Get the latest funding, research, and public health information from NINDS
Get the latest research information from NIH | Español
Get the latest public health information from HHS
Get the latest public health information from CDC

Research Spotlight

Man looking through microscrope.

The NINDS conducts stroke research and clinical trials at its laboratories and clinics at the NIH, and through grants to major medical institutions across the country.

Read More
View Literature »
View Research Programs »

Improving the Chain of Recovery for Acute Stroke in Your Community: Task Force Report image

Improving the Chain of Recovery for Acute Stroke in Your Community: Task Force Report

December 12-13, 2002

 Task Force Report
Choosing Your Level of Care

Andy Jagoda, M.D.
Task Force Chair
Mount Sinai Hospital
New York, New York
  Markku Kaste, M.D., Ph.D.
Helsinki University Central Hospital
Helsinki, Finland
Arthur M. Pancioli, M.D.
Task Force Co-Chair
University of Cincinnati
Chapel Hill
  Walter J. Koroshetz, M.D.
Massachusetts General Hospital and Harvard Medical School
Andrew W. Asimos, M.D
Carolinas Medical Center
Charlotte, North Carolina
  Thomas G. Kwiatkowski, M.D.
Long Island Jewish Medical Center
New Hyde Park, New York
William G. Barsan, M.D.
University of Michigan Health System
Ann Arbor
  Marc Mayberg, M.D., F.A.H.A.
Cleveland Clinic Foundation
Kevin Baumlin, M.D., F.A.C.E.P.
Mount Sinai School of Medicine
New York, New York
  Robert M. McNamara, M.D.
Temple University Hospital
William Dalsey, M.D.
Kimball Medical Center
Blue Bell, Pennsylvania
  C. Crawford Mechem, M.D.
University of Pennsylvania
Kathleen A. Delaney, M.D.
University of Texas Southwestern Medical Center
  Daniel Morelli, M.D.
Millard Fillmore Suburban Hospital
Williamsville, New York
Edward Goldman, J.D.
University of Michigan
Ann Arbor
  Hal Unwin, M.D.
University of Texas Southwestern Medical Center
Margaret Gradison, M.D.
Duke University Medical Center
Durham, North Carolina
  David Wang, D.O.
OSF Stroke Network
University of Illinois College of Medicine

  David W. Wright, M.D., F.A.C.E.P.
Emory University

It has now been 6 years since the guidelines from the NINDS National Symposium on the Rapid Identification and Treatment of Acute Stroke were published (1). Still, stroke continues to be a devastating disease that affects more than 600,000 Americans each year and killed approximately 278,000 in 1999 alone. In the United States, one in every 14.3 deaths is attributable to stroke (2). The magnitude of this "stroke burden" is projected to increase as the population ages.

The level of available resources to care for acute stroke victims varies widely among communities and geographic regions. According to a survey conducted by the American Academy of Neurology, 20 percent of the U.S. population is without access to acute neurological services (3). This marked variability means that the creation of a universal standard of care is not possible. Instead, this Task Force recommends that hospitals and medical centers assess their current capabilities to provide acute stroke care and determine the optimal level of stroke care that they can provide. In addition, hospitals should perform a community assessment to determine the level of stroke care capabilities offered by other local and regional facilities. This information should encourage local and regional triage or transfers of acute stroke patients when appropriate. The Task Force on Choosing Your Level of Care recommends that every emergency department be able to evaluate and stabilize the acute stroke patient. Ideally, for optimal treatment, most patients should have access to primary stroke centers that provide the level of care defined by the Brain Attack Coalition (BAC) guidelines (4). Finally, comprehensive stroke centers, in conjunction with primary stroke centers, provide care for more complicated cases or resource-intensive patients and serve as an educational resource to their referral community

To improve access to facilities capable of providing optimal stroke care, there should be a coordinated effort that involves the community, emergency medical services (EMS) systems, and hospitals. The management of trauma and burns in the United States has shown that facilitated access through care center designation can result in decreased morbidity and mortality. Because treatment of the acute stroke patient is time-sensitive and requires a multidisciplinary approach 24 hours a day, 7 days a week, the Task Force supports the concept of identified stroke centers to improve access to stroke care.

Return to top



Basic Emergency Service: A hospital or emergency department that provides an organized approach to the initial evaluation, stabilization, and treatment of stroke patients, including consideration of transfer for appropriate patients.

Primary Stroke Center: A hospital or emergency department that meets the criteria determined by the BAC for a primary stroke center (4).

Comprehensive/Specialized Center: A hospital or emergency department that meets the criteria for a primary stroke center but also has availability of neurosurgery, angiography, and neurointerventionalists to meet the specialized needs of some identified stroke patients.

