A NATIONAL INSTITUTE OF NEUROLOGICAL 

DISORDERS AND STROKE SYMPOSIUM

IMPROVING THE CHAIN OF RECOVERY 

FOR ACUTE STROKE IN YOUR COMMUNITY

Task Force Reports

December 12 – 13, 2002

National Institutes of Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES
T

Acknowledgements

he symposium that resulted in these Task Force Reports was made possible 

in part by the generous support of the American Stroke Association, a division 

of the American Heart Association, and the National Stroke Association. The NINDS 

also wishes to thank the Foundation for Education and Research in Neurological

Emergencies (FERNE) for posting the symposium lectures on its website (www.ferne.org),

and the University of Illinois at Chicago for making it possible to offer CME/CE credits 

to qualifying participants. 

For additional copies of the book please contact the NINDS Brain Resources and

Information Network (BRAIN) at P.O. Box 5801, Bethesda, Maryland 20892; the 

Task Force Reports are also available online at www.ninds.nih.gov/strokeworkshop.htm.
A NATIONAL INSTITUTE OF NEUROLOGICAL 

DISORDERS AND STROKE SYMPOSIUM

IMPROVING THE CHAIN OF RECOVERY 

FOR ACUTE STROKE IN YOUR COMMUNITY

Task Force Reports

National Institutes of Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES

September 2003

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Improving the Chain of Recovery for Acute Stroke in Your Community

Contents Page

Preamble iii

William G. Barsan, M.D.

Executive Summary v

Paul E. Pepe, M.D., M.P.H.

Task Force Reports

Increasing Public Recognition and Rapid Response to Stroke 1

Lewis B. Morgenstern, M.D., Wayne Rosamond, Ph.D., Mark J. Alberts, M.D., 

L. Kay Bartholomew, Ed.D., M.P.H., Alfred S. Callahan III, M.D., 

Marc Eckstein, M.D., Scott Kasner, M.D., Russell V. Luepker, M.D., 

and Karen Rapp, R.N.

Choosing Your Level of Care 11

Andy Jagoda, M.D., Arthur M. Pancioli, M.D., Andrew W. Asimos, M.D., 

William G. Barsan, M.D., Kevin Baumlin, M.D., F.A.C.E.P., 

William Dalsey, M.D., Kathleen A. Delaney, M.D., Edward Goldman, J.D., 

Margaret Gradison, M.D., Markku Kaste, M.D., Ph.D., Walter J. Koroshetz, M.D., 

Thomas G. Kwiatkowski, M.D., Marc Mayberg, M.D., F.A.H.A., 

Robert M. McNamara, M.D., C. Crawford Mechem, M.D., Daniel Morelli, M.D., 

Hal Unwin, M.D., David Wang, D.O., and David W. Wright, M.D., F.A.C.E.P.

Professional Education 29

Patrick D. Lyden, M.D., Susan L. Hickenbottom, M.D., M.S., 

Richard P. Atkinson, M.D., Lisa Davis, R.N., M.S.N., Jeremy Golding, M.D., 

Judith A. Hinchey, M.D., Kurt Kleinschmidt, M.D., Thomas G. Kwiatkowski, M.D., 

Christopher A. Lewandowski, M.D., Colin C. Rorrie, Jr., Ph.D., C.A.E., 

Edward P. Sloan, M.D., M.P.H., F.A.C.E.P., Judith A. Spilker, R.N., 

Robert E. Suter, D.O., M.H.A., and Steven Warach, M.D., Ph.D.

Templates for Organizing Stroke Triage 41

David Persse, M.D., Richard C. Hinton, M.D., Joe E. Acker III, M.P.H., E.M.T.-P., 

Todd J. Crocco, M.D., James V. Dunford, M.D., F.A.C.E.P., James C. Grotta, M.D., 

Anne D. Leonard, R.N., M.P.H., J.P. Mohr, M.D., Paul E. Pepe, M.D., M.P.H., 

Michael R. Sayre, M.D., Jane Wigginton, M.D., Paula Willoughby, D.O., 

Daniel J. Worman, M.D., and Judith R. Yates
A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Incentives for Enhancing Stroke Care 71

Sandra M. Schneider, M.D., Larry B. Goldstein, M.D., 

James G. Adams, M.D., F.A.C.E.P., Kenneth L. DeHart, M.D., F.A.C.E.P., 

Andrew M. Demchuk, M.D., Anthony J. Furlan, M.D., Michael D. Hill, M.D., 

Michael T. Rapp, M.D., J.D., and Joseph P. Wood, M.D., J.D.

Provider Support Systems for Acute Stroke 81

Phillip A. Scott, M.D., Sidney Starkman, M.D., John Y. Choi, M.D., 

Brian F. Connolly, M.D., Karen L. Furie, M.D., J. Stephen Huff, M.D., 

Walter N. Kernan, M.D., Marian P. LaMonte, M.D., M.S.N., 

Dennis M.D. Landis, M.D., Steven R. Levine, M.D., David B. Matchar, M.D., 

Brett C. Meyer, M.D., Debra G. Perina, M.D., Jeffrey L. Saver, M.D., 

and Lee H. Schwamm, M.D.

