Stroke reduction gets another weapon

TJC starts certification for stroke centers

Within days after The Joint Commission announced that it would begin certifying applicants for comprehensive stroke centers, there were dozens of hospitals either waiting for site visits or preparing their applications in the hope of getting certified this year. It is a potential boon to patients who have severe strokes. If the data from studies in Europe hold true in the United States, a patient with a complicated stroke diagnosis in need of advanced care will do better at hospitals that have achieved advanced stroke certification.

The Joint Commission and the American Heart Association/American Stroke Association joined together in the effort, which they hope will lead to hundreds of certified comprehensive stroke centers to which complicated patients can be referred. The program is based on a premise in a 2000 article in the Journal of the American Medical Association (JAMA)1 that having hospitals become certified in providing a certain level of care for stroke patients will improve outcomes for those patients.

"The initial process of creating primary stroke centers has been wildly successful, and they do reduce morbidity," says Mark J. Alberts, MD, director of the stroke program at Chicago's Northwestern Memorial Hospital. Alberts was on the original Brain Attack Committee that established the protocols outlined in the JAMA consensus paper.

"But primary stroke centers were envisioned to treat uncomplicated stroke patients with no surgical requirement," he says. "Comprehensive stroke centers are the next step, and are designed to treat large, complicated, hemorrhagic strokes that need surgical or other fancy interventions. Certainly patients with regular ones could also be cared for there, but the high-end interventions and protocols that are required of those centers are designed around the complex patient."

Requirements

Field certification began at the start of September, and Northwestern Memorial is awaiting its visit. Hospitals hoping to achieve the certification for comprehensive stroke center have to meet all the requirements of a primary stroke center, and meet additional standards, too. They have to have protocols in place for treating complex patients, have the personnel available and trained to deal with those patients, and must also meet minimum annual volume requirements for certain kinds of patients, including:

  • 20 or more patients with subarachnoid hemorrhage;
  • 15 or more endovascular coiling or surgical clipping procedures for aneurysm;
  • 25 intravenous tPA patients — although over two years is also acceptable for this metric, and patients who were given their tPA at another facility and transferred to the comprehensive stroke center or who were given their medicine at another facility while monitored by telemedicine at the comprehensive stroke center also count.

The requirements also mandate that the successful applicant will have advanced imaging capabilities, including carotid duplex ultrasound, catheter and CT angiography available on site at all times, day or night, and extracranial ultrasound. The facility must also have MR angiography and MRI, including diffusion weighted MRI available on site at all times, transcranial Doppler, and transesophageal and transthoracic echocardiography.

The comprehensive center will have post-hospitalization care coordination, and a dedicated neuro-intensive care unit for complex stroke patients. That ICU will have to have trained and experienced staff available to provide the kind of critical care complex stroke patients need 24 hours a day, seven days a week. There must be a peer review process to monitor patients with ischemic stroke and subarachnoid hemorrhage and the administration of tPA. Centers have to participate in approved stroke research, and they will be required to collect all performance measures for primary stroke centers, as well as additional performance measures for comprehensive centers as they are developed. The current list of performance measures is available at http://www.jointcommission.org/certification/advanced_certification_comprehensive_stroke_centers.aspx.

One element that Alberts says is different from the primary stroke centers is that you have to do a severity assessment on every patient that comes through the door. "We do this for ischemic strokes, but we haven't been as thorough for hemorrhagic strokes in the past," he says. "Now we are. It is best for the patients, but it also gives us a way to severity adjust our outcomes. We'll be getting all the sickest patients, and their outcomes will reflect that."

Hospitals will have to know their door-to-tPA time. There is a national goal of 60 minutes or less. As a vascular neurologist, Alberts says that doesn't mean you rush to give the drug before having all the information you need. "There are good delays and bad delays. If you have to make a call for more information before you give the drug, that is a good delay. A bad one involves inefficiencies in the system, like taking too long with the head CT. Time is brain, and you want to treat it ideally within 60 minutes, but only if it is reasonable and safe to do it then."

Obviously, the parameters for volume alone will prevent many hospitals from going for this certification. "But if you have the right volume of these patients, and are a high-volume referral center that sees a lot of the sickest patients, then I think it is good for the patient, and good for the hospital to do this," Alberts says. "We know from European studies that this will improve outcomes."

"We see this as the next step in helping to support state-of-the-art care for patients with stroke," says Jean Range, MS, RN, CPHQ, executive director for disease specific care certification programs at The Joint Commission. "This is the second leading cause of death worldwide," she says, noting that the primary stroke certification program, which began in 2003, has been shown to improve outcomes among stroke patients here.

The importance of the programs is evident in the number of states that stratify stroke centers. Fifteen states recognize primary stroke centers, and four — Texas, New Mexico, Maryland, and Missouri — already have legislation that recognizes comprehensive stroke center certification.

From a technology and care standpoint, Range says it seemed appropriate to do something that recognized the improved science around the care of complex stroke patients. The requirements took a while to put together and will continue to evolve over time. She says they will be re-evaluated in 2013, but not necessarily every year. If some new breakthrough is reported in the literature, it would probably lead to another review.

"This certification will represent an elite group of organizations that function as regional referral centers," says Range. "We would encourage organizations that meet the volume criteria, but also play an important role in their community and region for complex stroke patients, to consider this. They will work collaboratively with primary stroke centers — they will essentially be an extension of those primary centers for patients who require advanced testing and therapies." But she doesn't want to see organizations rushing out to get certified merely as a way to differentiate themselves among competitors. "We don't want them to see this as a way to compete in your community, but as a way of providing access to high-quality care." Some areas may have more than one comprehensive stroke center, while others may have just one, she adds.

By the end of the second day after the announcement, there were 70 applications waiting for review. "This isn't a small undertaking. Those organizations that can meet the requirements have made a substantial investment in personnel, infrastructure, and equipment and have been planning on this for years." She figures there will be somewhere between 200 and 250 such centers within a few years. "But it is all speculation. There are just about 1,000 primary centers, and we continue to have interest almost 10 years later. Our research just says over 100. I think it will be interesting to see how it plays out."

For more information on this topic, contact:

  • Mark J. Alberts, MD, Professor of Neurology, Chief of Division of Stroke and Cerebral Vascular Disease, Northwestern University School of Medicine, and Director, Stroke Program, Northwestern Memorial Hospital. Chicago, IL. Telephone: (312) 952-0257.
  • Jean Range, M.S., RN, C.P.H.Q., executive director, Disease-Specific Care Certification Program, The Joint Commission, Mountlake Terrace, IL. Telephone: (630) 792-5800.

Reference

  1. Alberts MJ, Hademenos G., Latchaw RE et al. Recommendations for the establishment of primary stroke centers. JAMA. 2000;283(23):3102-3109.