Return to top


Multidisciplinary Stroke Care

Considerable data support the concept that a streamlined, multidisciplinary approach to stroke care, including stroke protocols, stroke teams, and stroke units, results in improved outcomes (5-8). Over the past decade, written care protocols have flourished throughout the continuum of medical care, with studies demonstrating the efficacy of such protocols for generalized stroke patient care (9). These written guidelines, or pathways, help set operating procedures in a medical institution. They are especially helpful in fostering the systematic and expeditious care required to manage acute stroke, such as the administration of thrombolytics (10). The application of evidence-based protocols may improve outcomes, streamline hospital care from emergency department to hospital discharge, and likely decrease cost. Adherence to treatment protocols minimizes complications associated with intravenous t-PA therapy for acute ischemic stroke (11-13).

Based on the available resources, stroke programs can be developed and implemented to streamline cost-effective care and optimize patient outcomes. Formation of a specialized "stroke team" may reduce inpatient treatment delays and minimize hospital length-of-stay and cost (6,14-17). The composition of such teams varies across institutions, but typically stroke teams include nurses and physicians with emergency medical, neurological, neurosurgical, and neuroradiological expertise. Additionally, patient care in a "stroke unit" reduces short-term and long-term mortality rates, the need for institutional long-term care after stroke, and functional dependency (18-23). Based on one meta-analysis, compared with stroke patients who received care in general medical wards, patients receiving care in dedicated stroke units had a 17 percent reduction in death, an 8 percent reduction in length of stay, and a 7 percent increase in living at home (24).

An obvious ultimate extension of the stroke team and unit concept is the development of designated stroke centers. The most compelling evidence supporting stroke center development is the combination of the trauma center experience and the recognized association between volume and outcome in many areas of health care delivery (25-29). Since both stroke and trauma occur acutely and require time-sensitive, organized, and multidisciplinary evaluation to achieve the best outcome, the establishment of stroke centers, mirroring trauma centers, has been proposed (4,30). Such assemblies of stroke care resources and personnel would ensure their immediate availability upon patient presentation, likely resulting in a reduction in stroke-related death and disability. A referral system that pre-selects potential candidates for thrombolytic therapy and transports them to a stroke referral center can achieve outcome and complication rates comparable to those of multicenter trials (31). Such protocols could be implemented across EMS regions based on individual hospitals' diagnostic and therapeutic capabilities and a given patient's treatment preferences (32). Additionally, such systems could consolidate patient volumes, fostering both an economy of scale and the beneficial volume-outcome relationship that has been repeatedly demonstrated in other areas of health care (33-43). The following sections outline the elements necessary to assess the stroke resources within a community.

Return to top


The Emergency Medical Services System

Stroke management begins in the prehospital setting (4). Transport by EMS as opposed to private vehicle has been associated with a more rapid assessment in the receiving emergency department and less delay to head CT and evaluation by a neurologist (44-50). Unfortunately, approximately half of stroke patients reach the hospital by private vehicle. Clearly, EMS plays one of the major roles in the overall goal of decreasing the time to presentation for the acute stroke patient. As is the case for suspected myocardial infarctions, any patient with neurological symptoms suspicious for a stroke must be given the highest priority.

Recognition of stroke signs and symptoms by EMS personnel is an important step. Prehospital systems should assess their providers' knowledge of stroke symptoms on a regular basis and provide continuing educational courses to reemphasize stroke care and train EMS personnel on stroke symptoms. This training should be simple and incorporate prehospital screening instruments such as the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen, both of which have been shown to identify anterior circulation strokes with high sensitivity and specificity (51,52). In addition, a checklist of critical information needed by the treating team, such as time of onset of symptoms, co-existing illnesses that can mimic stroke (ie, hypoglycemia), and complicating medications (ie, warfarin), should be incorporated.

Once a potential acute stroke patient is identified, a sense of urgency should dominate. Rapid on-scene assessment and emergent transportation to the most appropriate facility will ensure the best possible outcome for the patient. Immediate notification of the receiving facility will help marshal the appropriate resources and personnel

The Task Force advocates identifying hospitals that can provide acute stroke care as primary stroke centers, and creating a system of transport to these centers as necessary depending on the location of the EMS call. This system should be planned in advance by prehospital system administrators and appropriate community leaders in order to optimize community-wide stroke services. Regular measures of compliance with the protocols (prehospital recognition of stroke, identification and documentation of time of onset and other critical information while on-scene, notification of the receiving facility, and rapid transport to the most appropriate facility) will ensure an efficient and efficacious system. The EMS community must be formally incorporated into the continuum of stroke care along with the emergency department (15,16). This can best be facilitated via the participation of the medical center and emergency department staff in the educational activities of the EMS personnel and via formal written agreements for prehospital notification and triage to stroke centers.

Return to top


Emergency Department Basics

There are fundamental principles in emergency management that will contribute to improving patient outcomes. In essence, these measures are intended to preserve oxygenation and cerebral perfusion and prevent complications.