Steering Committee and Task Force Members 97

Partners 105
n December 12 and 13, 1996, the 

National Institute of Neurological 

Disorders and Stroke (NINDS) sponsored a

National Symposium on Rapid Identification 

and Treatment of Acute Stroke.1 This initial

NINDS symposium followed on the heels 

of the publication of the NINDS t-PA stroke 

trial demonstrating the effectiveness of intravenous t-PA for victims of acute stroke.2 The 

goal of this conference was to provide a platform for coordinating nationwide efforts 

aimed at implementing acute stroke therapy 

for all types of stroke patients. The theme was 

that rapid evaluation and treatment would

improve the outcome for all stroke patients. 

In December 2002, the NINDS sponsored 

a second symposium titled Improving the 

Chain of Recovery for Acute Stroke in Your

Community. Six years after our initial call 

to action, we find that while there have been

improvements in the care of patients with 

acute stroke, we still have much to accomplish.

Implementing acute stroke treatment has not 

been easy, and nationwide only about 2 percent of patients with acute stroke are actually

receiving acute thrombolytic or interventional

treatment. We also find that the majority of

patients with acute stroke are still not presenting to the hospital within 3 hours of stroke 

onset. And while there are effective models 

for acute stroke treatment teams, most 

institutions in the United States are not 

utilizing these models. 

The goal of this second symposium is 

to improve the overall functional outcome 

for patients with acute stroke. We hope to 

accomplish this by identifying barriers to 

delivering acute stroke treatment and by 

defining solutions for overcoming these 

barriers. Six areas have been chosen for 

more detailed analysis. These include: public 

recognition of acute stroke, choosing your 

level of care, professional education, effective templates for stroke triage, incentives 

for acute stroke care, and support systems 

for those providing acute stroke care.

We are fortunate that many outstanding 

and knowledgeable individuals from a variety 

of professions and medical specialties contributed to this symposium. Our hope is that 

these Task Force reports will provide a roadmap for hospitals, health systems, payors, 

and medical professionals to follow in the 

ensuing years. Each year, more than 600,000

Americans suffer from acute stroke and there 

are more than 3 million Americans living with

some disability resulting from stroke. We also

hope that the information from these reports 

will help to alleviate this heavy burden on our 

society and lead to improved outcomes for 

all victims of acute stroke. 

Preamble

William G. Barsan, M.D. 

Steering Committee Co-Chair

University of Michigan Health System

Ann Arbor

O

1 Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. National Institute of Neurological Disorders

and Stroke, Bethesda, MD, August 1997, NIH Publication No. 97-4239.

2 The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;26: pp. 843-849.

iii

or months prior to the December 12–13,

2002 symposium, “Improving the Chain 

of Recovery for Acute Stroke in Your Community,”

the National Institute of Neurological Disorders

and Stroke (NINDS) convened several diverse

steering committee and task force subgroup 

meetings to begin thoughtful formulation of 

proposed task force reports and recommendations. Not only were these proposals debated,

edited, and re-debated long before the culminating symposium, they were also cumulatively

reviewed and ardently discussed during the 

symposium itself in several rotating panels. 

In these multiple rotating panels, the 

majority of participants had the opportunity to

provide feedback, input, and active involvement

in the final recommendation process for all of 

the topics covered. The deliberations and proceedings were formally recorded and summary

reports were articulated in plenary sessions. 

Most impressively, the group was interdisciplinary, diverse, talented, knowledgeable, and 

highly motivated by the quest for improved 

public health and strong patient advocacy.

Whether the participants were neurologists, 

stroke rehabilitation nurses, emergency specialists, professional group representatives, paramedics, medical educators, or hospital system

administrators (just to name a few of the participant groups), they eventually came together 

in unison to effect these recommendations. 

At the risk of oversimplifying the results 

of the extensive work and many countless 

hours of effort provided by the individual 

task forces, their leaders, and the general 

participants, the principal recommendations

detailed in the ensuing chapters can be summarized as follows:

Regarding the issue of Increasing Public

Recognition and Rapid Response to Stroke:

 For a variety of reasons, stroke 

patients, their families, and the public 

at large generally do not recognize 

and immediately act following the 

onset of stroke symptoms.

 To date, there is limited experience 

with interventions to reduce delays, 

but it is believed that key messages 

about stroke need to be succinct, 

intense, and sustained. They should 

also include motivational components 

to ensure immediate response to stroke.

 Therefore, multi-level interventions, 

targeted at high-risk individuals 

and their families as well as special 

populations and the public at large, 

must be researched, sponsored, 

implemented, and measured for 

cost-effectiveness and sustainability 

through a collaborative effort of 

multiple community stakeholders.

Executive Summary

Paul E. Pepe, M.D., M.P.H.

Steering Committee Co-Chair

University of Texas Southwestern Medical Center at Dallas

F

v
Regarding the issue of Choosing Your Level 

of Care:

 For a variety of reasons, the level of 

stroke care and access to acute stroke 

care interventions is diverse across the 

United States and other countries.

 Recognizing that, today, excellence 

in stroke care involves more than 

thrombolytics and invasive interventions, all health care institutions 

should evaluate their capabilities 

for stroke care using evidence-based 

practice guidelines and performance 

improvement measures.

 In turn, hospitals should explicitly 

state their round-the-clock stroke care 

capabilities and, through appropriate 

channels, provide confirmatory data 

of these capabilities so that patients 

and providers of prehospital stroke 

care can make appropriate decisions 

regarding the destination site for 

hospital care.

