Some of the key new clinical recommendations are:
- Acute stroke teams, a vital component in the success of a PSC, should have a minimum of two staff members – one physician and another health care provider – available on a 24/7 basis. A member of the acute stroke team should be at the patient’s bedside within 15 minutes of being called.
- Emergency medical services should transport acute stroke patients to the nearest facility that operates as a PSC. The authors recognized the increasing use of telemedicine for remote diagnosis and the availability of air ambulances for transporting stroke patients from rural areas to a PSC.
- Emergency department should be staffed with personnel who are well trained in the diagnosis and treatment of all types of acute stroke and have a clear delineation of their roles and those of other medical staff on the acute stroke team. The department should have written protocols for stroke triage, treatment, and frequent assessment of the patients’ vital signs and neurological status.
- The stroke unit, which is typically a defined group of beds, staff and protocols used for the acute care of stroke patients, was a key element of the initial paper. Data show that compared to general wards, patients cared for in a stroke unit have a 17-28 percent reduction in mortality, an 8 percent reduction in length of hospital stay, and a 7 percent increase in being able to live independently. In the new paper, the BAC authors recommend that stroke units have a telemetry system that monitors blood pressure, pulse, respiration and oxygenation. They also recommend a clinical monitoring protocol with specific instructions on who and when to call if the patient’s clinical status begins to deteriorate.
- Neurosurgical services should be available within two hours of the time they are deemed clinically necessary. Because neurosurgeons are not required to be on staff at a PSC, the patient may need to be transferred to another facility, and clearly written protocols and agreements for such transfers should be in place.
- Imaging studies of the brain and vascular system are vital to determining an accurate and timely diagnosis for a stroke patient. PSCs must have the capability to perform a CT scan within 25 minutes of being ordered. MRI of the brain may be performed acutely in lieu of the CT if the same time parameters can be met.Studies have established that MRI is more sensitive than CT for detecting some acute strokes, small strokes, and lesions that can produce stroke-like symptoms. Additionally, magnetic resonance angiography (MRA) and computerized tomographic angiography (CTA), both new but widely used techniques for imaging the brain’s vascular system, should be available at all PSCs, although they may not be required at the acute stage of patient evaluation. These imaging techniques are capable of detecting abnormalities that can be missed by routine imaging techniques.
- Cardiac imaging is recommended because a significant percentage of strokes are caused by blood clots from the heart. Cardiac MRI and two types of echocardiography, a type of ultrasound, are available to image the heart. The authors recommend that at least one of these tests be available at the PSC.
- Laboratory work should include tests for HIV and pregnancy, a chest X-ray, an electrocardiogram, and a drug toxicology screening because of the association between illicit drug use and stroke.
- Rehabilitation services can improve post-stroke recovery and function, and PSCs should work to develop early patient assessment and initiation of any needed speech therapy, physical and occupational therapy.
In addition, the authors made key administrative recommendations for PSCs, including having a director with training and expertise in stroke; maintaining a stroke registry, database or similar monitoring program to track outcomes and quality improvement; key staff receiving at least eight hours of education in stroke each year; and conducting at least two annual public education programs. The BAC authors also support independent stroke center certification programs as a means of ensuring proper designation and recognition of PSCs. The authors strongly discourage self-certification, based on studies that have shown such assessments are often unreliable.
Reference: Alberts MJ, Latchaw RE, Jagoda A, Wechsler L, Crocco T, George MG, Connolly ES, Mancini B, Prudhomme S, Gress D, Jensen ME, Bass R, Ruff R, Foell K, Armonda RA, Emr M, Warren M, Baranski J, Walker MD. “Revised and Updated Recommendations for the Establishment of Primary Stroke Centers: A Summary Statement from the Brain Attack Coalition.” Stroke, September, 2011, Volume 42, Pages 2651-2665.