Comprehensive Stroke Centers: Key Decision Points for Service Development and Certification

Currently there are more than 1,000 certified Primary Stroke Centers nationwide, and this number is growing as hospitals continue to place a much-needed emphasis on a programmatic approach to care for this large and complex patient population. In 2005, the Brain Attack Coalition developed recommendations for the establishment of comprehensive stroke centers to address delivery of specialized care needed by patients with complex cerebrovascular disease. In 2012, The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas (DNV) established specific criteria and initiated the certification process for Comprehensive Stroke Centers.  

The new level of certification requires significant resources not only for the planning stages, but also the implementation phase in terms of physician expertise, equipment, clinical infrastructure, specialized ancillary services, team complement, and staff training in order to care for a more advanced level of stroke patients.

In hospitals with certified Primary Stroke Center or Comprehensive Stroke Center designations, the cardiac cath lab staff, by following the established protocols, can rapidly and effectively treat their cardiac patients who develop peri-procedure strokes. Corazon believes it is essential to keep the clinical cath lab team aware and attuned to what their organization has implemented for stroke care.  

Having a hierarchical approach to stroke care allows each facility to determine its capabilities related to the level of care provided. At the base level, facilities that are considered “stroke ready” can assess the patient upon arrival in the emergency department and initiate intravenous (IV) thrombolytic therapy (t-PA), but then most likely transfer the patient to another hospital for basic care and expanded treatment. In this scenario, this ‘drip and ship’ protocol is all the hospital can handle, and it creates the best chance for success in terms of starting treatment and transferring, rather than transfer-only.  

Facilities that have advanced to offer a more formalized, programmatic approach to care have a Primary Stroke Center in place, which can additionally meet the patient’s needs for the duration of the hospitalization, including supportive care and rehabilitation activities, along with initiating a plan for post-discharge care. There is a rigorous application and certification process involved, though hospitals that have invested the time and effort should realize improved patient outcomes and satisfaction, more efficient utilization of resources, and a decreased length of stay and cost per case.

At the top tier of care, a Comprehensive Stroke Center, in addition to meeting all of the Primary Stroke Center requirements, would be able to perform complex procedures and provide post-procedure care for the patient as well. For example, for some patients, IV thrombolytics alone may not be sufficient to achieve maximum recovery, or the patient may require a different treatment course if the stroke is hemorrhagic in nature. Moreover, the ischemic stroke patient with a clot that is not amenable to IV thrombolytics may require a neurointerventionalist to perform a clot retrieval procedure. A patient with an intracerebral bleed or a subarachnoid bleed may require a surgical (clot evacuation, aneurysm clipping) or a neurointerventional procedure (aneurysm coiling).  

To obtain Comprehensive Stroke Center status, the following specific clinical requirements must be met:  

• Dedicated neurointensive care unit beds for complex stroke patients, available 24 hours a day, 7 days a week.
• Staff and licensed independent practitioners who have expertise and experience in providing neuro critical care 24 hours a day, 7 days a week.
• Post hospital care coordination for patients.
• Advanced imaging capabilities consisting of carotid duplex ultrasound, extracranial ultrasonography, transcranial Doppler, transesophageal echocardiography, and transthoracic echocardiography.  
• Catheter angiography, CT angiography, MR angiography, and MRI, including diffusion-weighted MRI available on-site 24 hours a day, 7 days a week, in order to provide care to patients with a diagnosis of subarachnoid hemorrhage.
• The ability to perform endovascular coiling or surgical clipping procedures for aneurysms, as well as to administer intra-arterial thrombolytics.
• A formal peer review process to evaluate and monitor care provided to all stroke patients.
• Demonstrated performance improvement activities.
• Participation in stroke research that is Institutional Review Board (IRB)-approved and patient-centered.

 As of this writing, certified Comprehensive Stroke Centers are to collect and report the standardized performance measures utilized by Primary Stroke Centers. Additional performance measures specific to Comprehensive Centers are in development and will be required in the future.

In addition to the above requirements, Comprehensive Stroke Centers are expected to meet targeted volume metrics for both t-PA administration and procedural interventions for subarachnoid hemorrhage patients. 

t-PA administration:

Administer IV t-PA to 25 eligible patients per year (can be averaged over a two-year period). This may also include IV t-PA ordered and monitored via telemedicine for a patient at another hospital or IV t-PA administered by another hospital for a patient transferred to the Comprehensive Stroke Center.

