Stroke Team Creation and Primary Stroke Center Certification

In June 1996, tissue-type plasminogen activator (t-PA; see alteplase) was the first drug to be approved by the US Food and Drug Administration (FDA) for the acute treatment of stroke. The initial NINDS trial showed efficacy for patients treated within the first 3 hours of onset of symptoms. ^[1] Subsequently, the ECASS III trial has shown benefit in individuals up to 4.5 hours from last known well, ^[2] making stroke treatment a true emergency. The short treatment window requires rapid evaluation of patients who may have had a stroke. Stroke teams have been created for this purpose.

The members of a stroke team vary depending on the needs of the individual hospital, although code team personnel often include 1 or more neurologists and nurses.

To achieve maximal efficiency, the team must integrate itself with the services and facilities involved in the care of patients with acute stroke, including the local community, emergency medical services (EMS), the emergency department (ED), interventional radiology (IR), neurosurgery, nursing, computed tomography (CT) scanning, laboratory, pharmacy, rehabilitation, and inpatient units.

The team educates the public and care providers about stroke warning signs and the availability of stroke treatments, evaluates and streamlines services, provides stroke treatment rapidly, and continually monitors the efficacy of its work. This article examines the creation of the stroke team and the role of the Primary Stroke Center in improving the delivery and coordination of care in acute stroke. ^{[3, 4]}

Stroke center guidelines

The Brain Attack Coalition published a set of recommendations for the establishment of primary stroke centers, in 2000. ^{[5, 6]} These recommendations consist of 11 major elements that help an organization to achieve the level of collaboration among services required to rapidly identify and treat acute stroke patients. The Joint Commission also adopted these elements for their Disease-Specific Primary Stroke Center Certification. ^[7] The 11 elements consist of the following:

• Hospital and administrative support

• Acute stroke team

• Written care protocols

• Emergency medical systems

• Emergency department

• Stroke units

• Neurosurgical services

• Neuroimaging

• Laboratory services

• Outcomes/quality improvement

• Educational programs

The first major element is the creation of an acute stroke team. The team is made up of 2 parts: (1) the code team members, who respond to a code pager and deliver urgent treatment, and (2) a task force that works daily to facilitate patient access to treatment.

Usually, the code team consists of a neurologist or, in some cases, an ED physician, and a nurse. The task force, which is frequently larger, may include members from many disciplines, including neurology, emergency medicine, neurosurgery, nursing, radiology, pharmacy, laboratory, physical medicine, and rehabilitation.

Development of the team often requires early input from the hospital's administration to enhance problem solving and integration between services. Designation of resources in the form of a specific individual, often an advanced practice nurse, to lead the initiative is beneficial for keeping the process organized and consistently moving forward.

Creating a written care protocol is helpful (see the document below). This outlines what each member of the team is responsible for and helps to set time frames for what is to be accomplished. Devising separate sections for actions based on the duration of a patient's stroke symptoms is a useful organizational strategy (ie, < 3 h, 3-8 h, >24 h). See the PDF below.

• Interdisciplinary Practice Standard for the Emergency Department (Includes Ischemic Stroke, Transient Ischemic Attack, Intracerebral Hemorrhage, and Subarachnoid Hemorrhage) (PDF)

Representatives from each discipline should take part in determining the content of the protocol. These discussions may seem time-consuming on the front end, but they can be extremely helpful on the back end, because all parties have come to a consensus on how the acute stroke patient is to be managed. Protocols should be reviewed and revised annually and can be used as part of quality improvement initiatives.

Public and care-provider education

Although many patients know the symptoms of a heart attack, few are aware of the signs and symptoms of stroke. Persons who are most at risk for stroke, the elderly, are the least likely to know the risk factors and warning signs of stroke. In addition, while a heart attack frequently causes discomfort that invites the patient to seek rapid medical attention, a stroke does not. These factors impede the early arrival of patients in the ED, preventing them from receiving treatment. Patient education regarding stroke symptoms and the need to call 911 for these symptoms is imperative.

Primary care providers also must be educated on the availability of therapy for acute stroke and the critical 4.5-hour time frame for treatment with intravenous t-PA and the window (up to 8 hrs) for intra-arterial t-PA or clot extraction maneuvers. ^[2] Primary care providers should encourage patients' use of the EMS system.

Because primary care physicians see patients before they present with ischemic events, care providers in the community can identify patients at high risk for stroke and initiate preventive therapies.