All patients suspected of having an acute stroke should be triaged immediately to a high-priority area of the emergency department. An acute stroke protocol / pathway should be in place and activated, thus facilitating rapid diagnosis and resource utilization. These patients require initiation of stabilization measures, vital signs, history and physical examination, a neurological exam, diagnostic testing, and implementation of preventive strategies to minimize complications. These actions should be performed simultaneously rather than sequentially. The goal is to complete the initial evaluation of the acute stroke patient, including initiation of laboratory testing and neuroimaging, within 25 minutes of arrival (53-55).

Initial stabilization - addressing the "ABCs" - ensures that the patient's vital functions are assessed and secured. Patients require a monitored bed that includes continuous cardiac and pulse oximetry monitoring. Vital signs must be obtained initially and repeated serially with dedicated nursing surveillance. An immediate glucose determination must be obtained since hypoglycemia and hyperglycemia can mimic acute stroke and may contribute to additional neuronal injury (56). Intravenous access must be secured early and, at the same time, blood should be drawn and sent for appropriate laboratory testing (10).

Endotracheal intubation should be considered in those patients who cannot be adequately oxygenated or ventilated, who show signs of increasing intracranial pressure, or for whom there is concern of potential airway compromise. When intubation is determined to be necessary, a rapid sequence intubation protocol is recommended in order to minimize hypoxic insult, to minimize increases in intracranial pressure, and to prevent aspiration. Hypotension and abnormalities in cardiac rate and rhythm must be addressed early in order to ensure central nervous system perfusion. On the other hand, elevated blood pressure is common and should be managed based on established guidelines. Excessive lowering of blood pressure in the acute ischemic stroke patient has been associated with neurologic worsening. When the blood pressure must be lowered, an intravenous medication that can be closely titrated is preferred to minimize the risk of cerebral hypoperfusion (10,57,58).

The history will determine if the acute stroke patient is a candidate for pharmacological interventions or for transfer to a center where those interventions are available. The history must focus on determining the time of onset of neurologic symptoms and those conditions that might exclude the patient from thrombolytic therapy. The history will also identify other medical conditions that could mimic an acute stroke, including hypoglycemia, seizures, metabolic disorders, or pre-existing neurologic deficits from past events. Past medical history, medications, social and family history, allergies, and a review of systems are all necessary to provide the data needed for clinical decision-making concerning these patients.

A physical and neurological examination establishes the baseline with which all future evaluations are compared. The NIH Stroke Scale (NIHSS) is the most commonly used and validated tool that documents and scores the neurologic deficits (59). The scale, in essence, is a formalized, quantitative assessment of key portions of the neurological exam. It allows for a reproducible, systematic evaluation and thus aids the clinician in communicating with others, performing serial assessments, and evaluating the individual patient in the context of the published literature. In order to facilitate the use of the NIHSS by clinicians who do not perform a complete neurologic exam on a regular basis, pocket cards, flow sheets, and, most recently, hand-held computer programs are available (60).

A fundamental element of acute stroke care is the prevention of secondary complications. Attention to detail in the management and prevention of aspiration, airway compromise, seizures, cardiac dysrhythmias, and labile hypertension will result in decreased mortality and morbidity (4,30,57). Consequently, the basic care of these patients must employ meticulous supportive care including continuous monitoring, detection of any deterioration, and ensuring measures to preserve oxygenation and cerebral perfusion. The presence of fever has been noted to correlate with poorer outcome (61). Antipyretics or other fever-lowering mechanisms are recommended early in the management of acute stroke (57). Patients with intracranial hemorrhage require early diagnosis, normalization of coagulation status, close management of blood pressure, and occasionally emergent hematoma evacuation (62).

In conclusion, hospitals that care for acute stroke patients should assess their ability to routinely perform the basic care requirements of the acute stroke patient. At a minimum, patients with an acute stroke require immediate triage to an area where continuous monitoring can be provided. An established stroke protocol / pathway that includes rapid neuroimaging should be implemented. Vital signs and serum glucose must be assessed and stabilization measures initiated. A history and physical exam must be performed with a focus on identifying mimics of stroke and establishing the baseline neurologic status of the patient. The clinician should be cognizant of the potential complications that may ensue and should proactively initiate supportive care measures necessary to prevent, identify, and/or manage them as they occur. The Task Force also recognizes that many hospitals lack resources to consistently offer thrombolytic therapy according to recognized protocols. Patients who require a higher level of care should be triaged as soon as possible to a facility with greater capabilities.

