Which of the study’s three predicted outcomes reflect the reality of acute stroke care?

The Joint Commission on Accreditation of Healthcare Organizations began certifying U.S. hospitals as primary stroke centers as recently as 2004. In 2005, Yale-New Haven Hospital was the first hospital in southern Connecticut and the fourth in New England to be awarded this distinction. At the end of 2006, nearly 300 institutions nationwide achieved this designation.

To determine if primary stroke centers improve patient care, the authors used the recommended 11 major BAC criteria to predict three outcomes: 1) in-hospital mortality, 2) discharge destination, and 3) increased t-PA use. However, neither acute mortality nor discharge destination accurately reflects the level of acute stroke care. Early in-hospital stroke death typically results from very large strokes which cannot be treated with t-PA or any other therapy. Discharge destination is a complex issue and reflects social and cost factors in addition to actual stroke outcome.

Additionally, stroke recovery may not peak for several months and this was not reflected in the study. Often, individuals are discharged from the hospital to an inpatient rehabilitation facility. Then at a later date, once independent, patients are discharged home.

Measuring increased t-PA use, however, is right on target. In 1996, t-PA was approved by the FDA for use in patients with an acute ischemic stroke.

t-PA is a “clot-busting” medication that works by dissolving clots that cause an interruption in blood flow to the brain. Typically it must be given within three hours of stroke onset. Since t-PA is the only FDA-approved treatment for acute ischemic stroke, efforts to enhance its use should increase the number of stroke survivors who have minimal or no disability. There is a tradeoff with a 6 percent risk of potentially fatal bleeding into the brain. But even with that risk, overall more individuals benefit than get worse when t-PA is used properly.

In addition to reducing the odds of physical disability, factors such as preservation of cognitive function, prevention of post-stroke complications such as pneumonia and pressure sores, and increased patient satisfaction are important questions that were not addressed in the study.

What the study did show was that the faster acute stroke patients get to the hospital, the greater their chance of getting t-PA. This means that patients have a better chance for an improved outcome. These findings are directly linked to community stroke education (i.e., knowing the warning signs of stroke) and ongoing stroke training for paramedics.

Another conclusion of the study is that certified primary stroke centers have dedicated stroke and emergency room clinicians, as well as radiology and other support staff who are committed to providing fast and efficient stroke care. This also optimizes acute stroke care and improves the chances of receiving t-PA, and thereby overall outcomes.

Data for this study was abstracted from stroke events that occurred between 1999 and 2001, only several years after t-PA was approved. At that time, the t-PA treatment rate was only 2 to 4 percent of eligible patients. Even today, less than 10 percent of eligible patients nationwide receive t-PA. We still have much to do in order to make a greater impact in the treatment of stroke, which is the No.1 cause of long-term disability and the No. 3 cause of death among adults in the United States.

Karin Nyström, APRN, is the clinical coordinator of the Yale New Haven Stroke Center and a part-time faculty member in the Adult Advanced Practice Program at the Yale University School of Nursing.