Abstract & Commentary
Commentary by Alan Segal, MD, Assistant Professor, Department of Neurology, Weill-Cornell Medical College, Attending Neurologist, New York Presbyterian Hospital, Assistant Editor, Neurology Alert.
Synopsis: BAC elements, such as quality of care initiatives and support of the medical organization, did not impact rates of tPA use, but may have had other quality of care effects, such as prevention of stroke-related complications.
Source: Douglas VC, et al. Do the Brain Attack Coalition’s Criteria for Stroke Centers Improve Care for Ischemic Stroke? Stroke. 2005;64:422.
The Brain Attack Coalition (BAC) published its criteria for primary stroke center designation in 2000. Prior literature (primarily from Europe) had shown that stroke units, as opposed to general medical wards, favorably effected discharge disposition and overall mortality. This was primarily a function of preventing complications and implementing rehabilitation services. Somewhat in contrast to this, the primary thrust of the BAC report was on acute stroke care. Its goal was to increase the use of intravenous tissue plasminogen activator (tPA), currently limited to less than 5% of stroke patients in the United States. Campaigns, such as the American Stroke Association’s "Get With the Guidelines" program, followed the lead of the BAC. Most recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began its primary stroke center designation process. With JCAHOs involvement, it is reasonable to assume that every hospital will aspire to achieve its stroke center imprimatur, if for no other reason than to avoid losing a significant portion of patient volume. This includes not only stroke patients, but also patients with other forms of acute central nervous system pathology that may initially mimick or be interpreted as stroke. In the report reviewed here, Douglas and colleagues address the important question of whether these new administrative constructs will actually increase tPA use and, more importantly, whether they can have measurable effects on stroke morbidity and mortality.
Douglas et al analyzed data from the University HealthSystem Consortium (UHC), with 16,853 patients admitted to the emergency departments of 34 participating hospitals. Seven of the 11 major elements identified by the BAC were correlated with a 2-3 fold increase in tPA administration. These are shown in bold in Table 1. In multivariate analysis, 4 of the 7 features remained significantly associated with increased tPA use: written care protocols, emergency medical services (EMS), emergency department (ED), and continuing medical education. The report emphasizes that since speed is the major issue in the delivery of tPA, it is the integration between EMS, the ED, and the stroke team that is the most crucial factor in a hospital’s ability to deliver tPA within 3 hours of symptom onset.
BAC requirements for stroke center designation
The presence of BAC requirements had no impact on in-hospital mortality or likelihood of discharge to home. Douglas et al note that not surprisingly, tPA has been shown to reduce long-term morbidity and not to decrease short term morbidity or mortality. BAC elements, such as quality of care initiatives and support of the medical organization, did not impact rates of tPA use, but may have had other quality of care effects not studied by Douglas et al, such as prevention of stroke-related complications.
Recent investigations in our own locale have been done as part of the New York State Department of Health Stroke Center Designation Pilot Project. This study involved 32 hospitals in Brooklyn and Queens (14 of which were designated as stroke centers), and showed improvements in ED door to MD contact time, door to CT scan time, and door to tPA administration. tPA use increased from 2.4% to 7.7% in stroke centers. These data have prompted New York State to initiate a state-wide process of stroke center designation, replicating the methodology of the pilot project.
Stroke certification by JCAHO (see Table 2) differs from the NYS program, as it is less stringent and detailed in its requirements for acute stroke treatment (tPA considered), but is much broader overall. JCAHO addresses in-hospital, stroke-related complications (such as prophylaxis for deep vein thrombosis and screening for dysphagia), and also draws attention to secondary stroke prevention (such as discharge on anti-thrombotic medications).
JCAHO stroke performance measurements
As neurologists, we should embrace the new attention paid to stroke, and campaign for greater stroke-related resources on a hospital, as well as governmental level. We should work to translate these guidelines into palpable clinical benefits for our patients. At the same time, we should work to prevent ourselves from drowning under the deluge of paperwork new regulations will inevitably bring.