Return to top


Primary Stroke Center

Primary stroke centers are hospitals that provide the level of stroke care outlined in the BAC guidelines (4). Their emergency departments should be able to offer approved therapies to appropriately selected patients whether the stroke is ischemic or hemorrhagic. Requirements for a primary stroke center with the capability to provide acute stroke care have been well described by the BAC in their publication on establishing primary stroke centers (4). Requirements include the following:

  1. Agreements with EMS systems for pre-notification.
  2. 24/7 physician-staffed emergency department.
  3. Written care protocols.
  4. A defined acute stroke team (should include emergency department staff).
  5. A named director of acute stroke treatment for the institution.
  6. Necessary support:
    • Commitment and support of the medical organization.
    • Neuroimaging services (24/7).
    • Laboratory services (24/7).
    • Inpatient services appropriate to the patient's level of illness with close neurologic and cardiorespiratory monitoring (inpatient services are required only for those primary stroke centers that will provide ongoing inpatient care for patients with stroke).
  7. On-site neurosurgical services or pre-specified transfer agreements.
  8. Outcome and quality improvement activities.
  9. Continuing medical education.

Necessary support includes a commitment from the medical center to provide appropriate facilities and staff to care for acute stroke patients. Ideally, primary stroke centers would have the capability to perform either CT scan or MRI within 25 minutes of a physician order (63). Physicians capable of interpreting the neuroimaging should be available to interpret the scans within 20 minutes of completion. Neuroimaging should be available 24 hours a day. This may be facilitated by cross-training of radiology technicians to perform CT scans as well as teleradiology for the interpretation by remote physicians (63). Appropriate laboratory facilities capable of performing blood chemistries, complete blood count, platelet count, and a coagulation panel should be available 24 hours a day with results available on a "stat" basis (64). Primary stroke centers should have either neurosurgical consultation available within 2 hours when clinically necessary, or pre-existing transfer agreements with a medical center that can provide neurosurgical care when a neurosurgical emergency arises. In geographic regions where a choice between medical centers for prospective stroke patients exists, medical centers should make known the level of stroke care that they are able to provide.

The Task Force recognizes the controversy over the safety and efficacy of the use of intravenous t-PA. However, the Task Force members agree that in a well-organized and supported system, intravenous t-PA is an effective therapy for appropriately selected, acute ischemic stroke patients. The risks and benefits of thrombolytic therapy for "eligible" patients with ischemic stroke should be carefully discussed with the patient and/or family.

A system of continuous quality improvement should be in place for the primary stroke centers. Ideally, the system would track the volume of stroke patients as well as any treatment provided and relevant outcomes measures. Specific benchmarks based on published guidelines for thrombolytic therapy should be measured and tracked. These data should be used to enhance patient care. In addition, educational opportunities and continuing medical education are critical for any multidisciplinary team success. Such education should be available to providers at all levels, from community and emergency medical services personnel to subspecialty physicians with neurological/neurosurgical expertise.

An infrastructure for acute care followed by multidisciplinary inpatient coordination is imperative and has been shown to improve outcomes (65). Hospitals that do not have the capability to coordinate such inpatient care may still designate their emergency departments as capable of caring for acute stroke patients. After the acute care phase, which may include fibrinolytic therapy, such centers should have EMTALA (Emergency Medical Treatment and Active Labor Act) compliant transfer agreements with a facility offering a higher level of care.

Return to top


Inpatient Stroke Care

After rapid emergency department determination of stroke type (ischemic vs. hemorrhagic, hyperacute vs. subacute), admission of the acute stroke patient to the stroke unit as defined by the BAC guidelines should be considered (4,57). Improved outcomes have been demonstrated by admission to an organized stroke unit with a neurologic stroke team (24,66). A clinical protocol or pathway for inpatient care that encompasses all disciplines (nursing, social work, radiology, cardiology, neurology, neurosurgery, psychiatry, pharmacy, administration, pastoral care, physical therapy, occupational therapy, and speech therapy) should be a part of each specialized stroke center (67).

Inpatient care at stroke centers should emphasize general supportive care and determination of the etiology of the patient's stroke. Special attention must be given to the patient's neurologic status, cardiac rhythm, risk of aspiration, nutritional support, skin care, blood pressure management, urologic care, blood sugar management, fever control, oxygenation, and ventilation. A dysphagia screen should also be completed within 24 hours and an active, restorative rehabilitation program initiated. Early mobilization within 24-48 hours should be accomplished with careful monitoring for the development of hypotension or worsening neurologic deficit. Prevention of deep venous thrombosis in all stroke patients is paramount. Subcutaneous unfractionated heparin, low-molecular weight heparin, or thigh-high pneumatic compression devices should be considered from the time of admission unless contraindicated (57,67).