Emergency medical services

EMS providers must be trained in the recognition of stroke and in prioritizing the patient with stroke for rapid transport to the hospital. The prehospital stroke scale used in Cincinnati defines 3 major physical findings to identify patients with stroke: facial droop, arm weakness, and speech abnormalities. ^[8]

For patients with a suspected large vessel occlusion (LVO), comprehensive stroke centers need to work collaboratively with EMS and other stroke centers in their regions to develop a system of care that allows for expedited treatment with thrombolytics and, when appropriate, mechanical thrombectomy. Regionally, individual sites will need to address whether to use the drip-and-ship or mothership approach. There is not a set of recommendations as to which approach is superior as traffic patterns, location of stroke centers, and availability of mechanical thrombectomy vary by region. ^{[1, 9]}

EMS providers can assist the treatment process further by establishing the time of onset of stroke symptoms. They need to be aware of the time frames for intravenous and intra-arterial thrombolytic therapy as well as clot extraction maneuvers, and they must know which facilities in their region are set up to provide these therapies. Although a variety of regional policies exist for the regulation of patient transportation, it is recommended that processes to enable rapid access to appropriate therapies be instituted. ^[10]

EMS staff members should be reminded not to overtreat high blood pressure in the stroke patient, in whom maintaining perfusion pressure to the brain is vital. Once a brief assessment has been performed, the time spent in the field must be minimized. Stroke patients should be transported to the hospital with the same level of urgency as those with myocardial infarction (sometimes referred to as "load and go"). Early notification of ED personnel can shorten the time to evaluation so that treatment can start as soon as the patient arrives in the ED.

Patients with strokes who arrive by EMS instead of private transport were more likely to receive brain imaging and physician interpretation of the imaging within recommended target times. ^[11] EMS arrivals with hospital prenotification had more rapid evaluations than those without hospital prenotification.

Emergency department

Once the patient arrives in the ED, ED personnel should perform a brief assessment of the patient and immediately contact the stroke code team. To make this as easy as possible, the code team is best reached through a single pager number. The efficiency of the ED evaluation and treatment can be enhanced by following the multidisciplinary written care protocol that outlines the role of each ED member and the steps to be followed.

The first step is to contact the stroke code team before the evaluation is complete. Full history, examination, CT scan, and other laboratory results may still be pending when the code team is called. The respective roles of the code team nurse and the ED nurse in performing such tasks as starting a second intravenous line, taking blood pressure, or mixing the t-PA, if it is to be administered, need to be defined. Standard orders may save valuable time and prevent omissions in the care of the patient with acute stroke. ED personnel can be helpful in locating family members who might have additional information about the time of onset of stroke and other issues concerning the patient. (See the PDFs below.)

Included in the 2018 update to the American Stroke Association treamtment guidelines is the use of tenecteplase for the treatment of acute ischemic stroke. Tenecteplase given at 0.25 mg/kg is listed as evidence level IIB and may be a resonable alternative to alteplase for patients presenting within 4.5 hours of symptom onset. ^[12]  Hopsitals will need to determine which thrombolytic will be appropriate for their facility. 

• Acute Stroke Checklist (PDF)

• Intravenous Administration of t-PA in Acute Ischemic Stroke (PDF)

• T-PA Dosing Chart (PDF)

• T-PA Administration Instructions (PDF)

Radiology, laboratory, and pharmacy

The stroke pathway or protocol in the ED should provide for diagnostic studies in every patient with stroke. ^[13] Of these, the most critical is the computed tomography (CT) scan. The procedure for obtaining the CT scan should be streamlined to ensure that the scan is obtained urgently (within 25 minutes of arrival). The CT scanner and someone to read the scan need to be readily available at all hours or arrangements must be made for transfer of the patient to another hospital with these facilities.

Code team members may need to transport the patient to the CT scanner if waiting for someone else to perform this service might delay the scan. Laboratory tests should be ordered and performed promptly so that the results are available within 45 minutes. A chest radiograph and 12-lead electrocardiogram (ECG) within 45 minutes is also helpful. If the drugs required for treatment, including t-PA, are not located in the ED, the procedure for obtaining them from the pharmacy after regular hours needs to be outlined and administration instructions should be easily accessible.

The protocol should include criteria for which patients will be admitted or transferred to another facility with more comprehensive stroke services available. (See Referring Stroke Patients (PDF).) ^[14]

Stroke units

Inpatient units receiving patients after the initial ED workup should have staff trained in the care of the acute stroke population. Multidisciplinary care protocols should be written outlining inpatient management in the critical care and acute care phase, as well as monitoring of the patient post–t-PA. (See the PDFs below.)

