Dr Johanna FifiJohanna Fifi, MD
In light of recent advances in scientific knowledge and innovations in clinical care in stroke systems, the American Stroke Association (ASA) published a policy statement1 to help guide policymakers and public healthcare agencies in updating stroke systems of care to reflect these advances, translating these developments into improvements in patient outcomes and facilitating optimal stroke care delivery.

The recommendations include early and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

“Now that we have one of the most effective treatments for stroke with thrombectomy, really one of the most effective treatments in all of medicine, the focus has to be on organizing systems of care such that we can get these patients as quickly as possible to centers that can perform this time-sensitive procedure,” Johanna Fifi, MD, associate professor of neurosurgery, neurology, and radiology at the Icahn School of Medicine at Mount Sinai and director, Endovascular Stroke Program at Mount Sinai Health System, told NeurologyLive. “We also have to balance this with resources and the ability to triage the appropriate patients for this treatment. These are exciting times in acute stroke care and positive change is happening quickly.”

The updated policy statement clearly backs a 4-tier system of stroke care, including primary stroke centers, comprehensive stroke centers, thrombectomy-capable stroke centers, and acute stroke-ready hospitals, and recommends that Emergency Medical Services (EMS) should consider additional travel time of no more than 15 minutes to reach a facility capable of offering endovascular thrombectomy for patients with a prehospital stroke severity scale score suggestive of large vessel occlusion when there are several intravenous alteplase-capable hospitals within reach.

"It is up to local and regional communities, however, to define how best to implement these elements into a stroke system of care that meets their needs and resources and to define the types of hospitals that should qualify as points of entry for patients with suspected LVO strokes as opposed to patients with potentially milder strokes that may not require advanced interventional therapies," wrote AHA president-elect Robert A. Harrington, MD, FAHA, MACC, in a related editorial.2 

In addition, the statement includes the following recommendations:
  • Stroke systems of care should support local and regional educational initiatives to increase awareness of stroke symptoms with an emphasis on at-risk populations. Innovative behavioral interventions addressing barriers should be encouraged.
  • EMS leaders, governmental agencies, medical authorities, and local experts should work together to develop consistent triage paradigms and protocols to rapidly identify patients with a known or suspected stroke.
  • Stroke centers should adopt approaches to secondary prevention addressing all major modifiable risk factors consistent with the national guidelines.
  • Stroke systems should establish support systems to ensure all patients discharged from the hospital and other facilities have appropriate follow-up with specialized stroke services when needed on discharge. To standardize the post-acute care after stroke discharge, stroke centers should comprehensively screen for post-acute complications, provide personalized care plans and referrals to community services, and reinforce secondary prevention and self-management of risk factors and lifestyle changes. All stroke survivors should receive a standardized screening evaluation to determine whether rehabilitation services are needed and the type, timing, location, and duration of such therapy.
  • Efforts should be made to advance the use of technology and patient-reported outcomes to facilitate improved care transitions. Prior to implementation, new policies should be evaluated for potential adverse impact.
  • Federal and governmental institutes should enact policies to standardize the organization of stroke care.
“There needs to be development of tools that can quickly and accurately identify stroke patients that are candidates for this treatment in the field. Until that time, we are using cruder tools to be able to identify and triage the patients. There is still a lot of work to be done on systems of triage around the country. Each city and region has its unique set of issues that need to be dealt with,” Fifi explained. “Primary and thrombectomy capable centers need to work together in conjunction with other stakeholders, such as EMS and government health agencies, to create the best geographic coverage for patients. This treatment has also re-opened the field for investigation of neuroprotective agents for those patients that are geographically far from thrombectomy centers.”
REFERENCES
1. Adeoeye O, Nyström K, Yavagal D, et al. Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update: A Policy Statement From the American Stroke Association. Stroke. Published online May 20, 2019. doi: 10.1161/STR.0000000000000173.
2. Harrington RA. Prehospital phase of acute stroke care: Guideline and policy considerations as science and evidence rapidly evolve. Stroke. Published online May 20, 2019. doi:
10.1161/STROKEAHA.119.025584.