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Jenny Edwards, MSN, RN, CNRN, SCRN
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Martha Power FNP, SCRN
Every year 795,000 people in the United States have
a stroke
 1 of 4 die
 87% of the strokes are ischemic, 13% are
hemorrhagic
 Over 1000 Certified Stroke Centers in the US
 Half of the population of the United States lives
more than 60 minutes from a Primary or
Comprehensive Stroke Center
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Improves quality of care by reducing variation in
clinical processes.
 Provides a framework for program structure and
management.
 Objective assessment of clinical excellence
 Facilitates marketing, contracting and
reimbursement
 Strengthens community confidence in your care
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http://www.jointcommission.org/certification/certification_main.aspx
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Stroke Ready 0
PSC >1000
CSC 93
Stroke Ready 0
PSC 90
CSC 25
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Stroke Ready 0
PSC 41
CSC 0
Stroke Ready 0
PSC 3
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Developed in Collaboration with AHA/ASA
Applications accepted starting 7/1/15
Derived from the BAC Rec 2013 “Formation and Function of
Acute Stroke Ready Hospitals within a Stroke System of Care”
in Nov 12, 2013 Stroke journal
Goal: to recognize hospitals equipped to treat stroke patients
with timely, evidenced-based care prior to transferring them
to a PSC or CSC
2yr certification after an onsite review
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“An Acute Stroke Ready Hospital will be the
foundation for acute stroke care in many
communities, allowing it to be the first stop on a
patient’s acute stroke journey before being
transferred to a Primary Stroke Center or
Comprehensive Stroke Center. Certification
demonstrates a commitment to a higher standard of
service, while promoting the best quality care for all
patients that present with a stroke.”
Wendi Roberts Executive Director, Certification Programs, TJC
http://www.jointcommission.org/the_joint_commission_american_heart_associatio
namerican_stroke_association_launch_new_stroke_certification_program/
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Dedicated Stroke Focused Program
Collaboration with EMS – encourage training in assessment
tools and prenotification of arrival
24/7 rapid diagnostic and laboratory tests
Availability of telemedicine technology
Ability to give IV thrombolytics to eligible patients.
Transfer agreements/protocols with facilities that provide PSC
and CSC services
In order for a hospital to be eligible for ASRH certification,
an organization should see its role in stroke management as
administering intravenous thrombolytics and then
transferring patients to a primary or comprehensive stroke
center (or center of comparable capability) for continued
treatment.
 There must be transfer protocols in place indicating
that transfer after thrombolytics is the planned pathway for
the vast majority of patients (unless the patient is unstable
or not a candidate for advanced therapies).
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http://www.jointcommission.org/assets/1/18/StrokeProgramGrid_abbr_AHA-TJC_5_1_15.pdf.
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Protocols to address the prompt diagnosis and emergency
treatment of stroke patients
One Physician, NP or PA onsite to supervise patient care, order
medication and manage emergent issues
Educational Requirements
Data Collection and Process Improvement
Free 90 day access of Standards at www.jointcommission.org
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The program maintains a stroke log that includes at a
minimum:
Number of times stroke team was activated
Practitioner response time to acute stroke patients
Type(s) of diagnostic tests and acute treatment if used
Patient diagnosis
Door-to-IV thrombolytic time
Patient complications
Disposition of the patient (for example, upon admission to the
organization, discharge, transfer to another organization)
The program utilizes a stroke registry or similar data
collection tool to monitor the data and measure outcomes.
The program monitors its IV thrombolytic complications,
which include symptomatic intracerebral hemorrhage
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Follows recommendations published by the Brain Attack Coalition and
the American Stroke Association consensus statements for stroke
Evaluates compliance with national standards, clinical practice
guidelines to manage and optimize care, and the institution’s
performance improvement
Any hospital (even small, rural) can be designated a PSC
 Willing and able to give IV tPA
 Systematic approach to QI and patient education
If a hospital performs intra-arterial (IA) or endovascular procedures
for stroke patients, the minimum level of Joint Commission
certification for which the hospital is eligible is PSC certification
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Administrative support is key!
