Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

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Executive Summary

The announcement, in late 1995, that acute ischemic stroke can be successfully treated with thrombolytic agents created the need for a national plan on how to make this treatment available to eligible patients as rapidly as possible. In response to this need, the National Institute of Neurological Disorders and Stroke sponsored a National Symposium on Rapid Identification and Treatment of Acute Stroke on December 12 and 13, 1996. The goal was to provide a platform for coordinating nationwide efforts aimed at implementing acute stroke therapy for all types of stroke. While thrombolytic therapy of ischemic stroke with t-PA was the impetus for this Symposium, it was recognized from the outset that the successful treatment of any type of stroke will require rapid response to all stroke types. The theme of the Symposium was that rapid evaluation and treatment will improve the outcome for all stroke patients.

This monograph presents the conclusions of the Symposium participants, who represented a full range of professionals involved in treating stroke patients, managing hospital and emergency response systems throughout the United States, and educating the public about health risks and new treatments.

Each year, 500,000 Americans suffer acute brain attacks, 400,000 of which are ischemic strokes caused by blood clots occluding brain arteries. The remainder are hemorrhagic strokes caused by intracerebral hemorrhage and subarachnoid hemorrhage. There are currently more than 3 million Americans living with some disability resulting from stroke. Therapy given promptly to carefully selected stroke victims could reduce the extent of this disability. To make prompt treatment widely available, a number of critical changes must be made in the nation's health care delivery systems. Specifically:

• Prehospital emergency response systems must train personnel to correctly identify potential candidates for treatment and work closely with hospital emergency departments to transport these patients rapidly to appropriate stroke centers. Thrombolytic therapy for ischemic stroke requires an especially rapid response in the first few minutes after a patient arrives at a hospital.

• Emergency departments must have specialized protocols in place for identifying candidates for therapy and treating those that require therapy within a narrow therapeutic time window.

• Hospitals must develop comprehensive acute stroke plans that define the specialized roles of nursing staffs, diagnostic units, stroke teams, and other treatment services such as pharmacy and rehabilitation.

• To take full advantage of effective stroke treatment, all health care systems involved in managing eligible patients must be carefully integrated, taking into consideration the wide diversity of health care that exists throughout the United States, from rural settings with minimal access to specialized care to urban settings with a high volume of emergency patients.

• Public education is critically important in ensuring that all of the efforts cited above are successful. The public must learn that a brain attack is a medical emergency, that a treatment is now available for some stroke patients, and that this treatment is only effective when given within a few hours of the onset of symptoms.

As a first step in planning the Symposium, the NINDS created a Steering Committee whose members developed the overall Symposium goals, guided by the five domains above. The committee then created three task forces (Prehospital and Hospital Care, Health Care Systems, and Public Education), each of which had responsibility for setting the agenda for that topic area. The committee members for all groups are listed in the Appendices section of this monograph.

Another critical element in the planning and implementation of the Symposium was outreach to the many professional groups (see Partners in the Appendices) who will be instrumental in changing the existing health care system. These Partners include the full range of allied health professionals--emergency physicians and nurses, emergency medical services personnel, radiologists, neurologists, and many others. Also represented among the Partners are government agencies, such as the Food and Drug Administration and the Health Care Financing Administration, and private advocacy groups, such as the Dana Alliance for Brain Initiatives and the National Coalition for Research in Neurological Disorders. By involving all such interested parties in the Symposium the NINDS hoped to reach into every corner of the national health care system to ensure that nothing was overlooked as we developed a consensus on a national stroke treatment plan.

Full details of the conclusions reached at the symposium can be found in the Recommendations section of this monograph. The following represents an overview of these recommendations:

Prehospital Emergency Medical Care Systems:

• EMS personnel must be trained to treat stroke as a time-dependent, urgent medical emergency, similar to acute myocardial infarction.
  
• A Chain of Recovery--beginning with the identification (either by the patient or an onlooker) of a possible stroke in progress and ending with a rehabilitation plan--must be established in every community of the country.
  
• New educational initiatives must be developed and implemented for all medical personnel in the Chain of Recovery, including 911 dispatchers, EMS technicians, and air medical transport personnel. This will require the creation of task forces to develop model educational initiatives, and standardized data sets to help ensure effective research and outcomes analyses.

Emergency Department:

• Acute stroke patients should be classified as quickly as possible to identify those eligible for thrombolytic therapy. Although this classification will often be done by physicians in emergency departments, it may also be accomplished by others, e.g., prehospital care providers, triage nurses, or other individuals competent to apply categorization criteria. Patients deemed ineligible for thrombolytic therapy will undergo a different rapid categorization to establish what treatment they should receive.
  