 All stakeholders in the community or 

health care region should join forces 

to set up mechanisms to assess available 

stroke care resources and create stroke 

care networks to better match and 

optimize patient needs and available 

resources, including designations of 

primary and comprehensive stroke 

care services.

Regarding the issue of Professional Education:

 For a variety of reasons, there have 

been shortcomings in the efforts to 

educate medical professionals regarding 

acute stroke care, including methodologies 

and targeted audiences, and there has 

even been some confusion in the information delivered.

 Therefore, comprehensive, consistent, 

and consensus-based curricula regarding 

acute stroke care should be targeted at 

disciplines involved in providing stroke 

care such as emergency medicine and 

neurological residencies and relevant 

nursing personnel.

 Also, on-going education of medical 

professionals, consistent with principles 

of multi-modal, interactive adult education, needs to be funded for appropriate 

development, implementation, and 

evaluation of any respective educational interventions.

Regarding the issue of Templates for Organizing

Stroke Triage:

 For a variety of reasons, including 

competitive proprietary interests, 

individual stroke care provider sustainability, or omission of widespread 

community-based support, mechanisms 

for designating and verifying appropriate stroke care sites for patient 

transport decisions are often lacking.

 Therefore, in addition to aggressive 

training of emergency medical services 

(EMS) personnel with appropriate 

tools to recognize an acute stroke and 

provide appropriate advice to patients 

and families, stroke system organizers 

must also achieve buy-in from all 

stakeholders — participating hospitals, 

neurologists, emergency medicine 

specialists, medical societies, local 

government, professional organizations, and community groups.

 Also, if feasible, a neutral, non-proprietary 

community organization (i.e., local stroke 

council) should be established to develop 

and monitor EMS triage protocol 

vi

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
compliance, and to monitor receiving 

facility capabilities and compliance 

through appropriate and confidential 

quality-assurance audits.

Regarding the issue of Incentives for Enhancing

Stroke Care:

 For a variety of reasons, there have 

been many disincentives for practitioners 

and facilities alike to provide optimal 

stroke care, including perceived and 

actual considerations such as fear of 

liability, lack of appropriate reimbursement, and even issues such as “off-hours”

absence of support.

 Therefore, it is essential that the 

importance of aggressive stroke care 

be widely accepted and rewarded in 

a community by developing strategies 

such as those involving education, 

practitioner support mechanisms, 

and a coordinated stroke reimbursement plan involving stroke advocates 

and professional organizations.

 An appropriate forum for discussion 

should be provided to facilitate: 

1) community consensus regarding 

new therapies and best practices; 

2) constructive dialogue between 

emergency and neurological specialists, 

nursing personnel, EMS personnel, 

and hospital administrators; and 

feedback on outcomes, research, and 

individual patient care successes.

Regarding the issue of Provider Support 

Systems for Acute Stroke:

 For a variety of reasons, many practitioners 

have avoided active participation in acute 

stroke care, and a central theme for these 

practitioners has been the sense of isolation 

and a lack of back-up support systems.

 Therefore, it is first recommended that 

many of the previous topic suggestions 

be rapidly implemented, particularly 

those involving incentives, education, 

community-wide support, and consensus 

for stroke care and public education.

 Mechanisms for real-time back-up 

support should be considered. These 

range from standard telephone advice 

and teleradiology to sophisticated 

automated image interpretation. 

 Stroke care credentialing and hospital 

“stroke drills” are other options to 

consider for improving practitioner 

implementation of acute stroke care.

In closing, it should be emphasized that 

these bulleted recommendations serve only 

to summarize and highlight some of the very

detailed and comprehensive text provided in 

the following chapters by the six task forces 

and the hundreds of dedicated 2002 symposium participants. It must be recognized 

that these recommendations generally focus 

on the limited subject of acute stroke care and

specific strategies for getting more acute stroke

patients into the health care system for the 

earliest possible treatment. While the recommendations still may not be as comprehensive 

or as complete as some might like, they are a

wonderful step in the right direction toward

achieving further improvements in our nation’s

management of this major cause of death and 

disability. Therefore, the NINDS and the other

supporting organizations must be strongly 

commended and appreciated for sponsoring 

and facilitating this symposium and for publishing these reports. We strongly believe that 

they can lead to clear improvements in the 

chain of recovery for stroke in your community.

vii

Improving the Chain of Recovery for Acute Stroke in Your Community

Increasing Public 

Recognition and 

Rapid Response 

to Stroke

Increasing Public Recognition and Rapid Response to Stroke

mproved in-hospital care and the advent 

of time-dependent treatments for stroke 

have increased the value of reducing delays from

the onset of symptoms to acute stroke therapy.

Delay to treatment can be generically divided 

into several components: (a) prehospital patient

delay (the time from symptom onset to contact

with the health care system); (b) transport time

(time from initial contact with the health care 

system to hospital arrival); and (c) in-hospital

delays in diagnosis and treatment. The longest 

of these is usually prehospital patient delay, 

which ranges from a median of 3 to 6 hours.1

Prehospital patient delay for stroke has been

well studied with generally consistent findings.

The patient or a witness must recognize the seriousness of the condition, decide to seek help, 

and arrange transport to a hospital, preferably 

by ambulance. Age, education, access to medical

care, and co-existing medical conditions are not

associated with prehospital delay. Gender, ethnic

group, and severity of symptoms do predict 

delay. Patients with prior stroke or TIA do not 

get to the hospital faster than patients who 

have not experienced a prior event.