Stroke centers providing inpatient care should have the ability to evaluate the stroke patient to determine stroke etiology. Imaging of the cervical and cranial vessels by carotid duplex doppler and/or transcranial doppler, magnetic resonance angiography, computed tomography angiography, or digital subtraction angiography should be undertaken. Cardiac imaging for sources of emboli with either transthoracic or transesophageal echocardiography should also be obtained. Laboratory evaluation for hypercoagulable disorders may be needed if other more common causes of stroke are not found. Specific secondary stroke prevention therapy can be tailored to the results of the etiologic evaluation. Each ischemic stroke patient should be considered for antithrombotic therapy to prevent secondary stroke. Evaluation for other treatable stroke risk factors (hypertension, smoking, diabetes, cholesterol, triglycerides, homocysteine), initiation of appropriate secondary stroke prevention therapy, as well as patient education should be a routine part of the inpatient stroke center evaluation.

In summary, in addition to providing emergency department evaluation and treatment of the acute stroke patient, specialized stroke centers offer an organized approach to inpatient care aimed at preserving and restoring neurologic function and preventing future neurologic damage.

Return to top


Comprehensive Stroke Centers

In addition to the recommendations for primary stroke centers, stroke specialists, including the BAC, are working to develop guidelines to care for the subset of stroke patients who may require a more advanced level of services to prevent death or severe disability. These guidelines will define comprehensive stroke systems in which patients with special cerebrovascular needs are admitted or transferred to institutions with the needed special expertise. This special expertise may be, but is not necessarily, housed in a single institution, termed a comprehensive stroke center. The services required for comprehensive stroke care, including advanced stroke expertise, neuroimaging technology, neurovascular surgery, intensive care services, neuroendovascular interventions, and cerebral angiography, are especially important in patients with hemorrhagic stroke.

A comprehensive stroke center offers the full spectrum of state-of-the-art stroke care for patients with ischemic as well as hemorrhagic stroke (Table 1, PDF file, 44 KB). The comprehensive stroke system is made up of primary stroke centers and their referral hospitals with more advanced services to which individual stroke patients are appropriately transferred. Pathways for patient care, patient transfer, and stroke prevention; inter-hospital communication; ongoing assessment and improvement of the quality of stroke care; and public and professional stroke education are also essential components of a comprehensive stroke system.

Return to top


Implications and Resources

The aging of the population ensures that stroke care will be an increasingly important consideration for health care systems (6). In addition, stroke care is advancing, and keeping pace requires resource commitment as well as specific commitments on the part of health care workers and hospitals. Improved patient care is the most important driver of this commitment. However, reimbursement must be adequate to allow for these specialized services.

Hospitals and their professional staffs need to be aware of the potential for local EMS systems to establish a policy that requires diverting stroke patients to institutions that have made the commitment to a higher level of care. The proven success of such a policy for trauma patients enhances this prospect. Communication with the surrounding prehospital providers is usually fostered through emergency department personnel (ie, physician medical directors) who participate in these activities. Hospital-based ambulances may also fall under scrutiny regarding their protocols for acute stroke patients.

The potential loss of stroke patients has to be considered in light of the economic consequences and the status of the hospital in the community. For teaching hospitals, the impact on medical students and graduate education must be considered, particularly for those with neurology, emergency medicine, radiology, and physical medicine and rehabilitation programs. The decision to commit to advanced stroke care presents a number of issues for prehospital providers, emergency departments, professional staff, and hospitals.

Twenty-four-hour capability of rapid CT scanning and immediate physician interpretation is standard in many major centers but will require additional resources in other centers. Available dedicated CT technicians or cross-training for after-hours coverage is necessary. If a radiologist is not continuously available in-house, placement of teleradiology systems will be necessary unless another member of the stroke team (emergency physician, neurologist) will assume the responsibility for early CT interpretation.

State-of-the-art stroke care will require a thorough assessment of the patient by a physician skilled in stroke diagnosis. Emergency physicians evaluating stroke patients commonly face competing patient demands in busy centers. Neurologists possess advanced skills but many are not accustomed to the rapid response requirements for state-of-the-art stroke care. On-call members of a stroke team will require compensation for this activity. Specific identification or recruitment of a physician "champion" for stroke care is considered by many to be vital for success.

If the hospital plans to transfer qualifying patients to sites with stroke units, the commitment beyond the emergency department will be minimal. State-of-the-art patient care will require the development of a stroke unit that will include dedicated beds with specialized stroke nursing care. Occupational, physical, and speech therapists, social workers, and discharge coordinators are generally included in the multidisciplinary stroke unit team (6).

Shortages of nursing, medical, and ancillary staff could present an obstacle to the development of a committed stroke center, although offering staff the opportunity to focus specifically on stroke care could be a powerful retentive tool. Development costs to get a stroke unit team up and running should be offset by improvements in the length of stay for many staff members (6,24). Dedicated stroke units also create cost efficiencies since patients generally return directly to their homes, rather than needing placement elsewhere in the hospital for recovery.

Return to top


Vision for the Future

At the 1996 NINDS National Symposium on the Rapid Identification and Treatment of Acute Stroke, the future of stroke care called for "...[C]oordinated systems of stroke care [that] will ... enhance the development of new and better strategies...." and "The rapid institution of stroke teams...[that] will lead more quickly to better stroke care for the nation" (1). How well have we achieved these goals? Where do we go from here?

