Stroke Centers of Excellence in the United States: Certification, Access and Outcomes

Introduction: Stroke is a leading cause of morbidity, mortality and healthcare costs in the United States. Evidence suggests that certified stroke centers have improved patient outcomes relative to non-certified hospitals. Our study explains the process, associated cost, quality and geographic proclivities of different certifying organizations. Methods: Data was collected from published literature, information on certifying organizations’ websites and through direct communication with representatives of The Joint Commission (TJC), Det Norske Veritas and Germanischer Lloyd (DNV-GL), and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of thrombectomy capable centers and comprehensive stroke centers was performed with the ArcGIS online tool. Results: Among the three certifying organizations, standards for recognition as acute, primary, thrombectomy capable and comprehensive stroke centers are not standardized. At the time of this review, there were 1406 TJC-certified stroke centers, 241 DNV-GL certified stroke centers and 66 HFAP-certified stroke centers in the United States. Cost for certification was similar with price scaled by complexity of capabilities. Quality metrics revealed a significantly higher rate of tPA administration and shorter door-to-needle time for TJC and DNV-GL centers than HFAP. All primary stroke centers exhibited improved in-hospital, 30-day and 1-year mortality when compared to non-stroke centers. Discussion: Despite lack of standardization of criteria between organizations, certification provides a mechanism for ensuring hospitals deliver higher standards of stroke care. Understanding variations in quality and scope of different organizations enables targeting of at-risk regions to maximize access and availability of care

Improving Medical and Endovascular Management for Acute Ischemic Stroke Through Multidisciplinary Education and Simulation

Primary goals: Reduce door to treatment times (both DTN and DTP) to meet and exceed existing guidelines metrics. Educate residents about acute stroke management, including national guidelines and new institutional protocols to improve efficiency during stroke alerts.https://jdc.jefferson.edu/patientsafetyposters/1097/thumbnail.jp

Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Objectives Teach incoming neurology residents how to respond efficiently and appropriately to stroke alerts Improve the confidence level of residents during stroke alertshttps://jdc.jefferson.edu/patientsafetyposters/1084/thumbnail.jp

Process Improvement for Endovascular Thrombectomy in Patients Presenting with Acute Ischemic Stroke

Aims Critically evaluate the existing stroke activation and ET protocols for compliance with new 2018 metrics and guidelines. Review DTP times under the existing protocol to assess for potential inefficiencies or gaps in care delivery, specifically addressing differences between processes at JHN compared to ED/Gibbon. Make changes to the existing stroke alert protocol to better reflect current guidelines, streamline care, and ultimately improve process metrics (DTP times). Establish a system for recursive continuous analysis of AIS patients to identify protocol gaps, inefficiencies and areas for further intervention.https://jdc.jefferson.edu/patientsafetyposters/1096/thumbnail.jp

Improving ED Door to Puncture Times for Endovascular Thrombectomy in Acute Ischemic Stroke

Objectives Optimize the management of patients presenting to TJUH with AIS who are candidates for ET. Enable continued process improvement through improved data collection methods and identification of new process metrics.https://jdc.jefferson.edu/patientsafetyposters/1145/thumbnail.jp

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE: Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS: Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS: Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS: The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices