In an effort to improve patient outcomes and facilitate stroke care delivery, the American Stroke Association (ASA) has released a 2019 update on recommendations for the development of comprehensive stroke systems of care. These recommendations focus on policies that reduce the barriers to emergency stroke care, standardize the delivery of care for stroke, and improve access to secondary prevention and rehabilitation and recovery post-stroke care resources. The policy update was published in Stroke.1

Overview on ASA’s Recommended Updates for Stroke Systems of Care

The recommendations in the new report are an update on the 2005 policy recommendations developed by the ASA. The new report includes recommendations centered on primordial/primary prevention, community education/engagement, emergency services, and hospital-based acute stroke management.

Primordial/Primary Prevention

Primordial prevention, a key recommendation in the update, is defined as any action(s) that help to inhibit the risk factors for stroke in selected or whole communities. Education and policy programs that center on social conditions, health behaviors, and/or dietary intake should be incorporated into primordial/primary prevention strategies, the panel members wrote.

The update now recommends that stroke systems should establish support mechanisms that assist communities as well as patients and providers with long-term adherence to primordial and primary prevention strategies. These prevention strategies should take into account both cultural and geographic customs, and local and regional public educational tools targeted to at-risk populations should be developed with health literacy targets in mind.

Community Education/Engagement

Several new recommendations for community education/engagement have been added to the 2019 ASA update. One recommendation encourages the development of stroke systems that “support local and regional educational initiatives to increase stroke awareness (including stroke warning signs, risk factors, primary and secondary prevention, and recovery), aimed at the general population with enriched targeting of populations at increased risk for stroke and poor outcomes after stroke.”

Stroke systems should also engage in active monitoring of community education efficacy for improving behavioral responses to various outcomes, including mortality, warning symptoms, and stroke treatment rates. The update also recommends the development of strategies that systematically identify and effectively manage risk factors in at-risk patients. Additionally, a revised recommendation states that behavioral interventions, including those that address barriers to healthy behaviors and prevention adherence, should be encouraged in clinical practice. Tools including digital phenotype analysis, gamification, social network analysis, and machine learning may assist in identifying barriers and improving the rate of sustainable behavioral change.

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Emergency Medical Services (EMS)

A new recommendation for EMS places public health leaders and medical professionals at the forefront in designing public education programs centered on emphasizing the importance of patients seeking emergency care rapidly. Diverse populations should be targeted, yet research is needed to determine which programs are the most effective.

Triage paradigms and protocols – developed by EMS leaders as well as by local, regional, and state agencies and in consultation with medical authorities – should also be developed. This new recommendation suggests that these programs should work toward ensuring “that all patients with a known or suspected stroke are rapidly identified and assessed with a validated and standardized instrument for stroke screening such as FAST (Face, Arm, Speech, Time), Los Angeles Prehospital Stroke Screen, or [Cincinnati Prehospital Stroke Scale].”

Hospital-Based Acute Stroke Management

Certification systems for the “data-driven development of hospital-based processes of care and outcome metrics” should meet or exceed the standards set forth by the comprehensive stroke center, primary stroke center, thrombectomy-capable stroke center, and acute stroke-ready hospitals, the update states. In addition, the timely completion of parenchymal and arterial imaging is recommended to identify patients who may experience benefit from thrombectomy.

The update also recommends the use of transfer protocols for hospitals without thrombectomy capability to ensure the rapid treatment of people with stroke. Patient flow should be tracked at all time points by centers that provide thrombectomy. Variables that should be tracked and reported include reperfusion rates, procedural complications, and patient clinical outcomes.

According to an accompanying editorial by Robert A. Harrington, MD, FAHA, MACC,2 local policymakers need to understand “how best to create local/regional stroke systems of care that maximize triage and ultimately the care of all patients with suspected stroke.” The updated recommendations by the ASA may provide a guideline for these individuals in how to approach the development of stroke systems across the board.

References

1. Adeoye O, Nyström KV, Yavagal DR, et al. Recommendations for the establishment of stroke systems of care: a 2019 update: a policy statement from the American Stroke Association [published online May 20, 2019]. Stroke. doi:10.1161/STR.0000000000000173

2. Harrington RA. Prehospital phase of acute stroke care: guideline and policy considerations as science and evidence rapidly evolve [published online May 20, 2019]. Stroke. doi:10.1161/STROKEAHA.119.025584