• Response systems, including optimal time-frames, must be established, maintained, and monitored in all emergency departments. The goal should be to (a) perform an initial patient evaluation within 10 minutes of arrival in the emergency department, (b) notify the stroke team within 15 minutes of arrival, (c) initiate a CT scan within 25 minutes of arrival, (d) interpret the CT scan within 45 minutes of arrival, (e) ensure a door-to-drug (needle) time of 60 minutes from arrival, and (f) transfer the patient to an inpatient setting within 3 hours of arrival.
  
• Although medical management of blood pressure remains a controversial and complex topic, general guidelines were outlined at the Symposium. For example, for acute stroke patients who are candidates for thrombolytic therapy antihypertensive treatment should not be given if systolic blood pressure is less than 185 mm Hg or diastolic pressure is less than 105 mm Hg. Acute stroke patients with a diastolic pressure greater than 140 mm Hg or a systolic pressure greater than 220 mm Hg on two readings are generally not candidates for thrombolytic therapy, although antihypertensive treatment should be given.

Acute Hospital Care:

• Every hospital providing care to stroke patients should develop a Stroke Plan that defines the optimal treatment pathways appropriate for that particular institution.
  
• Patients who meet thrombolytic treatment criteria should have access to stroke expertise within 15 minutes of hospital arrival and neurosurgical expertise within 2 hours of hospital arrival. Other time-frame recommendations are outlined above under Emergency Department.
  
• A Stroke Toolbox containing guidelines, algorithms, critical pathways, NIH Stroke Scale training tapes, and other stroke templates should be created, updated, and made easily available through the NINDS.
  
• Health professional training programs should be modified to include standards of acute stroke care, and the Acute Health Care Panel endorsed specialty-specific continuing medical education related to acute stroke.
  
• Criteria for primary, intermediate, and comprehensive stroke centers should be established.
  
• Communities should be encouraged to create local and regional stroke networks encompassing all levels of acute stroke care.

Health Care Systems:

• Creating an efficient stroke care delivery system should start with identifying committed prehospital and hospital leaders who will act as "champions." The task of these champions will be to develop and sustain teams for managing stroke patients through the various phases of care. Champions should use flow-charting techniques to help them understand the current components of care, decide on necessary modifications, and implement these modifications.
  
• All components of the stroke care delivery system must be integrated functionally, financially, and legally so they work together seamlessly. Those who activate the acute stroke treatment system should work with the approach that "one call does it all," with everyone on the team linked with pagers or cellular phones.
  
• Key indicators for acceptable outcomes of acute stroke care must be identified. Indicators should be established for the prehospital setting, the emergency department, and the acute stroke care unit within the hospital, as well as for the variety of discharge settings, including rehabilitation facilities.

Public Education:

• Behavior change is achievable, as demonstrated by many past public education successes. But change occurs slowly, so those implementing public education campaigns must be persistent and patient.
  
• Big, comprehensive programs that employ many communications vehicles are the most effective.
  
• Motivation to change occurs when the public perceives that the benefits of change exceed the cost of change. The messages about seeking prompt health care after a stroke must be simple, clear, and repeated often.
  
• We must understand our audience, which is comprised of many subgroups with different backgrounds and different methods of learning. Messages must be tailored to these various groups.
  
• Success is most likely if public educators follow a Madison Avenue approach to delivering messages. In this approach, strategy always precedes execution, and the best strategy tool to use is the creative brief, a document that defines the target audience, identifies the desired actions to be taken by that audience, presents current consumer beliefs and barriers to taking action, and establishes long-term goals.
  
• Strong national leadership will be required to move this initiative forward, and the Public Education Panel recommended that the NINDS take this leadership role.

The goal of successfully delivering thrombolytic therapy to all eligible ischemic stroke patients is an achievable one, but one that will take a great deal of thoughtful and informed decision-making. The NINDS, working closely with the Acute Stroke Partners and the Brain Attack Coalition,* are confident that changes in the health care delivery system will occur and that thousands of Americans will be spared many of the catastrophic disabilities that currently afflict more than 3 million surviving stroke victims.

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^* The Brain Attack Coalition is a group of national organizations dedicated to reducing the occurrence of stroke and death and disability associated with stroke. The Coalition facilitates coordination and communication among the many groups involved in stroke care and education, and is currently chaired by the National Institute of Neurological Disorders and Stroke.

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Last Edited: July 01, 1999

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892