inspecting and verifying that institutions met BAC criteria.
JCAHO is the same organization responsible for evaluating and accrediting
thousands of health care organizations and programs in the United States.
With JCAHO's stamp of approval, the term “Stroke Center” began
to have real meaning. “JCAHO certification” is now a widely
sought designation. For most of the country, it has become the “gold
standard” for stroke centers.
Demand for certification has swamped JCAHO’s ability to actually
perform certification inspections. A few states (for example, Massachusetts)
have elected to bypass JCAHO certification altogether by adopting an independent,
state-level system of certification.
To make matters more complicated, there will soon be two levels of stroke
centers–primary and comprehensive centers. A paper defining the elements
of a Comprehensive Stoke Center (CSC) was published in 2005(3).
The CSC will include all of the elements of a Primary Stroke Center. Additionally,
it will offer advanced techniques for acute treatment of both ischemic
and hemorrhagic strokes. To date, however, no organization or agency is
certifying that hospitals meet the Comprehensive Stroke Center criteria.
In choosing a hospital for stroke care, one can be most confident when
the hospital has JCAHO. Or state-equivalent stroke center designation.
There is, however, no current way for potential patients to insure
that they will be transported to the best hospital in the event of a stroke(4).
Given the state of flux regarding stroke center designation, emergency
transport policies are understandably inconsistent. In most states, the
hospital of choice is still the one nearest by. Factors such as contracts
between hospitals and insurance carriers also influence where a patient
is taken. Patient preference is given much weight by emergency transport
providers, but there is no guarantee that patient preference will outweigh
other considerations.
We in the “stroke community”…
recognize that stroke care can be improved by
better use of the knowledge and tools that are currently at our disposal.
Getting from where we are to where we ought to be is not so much a technological
problem as it is a sociological one. Many states, including our own Colorado,
are currently struggling with how best to develop and coordinate a system
of stroke centers in order to optimize efficiency and excellence in stroke
care(5).
This
is no easy task. Stroke is a complex condition with many variations. Stroke
care involves many health care providers across a range of disciplines.
Competition for stroke “business” is keen among institutions,
providers, professional associations, government agencies, and non profit
organizations. Long established patterns of referral and outmoded ideas
about stroke slow down innovation in the delivery of stroke care. Corralling
these elements in a cooperating, efficient, and effective system is indeed
a challenge.
Stroke
care in the United States is changing rapidly…
it is changing for the better, but change itself
can be disruptive and confusing, as the above comments may suggest. I
hope that they at least serve to aid in understanding where things currently
stand.
