Stroke Systems of Care: State Policy Interventions by Evidence Level

Includes all emergency medical care provided to the stroke patient prior to the handoff of the patient from EMS providers to staff at the acute care facility.

Stroke Pre-notification of Receiving Facility by EMS Providers

States can encourage emergency medical services (EMS) providers to pre-notify receiving facilities of a suspected stroke patient; for example, by incorporating pre-notification into EMS protocol algorithms and checklists, including pre-notification as a component of EMS training and continuing education, and reviewing the use of pre-notification as a part of continuous quality improvement activities within stroke systems of care.

State law example: A Wyoming regulation requires EMS providers to issue a “Notification of Stroke Alert” to the receiving Stroke Center as soon as possible for patients with a positive F.A.S.T. (Facial droop; Arm droop; Slurred speech; and Time to call for help) assessment.

EMS Triage and Transport to Most Appropriate Stroke Facility

EMS providers play a vital role in the rapid triage and transportation of suspected stroke patients. Pre-hospital EMS care protocols for stroke triage and transport to the closest stroke facility by ambulance may improve outcomes for patients with stroke. (Analyses included ground transport studies only.)

State law example: In collaboration with the District of Columbia Fire and EMS Department, the Department of Health is to establish standardized pre-hospital care protocols for stroke triage assessment, treatment, and patient transport to the closest most appropriate facility, which could be an Acute Stroke Ready Hospital (ASHR), Primary Stroke Center (PSC), or Comprehensive Stroke Center (CSC).

Air Medical Transport to Most Appropriate Stroke Facility

Air transport of stroke patients allows for the shortening of time to treatment, improvements in patient survival rates, potential lowering of the incidence of stroke in patients, improvements in access to interventional stroke care in rural settings. States could authorize air medical transport in stroke transport protocols.

State law example: A Missouri rule establishes protocols for “transporting suspected stroke patients by severity and time of onset to the stroke center where resources exist to provide appropriate care.” Suspected stroke transport protocol requirements include mandatory use of the state protocol (with some exceptions) by all ground and air ambulances to assess the presence of all ground and air ambulances must use the state protocol (with some exceptions) that assesses presence of life-threatening conditions for stabilization prior to transport to stroke center and timing of symptoms and therapeutic window for transport to level I, II, III, or IV and out-of-state facilities.

Inter-Facility Transfer to Most Appropriate Stroke Facility

Policies encouraging: (1) written inter-facility transfer agreements to ensure appropriate, timely acute stroke care at appropriate facilities; (2) strategies to improve efficiency including ‘drip and ship’ protocols to allow tPA infusion immediately before or during transport to endovascular-capable centers; and (3) reimbursement that covers costs for both transferring and receiving facilities. (Analyses included ground transport studies only.)

State law example: The Louisiana Emergency Response Network Board and the Department of Health and Hospitals are required to recognize four levels of stroke facilities: CSC, PSC, ASRH, and non-stroke hospitals. An ASRH is expected to provide timely acute stroke care in areas where transportation and access are limited using “drip-and-ship”, telemedicine, and other delivery models. A non-stroke hospital is only authorized to accept suspected stroke patients when clinically necessary, provided it has written transfer agreements with an ASRH, PSC, or CSC.

Includes the treatment of an acute stroke patient at the appropriate stroke hospital(s) and all the long-term, rehabilitative care received by the patient after they are discharged from the hospital.

Telestroke to Initiate Treatment On-site

Telemedicine involves the use of technology to provide healthcare, monitor health status, and share health information remotely. Telestroke involves using telemedicine to initiate treatment for acute stroke care and provide access to acute stroke specialists in medically underserved, rural, and geographically remote areas.

State law example: An Arizona statute requires all insurance contracts provided to subscribers by certain “hospital service corporations” and “medical service corporations” issued, delivered, or renewed on or after January 1, 2018 to provide coverage for stroke telemedicine services “if the health care service would be covered were it provided through in-person consultation… to a subscriber receiving the service in Arizona.”

State-level Continuous Quality Improvement Registry

A statewide continuous quality improvement (CQI) program, process, and/or plan is needed to ensure that stroke care delivery across the state applies to evidence-based national standards and best practices. As part of CQI, a state-level stroke database, data system, or registry helps to track nationally recognized consensus stroke care metrics.

State law example: All hospitals designated at any level by the Georgia Department of Public Health (DPH) as a stroke center must participate in the Georgia Coverdell Acute Stroke Registry and submit a minimum set of data elements to the Registry as required. DPH may suspend or revoke designation of non-compliant hospitals.

Nationally Certified Primary Stroke Centers

PSCs certified by nationally recognized accrediting bodies must have infrastructure and demonstrated ability to stabilize and treat acute stroke patients, including timely provision of intravenous thrombolytic therapy utilizing alteplase, neuroimaging capabilities, and the management of intracranial pressure.

State law example: The Illinois Department of Public Health is authorized to designate hospitals as PSCs with proof of certification from a Department approved nationally recognized certifying body using “current nationally recognized, evidence-based stroke guidelines.”

State Standards for Primary Stroke Centers

A state can designate a facility as a PSC or the equivalent when the facility meets specific standards set by the state. Standards could include: hospital-based emergency department and EMS staff education in acute stroke prevention, diagnosis, and treatment; hospital stroke CQI and submission of stroke data to the Department of Public Health; and EMS pre-hospital stroke notification.