Subarachnoid hemorrhage:

• Treat 20 or more patients per year with a subarachnoid hemorrhage diagnosis.
• Perform 15 or more endovascular coiling or surgical clipping procedures for aneurysms per year.

In order to provide the additional and/or advanced interventions obligatory of a Comprehensive Stroke Center, personnel with specific skills are essential, and should include:

• Physician with neuro-rehabilitation expertise.
• Neuro-interventionalist who can perform catheter-based interventions such as angioplasty, stenting, aneurysm coiling, and intra-arterial thrombolysis.
• Physician with imaging experience in head CT and brain MRI.
• Neuro-intensivist (or physician with critical care and cerebrovascular experience) to staff the intensive care unit.
• Neurosurgeons with expertise in cerebrovascular surgery.
• Vascular surgeons who can perform carotid surgical procedures.
• Pharmacist with expertise regarding neurology/stroke care.
• Nurse case managers with expertise regarding neurology/stroke care, care coordination, levels of rehabilitation, and community resources.
• Social workers with expertise regarding neurology/stroke care, care coordination, levels of rehabilitation, and community resources.
• Advanced practice nurses with expertise in neurology/stroke care.
• Radiology technologists who are available 24 hours a day, 7 days a week.

 There are a designated number of continuing education hours per year for select groups of personnel that are mandated to keep staff up-to-date on innovations, reinforce previous learning, and facilitate the maintenance of competencies. The cardiac cath lab staff should be kept current on any protocol changes that would impact their interventions for cardiac patients who develop peri-procedure strokes.  

Comprehensive Stroke Centers can provide much needed expanded services for regions across the country, serve as a resource for “stroke-ready” or Primary Center community hospitals, and ultimately improve the quality of care provided to stroke patients. Such a scenario can only be realized, however, through proper planning and execution.  

Corazon advocates a thorough review of available services within a market as well as a critical analysis of organizational preparedness. A readiness assessment will provide a valuable gap analysis, calling attention to the key areas to focus on when pursuing advanced stroke care.  

Indeed, these are the first key steps that must be taken by any hospital considering such an expansion. Corazon recommends a detailed review and objective analysis of findings of the following factors in advance of a “Go/No-Go Decision”:

• Is the population of the primary and secondary market sufficient to support full-time neuro-interventionalist coverage, typically considered to be one provider for every 2,000,000 people?
• Are the available facilities and equipment adequate to ensure the delivery of complex neuro-interventional care?
• Do opportunities exist within the market for cross-coverage to meet the 24/7 requirement for interventional capabilities 24/7/365, as required for certification?
• Does the medical infrastructure exist to provide post-procedural care for this patient population: neuro-intensivist, pulmonology, physical medicine and rehabilitation (PM&R), neurosurgery, etc.?
• Are ancillary services adequate to provide necessary supportive care: physical therapy, occupational therapy, speech, pharmacy, palliative care, etc.?
• Is adequate clinical neuroscience expertise available among the existing nursing staff to care for these patients both pre- and post-procedure?
• Is the emergency department staffed with physicians and frontline staff who possess special expertise in the care of the neurovascular patient?
• Do pre-hospital systems exist both by ground and by air to facilitate the safe and rapid transfer of critically ill neurovascular patients to your facility?

Only through this upfront planning effort and a truly objective analysis of your organization’s readiness for such an expansion can a reasonable decision be made that will ensure top-quality stroke care. A coordinated stroke program will be an efficient and effective means of not only providing quality care, but also improving outcomes of patients with strokes and complex cerebrovascular disease…a goal the entire organization can rally around.  n

Stacey is a Vice President and Jan is a Consultant at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedics specialties, with consulting, recruitment, interim management, and physician practice & alignment services available to clients across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Stacey, email slang@corazoninc.com; to reach Jan, email jyanko@corazoninc.com.   

For more information, please visit:

https://www.jointcommission.org 

https://www.heart.org/myhospital

https://www.hfap.org

https://www.dnvaccreditation.com

References

1. Leifer D, Bravata DM, Connors JJ 3rd, Hinchey JA, Jauch EC, Johnston SC, et al; American Heart Association Special Writing Group of the Stroke Council; Atherosclerotic Peripheral Vascular Disease Working Group; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42: 849-877.
2. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, et al; Brain Attack Coalition. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005 Jul; 36(7): 1597-1616.