AHA/ASA Back Four-Tier System for Stroke Care

Just using the word 'care' here means they have completely bought into the tyranny of low expectations. They would all be fired under my watch.  You fucking blithering idiots, survivors don't care about 'care', they want RESULTS, say 100% recovery. When the hell are you going to get there? Talk to survivors sometime, and not patronizingly.

AHA/ASA Back Four-Tier System for Stroke Care

Updated recommendations highlight role of thrombectomy-capable stroke centers

by Nicole Lou, Contributing Writer, MedPage Today May 20, 2019

A four-tier system of hospitals was endorsed by the American Heart Association (AHA)/American Stroke Association (ASA) in an updated policy statement on the organization of acute stroke care in the U.S.
Sitting between primary stroke centers (PSCs) and comprehensive stroke centers (CSCs) in terms of stroke care level are now thrombectomy-capable stroke centers (TSCs), newly designated hospitals that are alteplase- and thrombectomy-capable but not necessarily able to offer comprehensive care for the most complex stroke cases.
Occupying the lowest rung of the ladder, then, are nationally certified acute stroke-ready hospitals (ASRHs), or centers that are likely rural, alteplase- but not thrombectomy-capable, and lacking dedicated stroke units.
"The CSC, [PSC], TSC, and ASRH framework provides an appropriate platform for the data-driven development of hospital-based processes of care and outcome metrics. All certification systems should meet or exceed these standards," according to the writing group chaired by Opeolu Adeoye, MD, MS, of the University of Cincinnati, in the statement published in Stroke.
TSCs make sense in communities without access to thrombectomy, but where a CSC already exists nearby, they are more controversial, according to AHA president-elect Robert Harrington, MD, of Stanford University in California, in an accompanying editorial.
"A key issue will be what amount of extra travel time to access a CSC over a [PSC] or nearby TSC is acceptable. This will likely be a local decision based on the density of the population and distribution of resources until more research provides data needed for an evidence-based policy decision," he wrote.
"Ideally, when geography permits, locales will identify a CSC as the ideal choice for a suspected LVO [large vessel occlusion] patient if an ambulance needs to choose among several destinations, including [PSCs] and TSCs," Harrington added.
He predicted that the greatest challenges will be in urban and suburban areas, due to multiple municipalities governing emergency medical services, multiple competing hospital systems, and fluctuating traffic patterns, among other variables.
"The recommendation to prefer endovascular-ready hospitals just makes sense. I wish there was more data about how to factor in time but I know groups are working on models that will give us more information about this," commented S. Claiborne Johnston, MD, PhD, of The University of Texas at Austin.
Other new and revised recommendations in the AHA/ASA policy statement (its first update since 2005) include:

• Primary prevention: "A stroke system should develop support mechanisms to assist communities as a whole, patients, and providers in long-term adherence to primordial and primary preventive treatment regimens"

• Community education and engagement: "Innovative behavioral interventions addressing barriers to healthy behaviors, prevention adherence, and warning sign action with tools such as digital phenotype analysis, social network analysis, gamification, and machine learning offer opportunity for sustainable behavioral change, and research in these areas should be encouraged"

• Emergency medical services: "When there are several intravenous alteplase-capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity scale score suggestive of LVO. When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care"

• Acute stroke care at stroke centers: "Data suggest the benefit of more sophisticated imaging triage that assesses penumbral pattern in selecting patients for endovascular thrombectomy from 6 to 24 hours from last known normal. These data merit the broader adoption of this imaging technology in thrombectomy centers"

• Secondary prevention: "A stroke system should establish support systems to ensure that all patients discharged from hospitals and other facilities to their homes have appropriate follow-up with specialized stroke services when needed and primary care arranged on discharge"

• Rehabilitation and recovery: "A stroke system should ensure that all stroke survivors receive a standardized screening evaluation during the initial hospitalization to determine whether rehabilitation services are needed and the type, timing, location, and duration of such therapy"

"The guidelines recommend a number of community-wide interventions that could reduce the incidence and impact of stroke. Sadly, these are unlikely to be implemented in the U.S. given how dollars flow in our health system," according to Johnston.

Last Updated May 20, 2019

Adeoye reported no relevant conflicts of interest.
Harrington disclosed research grants from AstraZeneca and BMS.

Primary Source

Stroke

Source Reference: Adeoye O, et al "Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association" Stroke 2019; DOI: 10.1161/STR.0000000000000173.

Secondary Source

Stroke

Source Reference: Harrington RA "Prehospital phase of acute stroke care: guideline and policy considerations as science and evidence rapidly evolve" Stroke 2019; DOI: 10.1161/STROKEAHA.119.025584.