Reasons for delay are found in denial,

attempts at self-treatment, mild and/or variable

symptoms, living alone, and the incapacitation

that accompanies stroke. In addition, even when

knowledge about stroke is present, the skills and

motivation to take action are frequently missing

in the stroke victim and those around him or her.

It is apparent that action by a witness — whether

a relative, co-worker, or bystander — significantly

reduces delay. It is also well recognized that the

use of emergency 911 reduces delay to treatment.

Much is known about prehospital patient delay 

in responding to symptoms of stroke. This knowledge could be used to guide a public information

program aimed at improving awareness and

inspiring appropriate action resulting in more

timely access to medical care.

T ASK FORCE REPORT

Increasing Public Recognition and Rapid Response to Stroke

Lewis B. Morgenstern, M.D.

Task Force Chair

University of Michigan Health System

Ann Arbor 

Wayne Rosamond, Ph.D. 

Task Force Co-Chair

University of North Carolina

Chapel Hill

Mark J. Alberts, M.D.

Northwestern University

Chicago

L. Kay Bartholomew, Ed.D., M.P.H.

University of Texas Health Science Center 

at Houston 

Alfred S. Callahan III, M.D.

Neurologic Consultants

Nashville, Tennessee

Marc Eckstein, M.D.

University of Southern California Medical Center

Los Angeles

Scott Kasner, M.D.

University of Pennsylvania

Philadelphia

Russell Luepker, M.D.

University of Minnesota

Minneapolis

Karen Rapp, R.N.

University of California at San Diego

I
Lessons from Acute Myocardial Infarction

Much of the experience in reducing delay to 

hospital presentation with an acute episode of a

chronic illness comes from experience with acute

myocardial infarction (AMI). The problems faced

with reducing prehospital patient delay in AMI

were similar in many ways to those faced with

stroke. Various public and private agencies have

worked for nearly 40 years to reduce delay to AMI

treatment. A single symptom and action message

has been promoted (chest pain, act fast, call 

911) with varying intensity and frequency. The

result is that most adults, more than 90 percent,

recognize persistent chest pain as the critical

symptom. More than 80 percent recognize 

that calling 911 for ambulance transport is 

the appropriate behavior. Patient delay times 

have fallen from about 210 minutes in the 

1980s to 140 minutes in the early 1990s. Some

recent studies suggest that in the mid to late

1990s, improvements in patient delay stalled.

Public campaigns to reduce prehospital 

delay and increase use of 911 emergency medical services in AMI allowed researchers to gain 

considerable experience in what works. A 1-year 

education campaign in Sweden was associated

with a significant reduction in median delay 

time from 3.0 hours to 2.3 hours among 

patients with confirmed AMI. Another public

campaign in Switzerland was associated with 

a similar reduction of median delay time 

from 3.3 hours to 2.6 hours for those with 

confirmed AMI. More modest reductions in 

delay time were found in a study in King 

County, Washington, where median delays 

of 2.6 hours at baseline were reduced slightly 

to 2.3 hours following a media campaign. 

The REACT study — Rapid Early Action for

Coronary Treatment, sponsored by the National

Heart, Lung, and Blood Institute — was the 

largest effort, involving 20 cities and more 

than 2 million residents. Residents of ten 

cities participated in an 18-month educational

program and were compared to residents of 

ten control cities not involved in the educational

program. The baseline patient delay identified 

by the investigators was lower than expected 

and the trend of declining delay in the control

cities was larger than expected. Subsequently, 

the study failed to show significant reductions 

in this baseline in response to the intervention

strategies tested. Each of these programs used 

a wide selection of techniques, ranging from 

face-to-face education to mass media campaigns.

All of the programs tested various messages to

build knowledge and skills in both high-risk 

individuals and the general public.

Experience with AMI suggests that a 

program to reduce prehospital delay should 

(1) deliver a clear and simple educational 

message that teaches stroke knowledge and 

skills for action, including the use of 911; 

(2) emphasize the role of witnesses in getting 

help for the victim; (3) target both the general

public and high-risk individuals; (4) be intense

and sustained; and (5) involve multiple media

methods to reach all segments of society.

Lessons from Acute Stroke

There is limited experience with interventions 

to reduce delay time from onset of stroke to 

delivery of acute stroke therapies. In the mid

1980s in Durham, North Carolina, a public 

and professional education campaign to reduce

time from onset of stroke symptoms to arrival 

at a hospital emergency department was implemented.2 During the pre-education phase 

37 percent of stroke patients presented to the

emergency department within 24 hours of 

symptom onset. This percentage was increased 

to 86 percent during the post-intervention 

phase. The Temple Foundation Stroke Project

demonstrated an increase in the use of intravenous t-PA from 2 percent to more than 

11 percent of ischemic stroke patients in 

rural East Texas.3

4

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
The Key Message

The message for the public should be clear, 

crisp, tailored, and sustainable. The essential 

elements of the message should be symptom

recognition, immediacy (every second counts),

and a call to action (using 911). It must also

include a positive message that there are available treatments in order to motivate individuals

to activate emergency medical services. 

Examples of messages that have been 

promoted include a message developed by the

National Institute of Neurological Disorders 

and Stroke: Know Stroke. Know the Signs. Act 

in Time. The University of Cincinnati’s education program, FAST (face, arms, speech, time),

attempts to simplify stroke recognition and

action. This program needs to be validated for

community use. To maximize its effectiveness, 

any public education program to disseminate 

a message should be developed in cooperation

with professionals involved in public communication and public health education. 