• Acute Stroke Practice Guideline for Inpatient Management of Ischemic Stroke and Transient Ischemic Attack (TIA) (PDF)

• Acute Stroke Practice Guideline for Inpatient Management of Intracerebral Hemorrhage (PDF)

• Acute Stroke Practice Guidelines for Inpatient Management of Subarachnoid Hemorrhage (PDF)

Preprinted order sets can help ensure predefined care elements are considered. (See the PDFs below.)

• Admission Order Set for Stroke/Rule Out Stroke/Transient Ischemic Attack (PDF)

• Post-TPA Order Set (PDF)

• Aneurysmal Subarachnoid Hemorrhage Order Set (PDF)

• Craniotomy for Aneurysm: ICU Postoperative Orders (PDF)

• Ruptured Aneurysm: Postembolization Orders (PDF)

• NSICU Admission Orders (PDF)

Neurosurgical services

Patients who are identified as having a hemorrhagic stroke, and certain patients with ischemic stroke, will need neurosurgical evaluation.

Facilities keeping these patients will need to develop a plan to have fully functional operating room facilities and neurosurgical staff available within 2 hours of the clinical need being recognized. If that is not possible, a transfer plan should be developed for those patients who are identified as needing neurosurgical services the facility is not able to provide.

Remote consults from a regional comprehensive stroke center can be very helpful in making these decisions.

Interventional neuroradiology

Three trials initially looked at the use of endovascular therapy as an adjunct to intravenous r-tPA or in place of r-tPA. These trials, using first-generation mechanical thrombectomy devices, did not show benefit to recanalization rates or outcome. ^{[15, 16]} In contrast, trials using stent retrievers have shown improved results in recanalization rates and outcomes and have become a standard of care for treating LVO. ^{[17, 18, 19, 20]}

Primary stroke centers need to determine how they want to manage the care of patients with LVO. Facilities that intend to keep this patient population will need to develop a system to rapidly identify LVO, administer thrombolytic when appropriate, and transport patients to intervention neuroradiology suites for mechanical thrombectomy. If thrombectomy is not locally available a transfer plan should be created that will allow for the rapid transfer of this patient population to a comprehensive stroke center. ^[21]

Continual review of the entire stroke care system can help to improve its function. ^[22] In particular, delays in evaluation and treatment should be investigated and causes corrected. The stroke protocol can be used to assess outcome measures, such as the timeliness of interventions, patient recovery, and costs. Feedback given to the people involved in the patient's care, including EMS personnel and those in the ED, provides an educational opportunity and maintains interest in providing care to patients with acute stroke.

The Get With the Guidelines-Stroke database can be very helpful in driving quality improvement activities. ^[23] Demographic and clinical data are entered for each patient admitted with acute stroke (ischemic stroke, transient ischemic attack, intracerebral hemorrhage, or subarachnoid hemorrhage). Reports can be run to track performance on a variety of indicators, including 10 predetermined stroke performance measures. These 10 measures focus on early identification and treatment with t-PA, prevention of inhospital complications, and secondary stroke prevention. The performance measures are as follows:

• Deep venous thrombosis (DVT) prophylaxis

• Discharged on antithrombotics

• Patients with atrial fibrillation receiving anticoagulation therapy

• t-PA considered

• Antithrombotic medication within 48 hours of hospitalization

• Lipid profile

• Screen for dysphagia (See the PDF below.)

• Bedside Nurse Swallow Screen (PDF)

• Stroke education for patient/family

• Tobacco cessation counseling for patient/family

• Plan for rehabilitation considered

In some cities, coordinating stroke treatment efforts among multiple hospitals has been helpful. ^{[24, 25]} In these cases, a single stroke code team is mobile and travels between the hospitals. The mobile stroke team allows specialized stroke care to be provided to hospitals that by themselves may not have such resources, while avoiding time delays and costs incurred through transfer of a patient to a single site.

Telemedicine technology can also expand the reach of stroke neurologist expertise to community hospitals and rural areas. Clinical outcomes have been demonstrated to be similar for intravenous t-PA guided through telestroke technology and that given at a tertiary stroke center. ^[26]

Rapid recognition and treatment for the patient with acute stroke can improve clinical outcomes ^[12] . A coordinated multidisciplinary effort is necessary to accomplish this goal. The establishment of a stroke team and adherence to the recommendations for a Primary Stroke Center can provide a clear framework for development of a successful program.