At Thrombectomy Centers, Worse Outcomes for Patients Transferred In

Isn't this great, YOU will need to know ahead of time exactly what type of stroke you have and where to go. So you can direct the ambulance to the correct  hospital. This is totally solvable if the EXACT REASON for these worse outcomes can be determined. Then you have researchers solve that. But no, throwing up your hands in defeat is so much easier and doesn't require any leadership at all. My director never let me dissemble my way out of solving a problem. Excuses were not allowed, the door would have been the answer. I once spent 3 months solving a problem where a previous programmer had zapped a load module changing a branch hexadecimal instruction  but never changed the code. Changed 4740 to 47F0. When walking thru the code in test, I couldn't see why it wouldn't branch correctly since the variables being tested matched the condition. Finally dawned on me that looking at the hex representation was needed. Older programmers were impressed I found that out, zapping had quit being used a decade before. 

At Thrombectomy Centers, Worse Outcomes for Patients Transferred In

• by Nicole Lou, Reporter, MedPage Today/CRTonline.org February 01, 2019

Acute ischemic stroke patients undergoing endovascular therapy suffered worse outcomes in some respects if they had transferred from another hospital instead of being admitted directly, according to a study.
In-hospital mortality at thrombectomy centers was not significantly more common among transferred patients after adjusting for treatment delay (14.7% vs 13.4% for direct arrivals, adjusted OR 1.01, 95% CI 0.92-1.11), Get With The Guidelines-Stroke registry data showed.
But transferred patients did have:

• More symptomatic intracranial hemorrhage within 36 hours (7.0% vs 5.7%, adjusted OR 1.15, 95% CI 1.02-1.29)
• Lower odds of independent ambulation at discharge (33.1% vs 37.1%, adjusted OR 0.87, 95% CI 0.80-0.95)
• Less likelihood of being discharged home (24.3% vs 29.1%, adjusted OR 0.82, 95% CI 0.76-0.88)

Given the limited capabilities of current prehospital assessment tools and the fact that certain centers remain unable to provide mechanical thrombectomy, "it would not be feasible to eliminate interhospital transfer entirely," wrote Shreyansh Shah, MD, of Duke University Medical Center in Durham, North Carolina, and colleagues in Circulation.
Instead, they advocated the use of quality improvement programs to improve the workflow of centers not capable of endovascular therapy.(Dammit, no workarounds. Solve the real problem. You'd be fired in my hospital for suggesting this. ) Early mobilization of transport crew and the implementation of vascular imaging at the initial hospital are also important, they added.
"Overall, we need to create a system so that the correct patient goes to the correct hospital the first time around. That is the single biggest need that we have for the whole organization of acute stroke care," commented Mayank Goyal, MD, of the University of Calgary, Alberta, who was not involved in the project.
One problem is the lack of a centralized ambulance system in the U.S. that makes ambulances incapable of acting in a cohesive way -- for example, in deciding that a patient with severe stroke should be taken to the comprehensive stroke center, Goyal said in an interview.
There is no one-size-fits-all solution that would work everywhere in the U.S., however.
"You have to think at the level of geography. In New York City, if you're in a 5- or 8-mile radius of the NYU campus, there's absolutely no need for another center. Every stroke should go there," Goyal said. "If you're in Montana or upstate New York, you have to think differently."
If primary stroke centers keep creating endovascular therapy services, Goyal suggested what will happen is low volumes everywhere.
And it's too simplistic to think that a minimum volume requirement will fix the problem, he emphasized. Variables including the "number of interventionists, their experience, what is their practice like when they are not dealing with stroke, and what other options are available to the population" must be considered, he argued.
According to Shah and colleagues, transferred patients waited more than an hour longer to start thrombectomy (median time since last known well to endovascular therapy initiation 289 min vs 213 min, P<0.0001), suggestive of a delay in transit time, the authors said.
On the other hand, door-to-endovascular therapy initiation times were in the favor of this group (68.0 vs 128.0 min, P<0.0001). "This may reflect the benefit of pre-notification at the endovascular therapy center, enabling teams to prepare prior to the patient's arrival," Shah's group said.
The Get With The Guidelines-Stroke registry counted more than 1.8 million stroke patients admitted from 2012 to 2017, of whom 37,160 had endovascular therapy at 639 hospitals.
Shah and colleagues found that 42.9% of those had been transferred to the endovascular stroke center from another hospital. Interhospital transfers increased sharply starting at the end of 2014 (ultimately rising from 256 in the beginning of 2012 to 1,422 at the end of 2017).
Transferred patients were younger and more likely to be white compared to direct arrivals. They also had higher odds of treatment at teaching hospitals and Joint Commission-certified comprehensive stroke centers.
The study authors acknowledged the limited generalizability of their findings to hospitals not participating in the registry. Their risk adjustment for baseline stroke severity may also have been affected by en-route thrombolytics.
Moreover, the study did not account for late thrombectomy, which emerged in 2018's DEFUSE 3 and DAWN trials as beneficial to patients even 16-24 hours after stroke onset.

The study was funded by a grant from the American Heart Association/American Stroke Association.
Shah disclosed no conflicts of interest.

• Primary Source

  Circulation

  Source Reference: Shah S, et al "Use, temporal trends, and outcomes of endovascular therapy after interhospital transfer in the United States" Circulation 2019; DOI: 10.1161/CIRCULATIONAHA.118.036509.