Knowledge and Motivation

The stroke chain of recovery begins with the 

rapid identification of stroke symptoms by the

patient or a bystander during the prehospital

phase. The majority of prehospital delay occurs

while the patient or those around the patient 

are deciding whether or not to seek care. Accurate knowledge and directed motivation are 

essential components of this decision-making

process. Both should be targets for improvement if progress is to be made in reducing 

prehospital delay.

A key factor responsible for the low proportion of stroke patients obtaining timely 

medical care is a poor understanding of stroke

symptoms. A poor knowledge of the warning

signs of stroke has been reported in studies 

of stroke patients and in surveys of the general population.4 Current programs by the

NINDS, the American Stroke Association 

and others are important and necessary first 

steps toward making advances in improving 

the overall awareness of stroke symptoms.

Knowledge of stroke symptoms alone, 

however, is not sufficient to reduce prehospital

delay time. We know that calling 911 is a major

factor in reducing prehospital delay, as well 

as in-hospital delay, among stroke patients.5

Special attention should be given to overcoming barriers to calling 911 (e.g., concern for cost,

embarrassment) and to reinforcing this behavior

in the community. Furthermore, knowledge 

of symptoms among stroke patients has been

shown not to be associated with increased use 

of emergency medical services. In fact, patients

with better than average knowledge of stroke

symptoms and who reported having previously

received information about stroke symptoms 

are less likely to use emergency medical services

than those with a lower level of awareness.5

It is clear that there are factors in addition to

knowledge that underlie the public’s response, 

or lack of response, to stroke symptoms. A 

heightened sense of urgency together with 

knowledge of stroke symptoms may interact 

to stimulate rapid response. Knowledge alone 

is not sufficient to effect real change in prehospital care-seeking behavior among stroke

patients or those who may witness the onset 

of stroke symptoms. 

A public education effort about stroke 

symptoms that does not address the motivation or call-to-action component of care-seeking

behavior may fall short in reducing prehospital

delay. Programs that fail to consider the social/

environmental context of the person who suffers 

a stroke may also be ineffective, as many stroke

patients are aphasic and it is frequently others

who initiate a call to a medical professional for

acute stroke care. 

New approaches to instilling a higher 

sense of urgency around stroke symptoms are

needed. The best approach will be one that 

communicates messages designed to translate

5

Improving the Chain of Recovery for Acute Stroke in Your Community
knowledge into action. The most effective tactics

to achieve this goal, however, are often debated.

No single promotion and advertising campaign 

is effective in all environments. Whether the

approach is soft or hard edged, the nature of 

the problem calls for more emphasis on the 

call-to-action behavior and the emergency 

nature of stroke symptoms.

One important strategy may be to specify 

possible determinants of these behaviors. From 

a social cognitive perspective, these determinants

include knowledge of exactly what to do and 

how to do it (behavioral capability); confidence 

in one’s ability to do the behaviors (self-efficacy);

and belief that response to stroke symptoms 

will result in a better outcome (positive outcome expectation). Further, the bystander 

probably has to surmount the social discomfort of intervening in response to someone 

else’s symptoms. Finally, the public should 

have some access to vicarious reinforcement 

(seeing others rewarded for taking action) by 

an affirmative response from transport and 

emergency department professionals.

Who is Responsible?

All stakeholders in acute stroke treatment bear 

the responsibility of leadership. Responsibility 

for getting stroke patients to the hospital in 

time for acute stroke therapy is therefore 

shared by patients, their families, doctors, 

nurses, hospitals, and insurance companies, 

as well as by governmental agencies. A dual

approach — one from national organizations 

and one from the grass roots level — is required

to accomplish these goals. Grass roots efforts

should focus on advocating for increased funding and developing local education programs 

and systems. Health care providers and their 

facilities can use their position of responsibility 

to serve the public and to work toward improving the health of all community members. They

should offer the best available therapies to all

their citizens and reach out to them in an 

active manner. It is not enough simply to 

have a protocol in place for treating patients 

who are eligible for acute stroke therapy. 

National organizations such as the 

NINDS and its partners can take a leadership role in developing initiatives, influencing policy, and providing funding. Directors 

of specialty care and governmental departments of public health/national policy 

should work to infuse a sense of importance 

into stroke care and a sense of urgency about 

its execution.

A sense of partnership and shared responsibility is most likely to provide a platform for

progress and advancement in the short term. 

To be successful, strong central leadership 

has to have widespread support from all 

stakeholders. An informed public can do 

much by demanding better care as well as 

actively participating in a system of organized

stroke care. Once a hopeful outlook is engendered, it is expected that earlier recognition 

of symptoms will bring more patients to the 

hospital for treatment. The creation of hope 

in each community is necessary for any system 

to provide care. Each member of the health 

care community bears responsibility for 

transmitting the message that successful 

treatments for stroke exist.

Generating a sense of importance, developing a language, and continually transmitting 

a hopeful outlook are the fundamental forces 

to be created, tailored to each community, and

guided to successful conclusion. The public,

health care providers, facilities, and agencies 

of education, government, and organized 

medicine all share responsibility for providing the benefits of stroke care to each citizen.