State law example: As of April 2017, a Massachusetts regulation allows hospitals to apply to the Department of Public Health for designation as a Primary Stroke Service (PSS) provider to provide emergency diagnostic and therapeutic services to acute stroke patients through a multidisciplinary team approach, available 24 hours per day, seven days per week.

Includes all emergency medical care provided to the stroke patient prior to the handoff of the patient from EMS providers to staff at the acute care facility.

Pre-hospital Stroke Screening Tool Use by EMS Providers

The identification of stroke patients by EMS responders allows for initiation of appropriate treatment in the field along with rapid transport and triage of acute stroke patients. EMS responders can identify stroke patients with a high degree of accuracy when validated stroke screening algorithms for the pre-hospital setting are used. As such, policy encourages EMS responders to use a validated and standardized pre-hospital screening and neurological assessment tools to identify stroke patients.

State law example: The Nebraska Stroke System of Care Act requires the Nebraska Department of Health and Human Services to adopt and distribute to EMS a nationally recognized, standardized stroke triage assessment tool. All EMS providers must use the assessment (or substantially similar) tool and establish pre-hospital stroke-care and transport protocols.

Includes the treatment of an acute stroke patient at the appropriate stroke hospital(s) and all the long-term, rehabilitative care received by the patient after they are discharged from the hospital.

State Standards for Comprehensive Stroke Centers

A state can designate a facility as a CSC or the equivalent when the facility meets specific standards set by the state.

State law example: Since 2004, hospitals in New Jersey must apply to the Commissioner of Health and Senior Services for designation as a primary or comprehensive stroke center. Designated CSCs are required to meet the minimum PSC criteria set forth in statute and regulation as well as additional statutory and regulatory CSC criteria and standards.

Nationally Certified Comprehensive Stroke Centers

Nationally certified Comprehensive Stroke Centers (CSCs) provide highly specialized stroke care for patients who require more complex medical and surgical interventions. They also serve as a top-tier resource center for other facilities within the stroke system of care.

State law example: As of August 30, 2016, the Delaware Department of Health and Social Services is required to designate an in-state acute health-care facility, as well as out-of-state facilities upon request as a Comprehensive Stroke Center if the facility is certified by either the Joint Commission or by another nationally recognized accrediting organization with an equivalent certification.

Nationally Certified Acute Stroke Ready Hospitals

ASRH is a relatively new certification for facilities from nationally recognized accrediting bodies. ASRHs are intended to expand evidence-based stroke care to patients who are otherwise unable to access a Primary Stroke Center, for example, patients who live in rural areas.

State law example: The North Carolina Department of Health and Human Services is required to designate a hospital as a certified “Designated Stroke Center” if the hospital is certified by a nationally accrediting body “that requires conformance to best practices for stroke care” as a PSC, CSC, or ASRH.

Includes all emergency medical care provided to the stroke patient prior to the handoff of the patient from EMS providers to staff at the acute care facility.

Continuing Education on Stroke for EMS Providers

While most EMS providers will receive some education on stroke in their initial certification or licensure programs, states could encourage ongoing education for EMS providers about the signs and symptoms of stroke and training on stroke protocol.

State law example: The Illinois State Stroke Advisory Subcommittee is required to develop and disseminate to all EMS systems “an evidence-based statewide stroke assessment tool to clinically evaluate potential stroke patients.” With the State EMS Advisory Council, the Subcommittee is also required to “select or develop the educational curriculum for instructing EMS System personnel on the use of the tool.” In addition, each EMS Regional Stroke Advisory Subcommittee must make recommendations to the Region’s EMS Medical Directors Committee for pre-hospital personnel continuing education requirements.

Continuous Quality Improvement of EMSS for Stroke

Pilot and grant-funded quality improvement collaboratives have improved the quality of EMS and pre-hospital care in stroke systems. CQI interventions would involve ongoing assessments of the functions performed by all participants in the pre-hospital stroke system that affect the health outcomes of stroke patients.

State law example: The Rhode Island Department of Health must establish and implement a stroke care continuous quality improvement plan and require stroke centers and EMS agencies to report data for use in a statewide stroke database built on a nationally recognized platform, such as Get With The Guidelines/Stroke.

Includes the treatment of an acute stroke patient at the appropriate stroke hospital(s) and all the long-term, rehabilitative care received by the patient after they are discharged from the hospital.

Nationally Recognized Stroke Rehabilitation Facilities

National standards and certification for stroke rehabilitation facilities could assure quality and a commitment to continuous improvement of post-hospital stroke care and services.

State law example: A Florida regulation requires CFCs to ensure that patients meeting acute care rehabilitation admission criteria are transferred to an acute rehabilitation facility accredited by The Commission on Accreditation of Rehabilitation Facilities (CARF) or The Joint Commission (JC).

State Standards for Acute Stroke Ready Hospitals

A state can designate a facility as an ASRH or the equivalent when the facility meets specific standards set by the state.

State law example: In 2016, Georgia required the establishment of at least three levels of stroke centers to serve acute stroke patients. The three levels of stroke centers include CSCs for complex specialized care, PSCs, and remote treatment stroke centers (RTSC) for rural and underserved areas.