Our country faces significant health care challenges as our population ages. Since elderly individuals have an increased prevalence of risk factors, such as diabetes and hypertension, we will likely see a marked increase in the incidence of stroke. Organized systems for stroke care on regional and national levels are needed to make an impact. All patients should have access to the continuum of care, from basic support to the most advanced innovative strategies.

With the advent of the primary stroke center concept, groups have discussed formal programs to "certify" stroke centers. The implementation of a certification process will raise the level of stroke care by requiring evidence of compliance with evidence-based and consensus-based national standards. In addition, completion of a formal process of "certification" or "accreditation" would provide a mechanism for the public and EMS providers to recognize hospitals that are fully prepared to treat acute stroke patients.

There are several programs in the nation that have been successful in dealing with the challenging issue of access to stroke care, including academic programs, community initiatives, and rural networks. These programs all report good outcomes in their experience in delivering t-PA to patients with acute ischemic stroke. Their success is directly related to the infrastructures created for timely delivery of evidence-based acute stroke care. The rest of the country would benefit from the establishment of similar models. The Task Force recommends that each health care institution initiate a quality improvement process. The recommendations for acute stroke care suggested in this document should serve as a blueprint for the stroke care quality improvement process.

The Task Force fully acknowledges that each region in this country must assess its local requirements and resources. These regions need to evaluate their role in the continuum of care and coordinate the transport of patients to sites with a higher level of care, if necessary. Despite such regional and community resource variability, a stroke care quality improvement process should be established at every health care institution. Protocols and care plans tailored to each institution must be outlined and supported. While the American Heart Association has set its goal of reducing heart disease, stroke, and associated risk factors by 25 percent by the year 2010, this Task Force recommends the goal of having 80 percent of the health care institutions in the nation establish a stroke care quality improvement initiative by 2005.

The Task Force recommends the institution of a network for stroke care and a national stroke registry to provide reliable data for research and quality improvement. Based on the population distribution, comprehensive stroke centers and primary stroke centers will need to be located appropriately to optimize access. To further alleviate the critical shortage of stroke care expertise, the Task Force recommends the application of telemedicine technology. With advanced digital information techniques, many localities can receive real-time online consultation.

In the future, the complete recovery of stroke patients may be possible as the result of ongoing basic and clinical research. We must require continuing improvements and quality self-assessments of all aspects of the system. While we have made many advances in stroke care, we have a long way to go. In the next few years, as each link of the chain is forged, our vision is to build strong connections that reach every potential stroke patient and improve his or her health.

Return to top



Stroke places enormous and ever-increasing demands upon the health care system. Limited resources and increasing patient volume require careful personnel and monetary allocation decisions. Marked community variability in available resources requires medical centers to look both internally and externally to optimize the care of the acute stroke patient.

This Task Force recommends that medical centers conduct careful and thorough assessments of their level of stroke care. Institutions caring for stroke victims should use evidence-based practice guidelines and performance-improvement measures to maximize their effectiveness, given their level of resources. The hospitals' level of care should be explicitly stated so that patients and prehospital providers can make appropriate decisions regarding the site of care. Communities and regions should assess available stroke care resources and create cooperating stroke networks to match patient needs with available resources. All facilities providing emergency care must provide a basic level of resuscitative and supportive care. Transfer protocols should be written to ensure that patients receive appropriate care in a timely fashion. Finally, this Task Force endorses the concept of the designation of primary and comprehensive stroke centers that optimize the use of multidisciplinary teams to improve the outcome for acute stroke patients.