The cost of a sustained public and 

professional educational program will be 

substantial. Funding for such programs will

require support from public, private, and 

non-profit organizations.

6

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
Integration of the Community and 

Health Care Providers

The interaction and integration of the public 

with health care professionals is a key step

towards improving the recognition of and the

response to stroke. This requires an intricate 

communication chain between health care

providers, health care office personnel, pharmacists, emergency medical personnel, all 

other allied health providers, and the public. 

In addition, worksites and public education 

facilities such as schools should be included 

as important forums for educating the public

about rapid response to stroke.

Ideally, health care providers screen 

individuals for risk factors that could lead 

to cerebrovascular disease and use this opportunity to teach their patients about prevention. 

It is also incumbent upon health care providers 

to make maximum use of patient interactions 

as a venue for education about acute stroke, its

symptoms, and the need for emergent action. 

The office setting, including the waiting area, 

provides one potential environment in which 

the public may be educated in this regard. 

While waiting to see a provider, patients who 

are already interested in their own health may

learn from posters, videos, and other available

teaching materials. Although this may not be 

an efficient strategy for primary prevention in 

a relatively healthy population, it might be 

quite effective in patients with risk factors for 

vascular disease, those with pertinent family 

histories, and those with prior TIA or stroke. 

All of the vital stroke messages can be delivered 

in this setting, with encouragement to discuss

these issues in greater detail with the health 

care provider at the actual visit. In effect, 

this approach also allows for patients to 

motivate office-based health care providers 

to educate them.

Medical office personnel are often the 

first to receive a patient call about an acute 

problem such as a stroke. As such, the staff 

can significantly facilitate or obstruct emergent

care. In the acute setting of a phone call from 

a patient (or family member) who may be 

suffering a stroke, these staff serve in the same

capacity as emergency medical services dispatchers. Health care providers must educate their 

staffs about the key stroke messages, most 

importantly the need to call 911. Simple tools

such as an answering machine in a primary 

care physician office that directs patients who 

call regarding stroke-like symptoms to call 

911 may give the right message to the right 

person at the right time.

Pharmacists play a potential role in 

augmenting patient awareness and modifying patient behavior, as they often provide 

supplemental information that reinforces 

prior learning from the health care provider. 

This supplemental information could be 

expanded to include stroke messages when 

appropriate. This could occur by direct conversation, but could also be communicated 

by including printed information in, or 

actually printed on, the pharmacy bags.

Since the advent of acute stroke therapy, 

significant resources have been focused on 

educating the emergency medical services 

community and emergency department personnel about the time-critical nature of stroke

treatment. Emergency medical services and 

emergency department personnel can also 

play a critical role by altering the behavior 

of patients and hospital-based health care

providers. For example, upon arrival at the 

scene, emergency medical services could 

inform the patient (and/or family) that the 

diagnosis may be stroke and that rapid evaluation and treatment could dramatically help.

Information (both verbal and written) could 

be provided immediately to the patient and/

or family to initiate the urgent educational

process. Further, upon arrival at the hospital,

7

Improving the Chain of Recovery for Acute Stroke in Your Community
emergency medical services could accelerate 

the reaction of the health care providers by 

asking specifically if the patient is eligible to

receive acute stroke treatment. 

Communication can also flow from the 

public to health care providers. Patients expect

that they will receive the most appropriate care 

at every hospital. However, they could catalyze 

the action of triage personnel and health care

providers by asking explicitly for “immediate

treatment with the best appropriate therapy 

for me,” or even asking emergency medical 

services to take them to the “best hospital 

for stroke.” 

The Cost-Effectiveness Issue

There is a paucity of data on the cost 

effectiveness of public and professional 

educational programs. Although we do not 

have adequate data to say that expenditures 

to advance the public’s awareness of stroke 

are cost effective in reducing morbidity or 

morality from stroke, this should not prohibit

public health action. The costs associated with 

the disability and rehabilitation from stroke 

are staggering, both in individual suffering 

and in financial terms. Designing and implementing initiatives that increase the likelihood

that persons experiencing stroke-like symptoms

will obtain medical care in a timely manner 

is a public health strategy that has sound 

backing from a chronic disease secondary 

prevention perspective. 

Measuring Success 

More than 600,000 Americans suffer stroke 

each year, but few directly benefit from the 

acute treatments available. One goal should 

be for patients to immediately recognize and

respond to stroke. We recommend a target 

of increasing the percentage of stroke patients 

arriving at the hospital within 3 hours to 50 percent by 2008 and to 70 percent in 2013. The 

success of efforts to improve public response

should be measured in the numbers of stroke

patients arriving early at emergency departments, not only in the number of patients 

treated with thrombolytics. Other intermediate

measures of success are needed to guide the

refinement and implementation of effective 

education programs.

Special Populations

Public recognition of stroke must include each

and every segment of the population. Certain 

segments may be most vulnerable to suffering 

a stroke, while others may require specialized 

educational interventions. In addition to highrisk patients with traditional cardiovascular risk

factors, other groups such as minority groups,

women, elderly adults, children, and rural 

populations require special focus. Furthermore,

different populations have different educational

needs and capabilities. The messages to each 

target group must be culturally sensitive and 

delivered through means tailored to each group. 

If a public education message reflects that group’s

perspectives and customs, it is more likely to be

well received and to translate into behavioral

changes, which will subsequently lead to a 

reduction in death and disability from stroke.