 Administrative lines of authority
 Organizational chart for Stroke Center
 Medical Director appointed
 Physicians with expertise in
cerebrovascular disease
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Written protocols
◦ Describing/defining the team
 Specification of qualifications, education requirements, assignments of duties
◦ Notification process
 Expected response times
 Stroke team log
 Performance Improvement process
• Protocols based on published guidelines and updated
regularly
• Acute work up of ischemic/ hemorrhagic stroke
available in the ED, patient care areas
• Readiness evident no matter how or where individual
enters the system
• tPA protocols – stick to the guidelines
• Use of protocol reflected in order sets, pathways,
medical records
• Time parameters in ED
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Improved coordination between hospitals and EMS
is a cornerstone of a Primary Stroke Center
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Effective communications between EMS personnel
and the stroke center during rapid transport
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Stroke is recognized as a priority
◦ Definition: a specific unit where most stroke patients are
admitted
◦ Care providers show evidence of initial and ongoing education
in care of stroke patients
◦ Receive at least 8 hours annually of continuing education as
appropriate to their responsibility
◦ Monitoring systems
 Telemetry
 Noninvasive blood pressure
 Oximetry
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Some hospitals may choose to stabilize
patients and transfer them to another facility
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Provides care (ICU or stroke designated area)
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Written care protocols (pathways/orders)
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Use evidence based guidelines
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Protocols
◦ Increase use of t-PA
 11% – 13% have excellent outcome at 90 days
 48% likelihood of being discharged to home compared to 38% not
receiving
◦ Utilizing clinical guidelines – organizes care and decreases
complications
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Stroke Units
◦ 17% reduction in death
◦ 7% increase in being able to live at home
◦ 8% reduction in LOS
◦ Available within two hours of when the services are
deemed necessary
 Fully functioning OR and staff for neurosurgery
available 24/7
 Call schedule available to stroke team
◦ Written transfer plan and protocol in place if
patients are to be transferred to another facility for
these services
◦ Specific stroke performance measurement and
review by QI department and stroke team
 PI measures tracked
 Documentation of interventions to improve
 Outcomes to determine success
 Implementation period and re-evaluation point
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Stroke registry: clinical/financial
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Public education
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Primary and secondary prevention
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Professional education
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Clinical research
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With guidance of the Brain Attack Coalition, TJC
has developed advanced certification for CSCs
◦ Hospitals with specific abilities to receive and
treat the most complex stroke cases
The goal of CSC:
◦ To recognize the significant differences in
resources, staff and training that are necessary
for the treatment of complex stroke cases
◦ Personnel with specific areas of expertise
◦ Specialized diagnostic and treatment
techniques
◦ Facility Infrastructure
◦ Programmatic Areas
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Center Director
Neurologists; Neurosurgeons; Intensivists
Surgeons with expertise in CEA
Diagnostic Radiologists
Interventional endovascular neuroradiology
ED and links to EMS
Radiology technologists
Nursing staff trained in acute stroke care
APNs
Physicians and therapists trained in rehab
Case managers; social workers
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Patients need accurate imaging of brain and
cerebrovasculature (same as for PSC, plus):
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MRI/MRA
DSA
TCD
TTE/TEE
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EMS, ED, Referral, Triage
Rapid, efficient patient assessment and triage
Pre-hospital communication with hospital staff
Medical stabilization en route
Support education
 evidence of cooperative educational activities 2x/year
◦ ED protocols
 Stroke team notification
 Door to treatment
◦ CSC should be viewed as community and regional resource
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Stroke Unit and ICU
◦ Dedicated neurointensive care unit
◦ Rehab and post-stroke care
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Education
◦ Professional
 > 2 educational courses per year for health care professionals
◦ Public
 Sponsor at least 2 educational activities per year that focuses on some
aspect of stroke
 Stroke risk factors, health fairs, etc
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Stroke Registry/Database
◦ LOS; treatment rate; discharge destination & status
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Quality Assurance and improvement
◦ Peer review process to evaluate/monitor care
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Patient-centered research approved by IRB
Coordinate post-hospital care for patients
◦ Stroke clinic
Systems of Stroke Care
 1. Patients should be transported rapidly to the closest available certified primary
stroke center or comprehensive stroke center or, if no such centers exist, the most
appropriate institution that provides emergency stroke care as described in the
2013 guidelines (Class I; Level of Evidence A). In some instances, this may involve air
medical transport and hospital bypass. (Unchanged from the 2013 guideline)
 2. Regional systems of stroke care should be developed. These should consist of
consisting of:
 (a) Healthcare facilities that provide initial emergency care including administration
of intravenous r-tPA, including primary stroke centers, comprehensive stroke
centers, and other facilities.
 (b) Centers capable of performing endovascular stroke treatment with
comprehensive periprocedural care, including comprehensive stroke centers and
other healthcare facilities, to which rapid transport can be arranged when
appropriate (Class I; Level of Evidence A). (Revised from the 2013 guideline)