The revised 2011 recommendations for Primary Stroke Centers (PSCs) update the original 2000 guidelines. Key changes include shorter time targets for brain imaging, acute stroke team response, and establishing protocols for emergency medical services, the emergency department, and rehabilitation services. Certification through The Joint Commission remains important for PSCs and requires ongoing quality improvement efforts such as benchmarking and use of a stroke registry.

1. REVISED
RECOMMENDATIONS FOR
PRIMARY STROKE
CENTERS
Samuel Bierner, MD
Professor, PM&R
UT Southwestern Medical Center

5. Brain Attack Coalition report Stroke
2011;42:2651-2665
First Recommendations Revised Recommendations
• 2000 • 2011

6. Burden of stroke
United States Causes of death
• 795,000 persons per year • 4th Leading Cause of
have a new or recurrent Death (down from 3rd)
stroke • Major cause of adult
disability

7. 2 Levels of Stroke Centers
CSC (Comprehensive Stroke
PSC (Primary Stroke Center) Center)
• Provide acute care to • Large or complex stroke;
most patients with stroke • Hemorrhagic stroke;
• Use some acute stroke • Requiring specialized
therapies; treatments
• Admit the patient to a (endovascular, surgery)
stroke unit • Multi-system involvement
• Neurosurgical services
immediately available

8. Major Elements of a PSC
Patient Care Administrative/Support
• Acute Stroke Team (AST) • Institutional Support
• Written care Protocols • PSC Director, call
• Emergency medical services reimbursement
(EMS); • Stroke Registry with
• Emergency Department; outcomes and QI
• Stroke Unit; components;
• Educational Programs for
• Neurosurgical Services;
Public and Professionals
• Imaging Services;
• Certification
• Rehabilitation Services;
• Participate in Stroke System
• Laboratory Services of care

9. Acute Stroke • At bedside within 15
Team MINUTES
Initiate diagnostic and • At least 2 members
Immediate care
At least • If a rapid response team from
1 Physician with
expertise in
cerebrovascular
outside hospital, must be
disease;
1 other healthcare
able to respond in less than
provider (nurse, PA or
NP) or = 15 minutes
Available 24/7 basis

10. Class I A • Written Care Protocols
Recom-
• Swallow evaluation before
mendation
feeding
• DVT prophylaxis

15. EMS
• “drip and ship” • Los Angeles Pre-
protocols for use of hospital Stroke Screen
intravenous tPA; • Establish time of
• Inclusion of “air onset;
ambulances” is a new • Transport patient’s
recommendation; medications with them
• New technologies: to hospital;
telemedicine, telestrok • Cooperative
e/teleradiology educational activities 2
x per year

16. Emergency Department
• ED personnel must be • Key ED personnel
trained in diagnosis should participate in
and treatment of all educational activities
types of acute stroke at least 2 times per
• -Use of tPA in acute year;
ischemic stroke • 8 hours CEU per year;
• Door-to-physician • Log of patients and
assessment time of 15 door to physician times
minutes maintained

17. Stroke Unit
• Defined group of beds • Stroke Units reduced
• Step-down unit with death by 17 to 28%;
nurse: patient ratio of
1:3. • 7% increase in ability
• Written care protocols to live at home;
• Nursing expertise in
NIHSS and vital signs • 8% reduction in length
checked every 1-2 hrs. of stay
• Multi-channel
telemetry
(BP, P, O2, Resp)

18. Neurosurgical Services
• Ventricular drainage • NSG care must be
catheter placement; available within 2
• Evacuation of a hours of the time it is
hematoma; deemed clinically
• Decompressive
necessary
hemicraniectomy for
massive cerebral
infarction

19. Cerebral and Cerebrovascular Imaging
• Must be able to • Brain MRI may be
perform head CT used in lieu of head CT
within 25 minutes of if same time
the order being written; parameters can be
• Physician can read met.
scan within 20 minutes • Vascular imaging
of its completion (MRA or CTA) should
be available for those
patients who might
benefit from this
testing

20. Cardiac Imaging
• Significant % of • TTE
ischemic strokes are • TEE
due to cardio-embolic • Cardiac MRI
disease:
• PSC should have at
• Atrial fibrillation;
least 1 modality
• Myocardial infarction; available to image the
• Valvular disease; heart for all admitted
• Aortic Arch plaques; patients with stroke.

21. Laboratory Services
• Blood chemistries • ECG
• Coagulation studies • Chest X-ray
• Pregnancy test (when • HIV test
appropriate) • Pregnancy test
• Studies must be • Drug toxicology test
completed within 45 • All must be done
minutes of being
ordered

22. Rehabilitation Services
• TJC (Joint • Early assessment of
Commission) has needs (PT, OT, ST)
included rehabilitation • Early assessment of
consideration as a rehabilitation potential
disease performance • Early initiation of basic
measure for PSC rehabilitation activities
• Does not have to have
inpatient unit (IRF)

23. TJC Certification Program
• Launched in 2004 • UTSW and Parkland
• More than 800 PSC’s are both certified
in current network
• Must select 2 relevant
patient-care
parameters for
benchmarking each
year
• Quality Improvement –
Stroke Registry or
Database