A Blueprint for Building and Sustaining a Stroke Program
Last Updated: February 13, 2023
Over the past two decades, a growing number of studies suggest that stroke center certification is associated with improved patient outcomes.1 Patients who receive care at a certified stroke center are more likely to receive faster care and may have lower mortality than those treated at hospitals without a certified stroke center.2,3 Some studies report patients receiving care at a certified stroke center are more likely to evidence-based care.4 Over the past two decades, regionalization of care through the development of stroke centers was central to the organization of care and resources throughout the United States.5 Despite this, we know not all people have equal access to these improved outcomes as stroke center availability is not evenly spread through the United States.6
However, the challenges that organizations face when building and sustaining a stroke program to maintain certification is less well elucidated in the peer reviewed or research literature. Yet the challenges are well known to those who work in these systems. When embarking on stroke certification, and organization is committing to their providers and the public that they will sustain the infrastructure needed to maintain excellent stroke care. While certification standards published by certifying agencies outline many aspects of required care at a stroke center, the organizational and structural investment required of a stroke center has not been well-defined over the past 20 years. Dusenbury et al. aim to fill this gap with their scientific statement on the Ideal Foundation Requirements for Stroke Program Development and Growth. This statement provides a road map or blueprint for ideal structural resources to support and sustain certified stroke centers at multiple levels. They address personnel, imaging, procedural and other hospital resources required to build and sustain a certified stroke center and outline how that stroke center might best orient to the overall hospital system. While not exhaustive, this document provides hospital administrators and stroke program leaders an overview of care organization to guide the stroke center as they work to provide stroke care to the public they serve.
Some areas of the statement address long-standing concerns amongst the stroke coordinator and stroke leader community about staffing of a stroke program with knowledgeable coordinators and data analysts. While stroke certification standards and studies on stroke programs and their outcomes are largely silent about the personnel required to maintain such a program, staffing roles and workload are often a topic of concern at conferences and other venues where stroke program staff gather. The statement provides guidance for stroke program coordinator and data analyst roles and provides some guidance for staffing depending on stroke program volume. The authors also provide further guidance for advanced practice provider (APP) staffing, physician staffing and leadership in a stroke center that may supplement certification requirements. Finally, the document provides a guide for staff knowledge about stroke and provides guidance on rounding models that may facilitate interprofessional care.
Some areas addressed by the statement may be met with resistance and should facilitate a needed conversation in the United States (US) regarding our organization of stroke care. For example, the statement highlights that many US stroke centers do not have dedicated beds within a stroke unit despite evidence suggesting the cohorting of patients in a unit clearly identified for the care of patients with stroke improves patient outcomes.7,8 The statement provides some guidance for re-examining the practice of using critical care beds to care for some patient's immediately after stroke and provides suggestions for other bedding models that might better cohort patients. This may prompt a more thorough evaluation within hospitals regarding appropriate unit organization to best serve stroke survivors. When ideal resources are not currently followed in long-standing organizations, this statement might serve as a catalyst for further internal review and examination of the risks and possible benefits associated with structural change.
This statement should be added to the overall toolbox of resources used by stroke program leaders to build and maintain their programs. When paired with stroke certification standards, clinical trials guiding the science of stroke care, and other stroke publications, this document provides a map for hospital leaders to evaluate multiple components of their care. When they are unable to meet the ideal requirements, this might prompt a thorough internal evaluation of how this impacts their outcomes.
Dusenbury W, Mathiesen C, Whaley M, Adeoye O, Leslie-Mazwi T, Williams S, Velasco C, Shah S, Gonzales N, Alexandrov AW; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing and the Stroke Council. Ideal foundational requirements for stroke program development and growth: a scientific statement from the American Heart Association [published online ahead of print February 7, 2023]. Stroke. doi: 10.1161/STR.0000000000000424
- Man S, Schold JD, Uchino K. Impact of stroke center certification on mortality after ischemic stroke. Stroke. 2017;48(9):2527-2533. doi:10.1161/strokeaha.116.016473
- Effectiveness of primary and comprehensive stroke centers. https://www.ahajournals.org/doi/10.1161/strokeaha.109.577718. Accessed January 11, 2023.
- Dustin W.BallardMD, W.BallardMD D, a, et al. Does primary stroke center certification change Ed Diagnosis, utilization, and disposition of patients with acute stroke? The American Journal of Emergency Medicine. https://www.sciencedirect.com/science/article/abs/pii/S0735675711004074. Published November 17, 2011. Accessed January 11, 2023.
- Jasne AS, Sucharew H, Alwell K, et al. Stroke center certification is associated with improved Guideline Concordance. American journal of medical quality: the official journal of the American College of Medical Quality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476218/. Published 2019. Accessed January 11, 2023.
- de Havenon, A., Sultan-Qurraie, A., Hannon, P. et al. Development of Regional Stroke Programs. Curr Neurol Neurosci Rep 15, 19 (2015). https://doi.org/10.1007/s11910-015-0544-2
- Shen Y-C, Sarkar N, Hsia RY. Structural inequities for historically underserved communities in the adoption of stroke certification in the United States. JAMA Neurology. 2022;79(8):777. doi:10.1001/jamaneurol.2022.1621
- Indredavik B;Bakke F;Solberg R;Rokseth R;Haaheim LL;Holme I; Benefit of a stroke unit: A randomized controlled trial. Stroke. https://pubmed.ncbi.nlm.nih.gov/1866749/. Accessed January 11, 2023.
- Alexandrov AW;Coleman KC;Palazzo P;Shahripour RB;Alexandrov AV; Direct stroke unit admission of intravenous tissue plasminogen activator: Safety, clinical outcome, and Hospital Cost Savings. Therapeutic advances in neurological disorders. https://pubmed.ncbi.nlm.nih.gov/27366237/. Accessed January 11, 2023.
Science News Commentaries
Commentary: The Birth of Pediatric Primary Hypertension 03/30/2023 | Author: Joshua Samuels, MD, MPH | When I was a kid so many things were ...
Commentary: Interpreting Incidentally Identified Variants in Genes Associated with Heritable Cardiovascular Disease 03/27/2023 | Author: Dan M. Roden, MD | The Human Genome Project and a vision ...
Commentary: Exercise Training Can Improve Symptoms and Quality of Life Among Patients with Chronic Heart Failure with Preserved Ejection Fraction 03/21/2023 | Author: Ambarish Pandey, MD, MSCS; Neil Keshvani, MD | Heart failure (HF) with preserved ...
Commentary: Pulmonary Hypertension in Non-Cardiac Surgery – a mandate for the multidisciplinary team! 03/16/2023 | Author: Irene M Lang, MD | Pulmonary Hypertension (PH) is due to a ...
Commentary: Atrial Fibrillation Occurring During Acute Hospitalization 03/13/2023 | Author: Fred Kusumoto MD | Atrial Fibrillation ...
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --
Pub Date: Tuesday, Feb 07, 2023
Author: Sarah L. Livesay, DNP, APRN, FNCS, FAAN
Affiliation: Rush University, University of Washington