New stroke guidelines: Better data reporting can improve stroke center care

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Providing a framework for which metrics should be collected at comprehensive stroke centers can help with quality improvement and reduce stroke related events and improve patient care, according to new American Heart Association/American Stroke Association guidelines published online Jan. 13 in Stroke.

Because stroke affects almost 795,000 people per year, the Brain Attack Coalition (BAC) has proposed two levels of hospitals for the treatment of stroke patients: primary stroke centers (PSCs) and comprehensive stroke centers (CSCs).

To help better develop these CSCs and enhance stroke quality improvements, Dana Leifer, MD, and colleagues from the American Heart Association’s (AHA) stroke council, created a set of metrics on what data CSCs should track and monitor by conducting a literature review of previous data.

The metrics include how to track and measure metrics for patients in three categories: those with ischemic cerebrovascular disease, those with aneurysmal subarachnoid hemorrhage (SAH) and those with unruptured aneurysms and nontraumatic intracerebral hemorrhage.

In addition, Leifer and colleagues proposed metrics that looked at the severity of stroke, intensive care unit treatment and rehabilitation care and patient transfer from outside the hospital to a CSC.

The council presented 26 core metrics for CSCs, and some of the standards are as follows:

  • Percentage of  ischemic stroke patients eligible for intravenous thrombolysis who receive it within the appropriate time window;
  • Percentage of patients who are treated for acute ischemic stroke with intravenous thrombolysis whose treatment is started 60 minutes or less after arrival;
  • Median time from arrival to start of multimodality CT or MR brain and vascular imaging for ischemic stroke in patients arriving within six hours of the time that they were last known to be at baseline;
  • Percentage of patients treated with intravenous thrombolysis who have a symptomatic intracranial hemorrhage within 36 hours of treatment;
  • Tracking the time from hospitalization to treatment to repair blood vessels for patients with a ruptured aneurysm; and
  • Performing 90-day follow-up of ischemic stroke patients to assess their outcome after acute interventions, including treatment with tissue-type plasminogen activator (tPA).

"Some of the metrics have stronger evidence supporting them or have greater clinical significance," said Leifer.

“The data that CSCs collect will be more useful if they are collected in a standardized way so that they can be pooled for analysis,” the authors wrote. “The willingness of CSCs to share data for this purpose will therefore be important.”

The authors recommended that the initial goals of CSC should be a “refinement” of the proposed metric. “We expect that such analysis will lead to improved protocols for clinical care and to hypotheses that can be tested in clinical trials.”

While PSCs have already shown that formalizing protocols for stroke care can enhance care, “the metrics that we have proposed for CSCs should help provide a framework for establishing CSCs and a foundation for improving care once they are established,” the authors concluded.

The proposed metrics align with the American Stroke Association’s Get with the Guidelines program and the American Heart Association’s 2020 goal, which is to reduce cardiac disease and stroke deaths by 20 percent.