Children

A long-term strategy for improving rapid 

recognition of stroke includes enhancing 

health education for children and including 

the time-urgent nature of stroke along with 

strong primary prevention. This may serve as 

a basis for lifelong knowledge about stroke 

prevention and treatment. It may also enable 

children to activate the emergency health care 

system if a family member suffers a stroke.

8

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
Women

More women than men die each year of 

stroke. Women are more likely to present 

with so-called non-traditional stroke symptoms, such as an altered level of consciousness 

or confusion, pain, or disorientation. Since 

these signs and symptoms are not usually 

associated with stroke, women must be 

particularly vigilant so that whenever they 

experience any stroke symptoms, they 

immediately seek medical attention. 

Minority Groups

Certain minority groups are at particularly 

high risk for suffering acute stroke. The frequency of stroke and stroke-associated mortality is higher in blacks and Hispanics than 

in non-Hispanic whites. Concerted educational

efforts must be targeted toward these groups 

in a way that is supportive, culturally appropriate, and empowering. While the goals and 

overall message of public education for stroke

recognition are homogeneous, in order for 

the messages to be effective they must be 

delivered to many diverse groups in our 

society in a language that is understood 

by the intended audience.

Conclusions

The Public Recognition Task Force members 

make the following recommendations:

 To improve rapid recognition of stroke, 

a multilevel intervention (sponsored in 

a collaborative fashion by health care 

organizations, communities, and 

government) is needed.

 Key stroke messages should be intense 

and sustained. 

 Knowledge of symptoms alone is not 

sufficient to improve patients’ rapid access 

to care. Education must combine knowledge

and motivation for an immediate response 

to stroke symptoms.

 The target audience for improved knowledge

and elevated motivation for action should 

be defined as all members of the public, 

not just individuals at high risk of stroke.

 Special attention for such interventions

should be given to high-risk groups.

 Areas for additional research that should

focus on demonstrating efficacy of healthbehavior interventions include:

– Cost effectiveness

– Sustainability

– Outcomes

– Reaching special populations

References

1 Evenson K, Rosamond W, Morris D. Prehospital 

and in-hospital delays in acute stroke care.

Neuroepidemiology 2001;20: pp. 65-76.

2 Alberts MJ, Perry A, Dawson DV, et al. Effects of

public and professional education on reducing 

the delay in presentation and referral of stroke

patients. Stroke 1992;23: pp. 352-356.

3 Morgenstern LB, Staub L, Chan W, et al. Improving

delivery of acute stroke therapy: the TLL Temple

Foundation Stroke Project. Stroke 2002;33: 

pp. 160-166. 

4 Pancioli AM, Broderick J, Kothari R, et al. Public

perception of stroke warning signs and knowledge 

of potential risk factors. JAMA 1998;279: 

pp. 1288-1292.

5 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: pp. 2591-2596.

9

Improving the Chain of Recovery for Acute Stroke in Your Community

Choosing Your 

Level of Care

Choosing Your Level of Care

t 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

T ASK FORCE REPORT

Choosing Your Level of Care

Andy Jagoda, M.D.

Task Force Chair

Mount Sinai Hospital

New York, New York

Arthur M. Pancioli, M.D.

Task Force Co-Chair

University of Cincinnati

Andrew W. Asimos, M.D.

Carolinas Medical Center

Charlotte, North Carolina

William G. Barsan, M.D.

University of Michigan Health System

Ann Arbor

Kevin Baumlin, M.D., F.A.C.E.P.

Mount Sinai School of Medicine

New York, New York

William Dalsey, M.D.

Kimball Medical Center

Blue Bell, Pennsylvania

Kathleen A. Delaney, M.D.

University of Texas Southwestern Medical Center 

at Dallas

Edward Goldman, J.D.

University of Michigan

Ann Arbor

Margaret Gradison, M.D.

Duke University Medical Center

Durham, North Carolina

Markku Kaste, M.D., Ph.D.

Helsinki University Central Hospital

Finland

Walter J. Koroshetz, M.D.

Massachusetts General Hospital and 

Harvard Medical School

Boston

Thomas G. Kwiatkowski, M.D.

Long Island Jewish Medical Center

New Hyde Park, New York

Marc Mayberg, M.D., F.A.H.A.

Cleveland Clinic Foundation

Robert M. McNamara, M.D.

Temple University Hospital

Philadelphia

C. Crawford Mechem, M.D.

University of Pennsylvania

Philadelphia

Daniel Morelli, M.D.

Millard Fillmore Suburban Hospital

Williamsville, New York

Hal Unwin, M.D.

University of Texas Southwestern Medical 

Center at Dallas

David Wang, D.O.

OSF Stroke Network

University of Illinois College of Medicine

at Peoria

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

Emory University

Atlanta

I
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.

Definitions

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.

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 evidencebased 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

14

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
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 shortterm 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.

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 

15

Improving the Chain of Recovery for Acute Stroke in Your Community
team, such as time of onset of symptoms, 

co-existing illnesses that can mimic stroke 

(i.e., hypoglycemia), and complicating medications (i.e., 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 communitywide 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.

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 highpriority 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.

16

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
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.

17

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

 Agreements with EMS systems for 

pre-notification.

 24/7 physician-staffed emergency 

department.

 Written care protocols.

 A defined acute stroke team (should 

include emergency department staff).

 A named director of acute stroke 

treatment for the institution.

 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).