Return to top



  1. Marler J, Jones PW, and Emr M, eds. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, MD, National Institute of Neurological Disorders and Stroke, NIH Publication No. 97-4239, 1997.
  2. American Heart Association. 2002 Heart and Statistical Update. Dallas, TX, American Heart Association, 2001.
  3. Swarztrauber K, and Lawyer BL. Members of the AAN Practice Characteristics Subcommittee. Neurologists 2000. AAN Member Demographic and Practice Characteristics. St. Paul, MN, American Academy of Neurology, 2001.
  4. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000;283(23): pp. 3102-3109.
  5. Bowen J, and Yaste C. Effect of a stroke protocol on hospital costs of stroke patients. Neurology 1994;44(10): pp. 1961-1964.
  6. Wentworth DA, and Atkinson RP. Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke 1996;27(6): pp. 1040-1043.
  7. Summers D, and Soper PA. Implementation and evaluation of stroke clinical pathways and the impact on cost of stroke care. J Cardiovasc Nurs 1998;13(1): pp. 69-87.
  8. Odderson IR, and McKenna BS. A model for management of patients with stroke during the acute phase. Outcome and economic implications. Stroke 1993;24(12): pp. 1823-1827.
  9. Newell SD, Jr., Englert J, Box-Taylor A, et al. Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998;29(6): pp. 1092-1098
  10. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1996;94: pp. 1167-1174.
  11. Albers GW, Bates VE, Clark WM, et al. Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000;283: pp. 1145-1150.
  12. Lopez-Yunez AM, Bruno A, Williams LS, et al. Protocol violations in community-based rt-PA stroke treatment are associated with symptomatic intracerebral hemorrhage. Stroke 2001;32: pp. 12-16.
  13. Tanne D, Bates VE, Verro P, et al. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group. Neurology 1999;53: pp. 424-427.
  14. Gomez CR, Malkoff MD, Sauer CM, et al. Code stroke. An attempt to shorten inhospital therapeutic delays. Stroke 1994;25: pp. 1920-1923.
  15. Bratina P, Greenberg L, Pasteur W, et al. Current emergency department management of stroke in Houston, Texas. Stroke 1995;26: pp. 409-414.
  16. Lyden P, Rapp K, Babcock T, et al. Ultra-Rapid Identification, Triage, and Enrollment of stroke patients into clinical trials. J Stroke Cerebrovasc Dis 1994;4: pp. 106-113.
  17. Webb DJ, Fayad PB, Wilbur C, et al. Effects of a specialized team on stroke care. The first two years of the Yale Stroke Program. Stroke 1995;26: pp. 1353-1357.
  18. Langhorne P, Williams BO, Gilchrist W, et al. Do stroke units save lives? Lancet 1993;342(8868): pp. 395-398.
  19. Indredavik B, Bakke F, Solberg R, et al. Benefit of a stroke unit: a randomized controlled trial. Stroke 1991;22(8): pp. 1026-1031.
  20. Indredavik B, Bakke F, Solberg R, et al. Stroke unit treatment improves long-term quality of life: a randomized controlled trial. Stroke 1998;29(5): pp. 895-899.
  21. Jorgensen HS, Nakayama H, Raaschou HO, et al. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study. Stroke 1995;26(7): pp. 1178-1182.
  22. Jorgensen HS, Kammersgaard LP, Nakayama H, et al. Treatment and rehabilitation on a stroke unit improves 5-year survival. A community-based study. Stroke 1999. 30(5): pp. 930-933.
  23. Jorgensen HS, Kammersgaard LP, Houth J, et al. Who benefits from treatment and rehabilitation in a stroke unit? A community-based study. Stroke 2000;31(2): pp. 434-439.
  24. Stroke Unit Trialists' Collaboration. Collaborative systematic review of the randomized trials of organized in-patient (stroke unit) care after stroke. BMJ 1997;314: pp. 1151-1159.
  25. Halm EA, Lee C, and Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137(6): pp. 511-520.
  26. Nathens AB, Jurkovich GJ, Cummings P, et al. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 2000;283(15): pp. 1990-1994.
  27. Mann NC, Mullins RJ, MacKenzie EJ, et al. Systematic review of published evidence regarding trauma system effectiveness. J Trauma 1999;47(3 Suppl): pp. S25-S33.
  28. Mullins RJ, and Mann NC. Population-based research assessing the effectiveness of trauma systems. J Trauma 1999;47(3 Suppl): pp. S59-S66.
  29. Wenneker WW, Murray DHJ, and Ledwich T. Improved trauma care in a rural hospital after establishing a level II trauma center. Am J Surg 1990;160(6): pp. 655-657; discussion pp. 657-658.
  30. Marler JR, Tilley BC, Lu M, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 2000;55(11): pp. 1649-1655.
  31. Grond M, Stenzel C, Schmulling S, et al. Early intravenous thrombolysis for acute ischemic stroke in a community-based approach. Stroke 1998;29(8): pp. 1544-1549.
  32. Hainsworth DS, Lockwood-Cook E, Pond M, et al. Development and implementation of clinical pathways for stroke on a multihospital basis. J Neurosci Nurs 1997;29(3): pp. 156-162.
  33. O'Neill L, Lanska DJ, and Hartz A. Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy. Neurology 2000;55(6): pp. 773-781.
  34. Hannan EL, Popp AJ, Tranmer B, et al. Relationship between provider volume and mortality for carotid endarterectomies in New York state. Stroke 1998;29(11): pp. 2292-2297.
  35. Vakili BA, Kaplan R, and Brown DL. Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York state. Circulation 2001;104(18): pp. 2171-2176.
