New recommendations for stroke systems of care - American Stroke Association policy statement

Approximately 7.2 million Americans 20 years or older have had a stroke. Nearly 800,000 people in the U.S. have a new or recurrent stroke each year. A stroke occurs every 40 seconds in the U.S., and someone dies of a stroke every four minutes.

According to a policy statement published by the American Stroke Association, and published in the journal Stroke, improvements in stroke systems of care are imperative to ensure advancement in the treatment and care of stroke patients and to improve patient outcomes. The statement was released during the National Emergency Medical Services (EMS) Week. Over the last decade, stroke systems have seen vast improvements in the availability of endovascular therapy, neurocritical care, and stroke centre certification. The use of telestroke and mobile stroke units have further improved access for stroke patients to alteplase, a lifesaving, clot-busting drug.

As Opeolu Adeoye, the chair of the writing group for the statement and associate professor of emergency medicine and neurosurgery at the University of Cincinnati points out, there have been monumental advancements in acute stroke care over the last 14 years. The concept of a comprehensive stroke system of care has evolved. This new policy statement reflects the progress that has been made so far and highlights what still needs to be done to maximise patient outcomes.

As per the statement, if more than one intravenous alteplase-capable hospital is within reach, EMS should consider additional travel time of up to 15 minutes to reach a hospital that is capable of performing endovascular thrombectomy for patients who have had a severe stroke. Both these treatments, intravenous alteplase, and endovascular thrombectomy, should be administered as soon as possible to be effective. However, not every hospital can deliver these services. As Adeoye points out, getting to the hospital quickly is important for patients with a large vessel blockade, but so is getting to the right hospital.

The new policy statement from the American Stroke Association also addresses disparities in care among racial and ethnical minorities, who are less likely to use EMS and who also have the lowest awareness of the causes and symptoms of stroke. This lack of knowledge, especially among the Hispanic and black population, can hamper timely stroke care. That is why the American Stroke Association has emphasised on the importance of implementing public education programmes that focus on stroke systems and highlights the importance of seeking emergency care by calling 9-1-1 if stroke symptoms are observed.

Other recommendations include:

• Implementation of local and regional public education initiatives to increase awareness of symptoms with an emphasis on high-risk populations.
• The need for EMS leaders, governmental agencies, medical authorities, and local experts to work together and to adopt consistent and standardised triage protocols to rapidly identify patients with a known or suspected stroke.
• For certified stroke centres to provide help to stroke survivors to reduce the risk of subsequent strokes, as per the guidelines for secondary prevention.
• To design a stroke system that provides comprehensive post-stroke care, including primary care and specialised stroke services including physical, occupational, speech, and/or other therapies needed at time of discharge.
• To enact policies to standardise the organisation of stroke care, to lower barriers to seeking emergency care for stroke, to ensure that stroke patients receive care at the right hospital at the right time, and to facilitate access to secondary prevention of rehabilitation and recovery resources after stroke.

Overall, the goal of these recommendations is to create optimised stroke systems of care. The American Heart Association's Get With The Guidelines - Stroke at U.S. Hospitals have been associated with an 8% reduction in mortality at one year and improved functional outcome at the time of discharge.