  36. Jollis JG, Peterson ED, DeLong ER, et al. The relation between the volume of coronary angioplasty procedures at hospitals treating Medicare beneficiaries and short-term mortality. N Engl J Med 1994; 331(24): pp. 1625-1629.
  37. Kimmel SE, Berlin JA, and Laskey WK. The relationship between coronary angioplasty procedure volume and major complications. JAMA 1995;274(14): pp. 1137-1142.
  38. Hannan EL, Racz M, Ryan TJ, et al. Coronary angioplasty volume-outcome relationships for hospitals and cardiologists. JAMA 1997;277(11): pp. 892-898.
  39. McGrath PD, Wennberg DE, Malenka DJ, et al. Operator volume and outcomes in 12,998 percutaneous coronary interventions. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol 1998;31(3): pp. 570-576.
  40. Ellis SG, Weintraub W, Holmes D, et al. Relation of operator volume and experience to procedural outcome of percutaneous coronary revascularization at hospitals with high interventional volumes. Circulation 1997;95(11): pp. 2479-2484.
  41. Jollis JG, Peterson ED, Nelson CL, et al. Relationship between physician and hospital coronary angioplasty volume and outcome in elderly patients. Circulation 1997; 95(11): pp. 2485-2491.
  42. Canto JG, Every NR, Magid DJ, et al. The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators. N Engl J Med 2000;342(21): pp. 1573-1580.
  43. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346(15): pp. 1128-1137.
  44. Thurman RJ, and Jauch EC. Acute ischemic stroke: emergent evaluation and management. Emerg Med Clin North Am 2002;20(3): pp. 609-630.
  45. Brice JH, Griswell JK, Delbridge TR, et al. Stroke: from recognition by the public to management by emergency medical services. Prehosp Emerg Care 2002;6(1): pp. 99-106.
  46. Evenson KR, Schroeder EB, Legare TB, et al. A comparison of emergency medical services times for stroke and myocardial infarction. Prehosp Emerg Care 2001;5(4): pp. 335-339.
  47. Schroeder EB, Rosamond WD, Morris DL, et al. Determinants of use of emergency medical services in a population with stroke symptoms: the second delay in accessing stroke healthcare (DASH II) study. Stroke 2000;31(11): pp. 2591-2596.
  48. Lang ES. Evidence-based emergency medicine. Use of thrombolytic therapy in patients with acute ischemic stroke. Ann Emerg Med 2002;39(3): pp. 296-298.
  49. Morris DL, Rosamond WD, Hinn AR, et al. Time delays in accessing stroke care in the emergency department. Acad Emerg Med 1999;6(3): pp. 218-223.
  50. Rosamond WD, Gorton RA, Hinn AR, et al. Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study. Acad Emerg Med 1998;5(1): pp. 45-51.
  51. Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999;33(4): pp. 373-378.
  52. Kidwell CS, Starkman S, Eckstein M, et al. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000;31(1): pp. 71-76.
  53. NINDS rt-PA Stroke Trial Investigators and Coordinators. A systems approach to immediate evaluation and management of hyperacute stroke: experience at 8 centers and implications for community practice and patient care. Stroke 1997;28: pp. 1530-1540.
  54. Katzan IL, Furlan AJ, Lloyd LE, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 2000;283(9): pp. 1151-1158.
  55. NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 1997;28: pp. 2109-2118.
  56. Bruno A, Biller J, Adams HP, et al. Acute blood glucose level and outcome from ischemic stroke. Neurology 1999;52: pp. 280-284.
  57. Adams HP, Jr., Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke (AHA Medical/Scientific Statement). Stroke 1994;25(9): p. 1901-1914.
  58. Bath F, and Bath P. What is the correct management of blood pressure in acute stroke? Cerebrovasc Dis 1997;7: pp. 205-213.
  59. Adams HP, Jr., Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999;53(1): pp. 126-131.
  60. Shapiro J, Bessette M, Baumlin K, et al. Rapid stroke assessment: an NIH Stroke Scale and Acute Ischemic Stroke Management Assistant for Palm OS handheld computers. Acad Emerg Med 2002; 9: p. 1060.
  61. Reith J, Jorgensen HS, Pedersen PM, et al. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet 1996;347(8999): pp. 422-425.
  62. Broderick JP, Adams HP, and Barsan W. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999;30(4): pp. 905-915.
  63. Clark WM. Acute Stroke Team. J Stroke Cerebrovasc Dis 1998;8: pp. 111-113.
  64. Furlan A, Murdock M, Spilker J, et al. NSA Stroke Center Network stroke center recommendations. J Stroke Cerebrovasc Dis 1997;6: pp. 299-302.
  65. Kaste M, Palomaki H, and Sarna S. Where and how should elderly stroke patients be treated? A randomized trial. Stroke 1995;26(2): pp. 249-253.
  66. Stroke Unit Trialists' Collaboration. How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke 1997;28: pp. 2139-2144.
  67. Coull BM, Williams LS, Goldstein LB, et al. Anticoagulants and antiplatelet agents in acute ischemic stroke: report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a division of the American Heart Association). Neurology 2002;59(1): pp. 13-22.

Return to top

Return to Table of Contents

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

Last updated August 19, 2008

NIH...Turning Discovery Into Health®