 On-site neurosurgical services or 

pre-specified transfer agreements.

 Outcome and quality improvement 

activities.

 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 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 

18

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
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.

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.

19

Improving the Chain of Recovery for Acute Stroke in Your Community
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.

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). 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. Other essential components of a comprehensive stroke system are 

pathways for patient care, patient transfer, and

stroke prevention; interhospital communication;

ongoing assessment and improvement of the

quality of stroke care; and public and professional stroke education.

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 (i.e., 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 crosstraining for after-hours coverage is necessary. 

20

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM
21

Improving the Chain of Recovery for Acute Stroke in Your Community

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-theart 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 

includes 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.

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 
22

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

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.

Conclusions

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.
23

Improving the Chain of Recovery for Acute Stroke in Your Community Table 1 Specialized Medical Services for Patients with Specific Stroke Subtypes Surgery: vascular/ Cerebral Neuroendovascular Intensive care ICU Stroke subtype Stroke expertise neurosurgery angiography intervention or NICU Neurorehabilitation MRI/MRA/CTA/TCD/CNI Subarachnoid a)Guide use of a)Aneurysm To identify: a)Coiling of a)Intensive a)Motor, cognitive, a)CTA to define anatomy hemorrhage neurointensive clipping a)aneurysm(s) aneurysm monitoring for speech/swallowing for neurosurgeon (SAH) care strategies b)Ventricular b)vasospasm b)Angioplasty neurologic change therapy may be and to detect b)Treatment of drainage for c) occlusive and/or direct b)Ventilatory required depending aneurysms neurologic hydrocephalus, or stenotic intra-arterial management of upon degree and b)Serial CT required complications often ventriculo- complications instillation of intubated patients distribution of for detection of peritoneal of vasodilators c) Blood pressure neurologic deficits hydrocephalus, shunt for endovascular for vasospasm control prior to b)Respiratory infarction communicating or surgical aneurysm treatment therapy may c) TCD screening hydrocephalus aneurysm d)“Triple H” therapy be required if for evidence of treatment for treatment of tracheostomy vasospasm symptomatic vasospasm e) Management of elevated intra- cranial pressure Arteriovenous a)Neurologic a)AVM removal a)To identify a)Endovascular a)Ventilatory a)Motor, cognitive, a)MRI often detects malformation assessments b)Hematoma AVM and its embolization management of speech/swallowing flow voids which 

(AVM) with to guide use of evacuation vascular or coil intubated patients therapy leads to diagnosis intracerebral neurointensive c) Ventriculostomy anatomy occlusion of b)Intensive b)Respiratory therapy of AVM in a patient hemorrhage care for secondary feeding vessels monitoring for if tracheostomy presenting with ICH(ICH) hydrocephalus neurologic change b)Serial CT required 

c) Blood pressure for follow-up of 

control mass effect, cerebral 

d)Management of edema, hydrocephalus, 

elevated intra- infarction related

cranial pressure to treatment

(continued)
24

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Table 1 Specialized Medical Services for Patients with Specific Stroke Subtypes (continued)

Surgery: vascular/ Cerebral Neuroendovascular Intensive care ICU 

Stroke subtype Stroke expertise neurosurgery angiography intervention or NICU Neurorehabilitation MRI/MRA/CTA/TCD/CNIBasal ganglia a)Patient a)Hematoma a)To rule out N/A a)Ventilatory a)Motor, cognitive, a)MRI often used as or lobar management evacuation for vascular management of speech/swallowing screening tool to hemorrhage b)Guidance of progressive malformation intubated patients therapy detect abnormal flow

intensive care neurologic or vasculitis b)ICU level monitor- b)Respiratory voids of an AVM

c) Management of deterioration as cause of ing of vital signs therapy if b)MRA or CTA in some

complications b)Ventriculostomy hemorrhage c) Intensive monitor- tracheostomy cases to rule outincluding for secondary in select cases ing for neurologic aneurysmal seizure, brain hydrocephalus deterioration hemorrhage dissectingedema d)Management of into brain

d)Secondary elevated intracranial

prevention pressure

Cerebellar a)Neurologic a)Hematoma a)To rule out N/A a)Intensive monitor- a)Motor therapy, a)MRI to screen for vascuhemorrhage assessment evacuation for vascular ing for signs of speech/swallowing lar malformation as the

to guide most bleeds malformation deterioration due therapy cause of hemorrhageneurointensive greater than as cause in to brainstem b)Respiratory therapy b)DWI useful in distincare 3 cm. in some cases compression and/ if tracheostomy guishing primary

b)Secondary diameter or or hydrocephalus hemorrhage from

prevention if brainstem b)Management of bleed into infarct

compression cerebral edema c) In posterior fossa MRIand/or c) Respiratory support is superior to CT in

b)Ventriculostomy in event of inability defining brainstem

for obstructive to protect airway or compressionhydrocephalus central respiratory d)Serial CT to follow 

failure for hydrocephalus

Brainstem Guide complicated a)Emergent a)To assess a)Intra-arterial a)Intensive monitor- a)Motor, cognitive, a)MRI/DWI necessaryand/or decision-making decompressive patency of thrombolysis for ing for neurologic speech/swallowing to chart degree and cerebellar regarding: cerebellectomy vertebral and patients with deterioration requir- therapy distribution of infarcinfarction a) cause of infarction for brainstem basilar arteries otherwise fatal ing neurosurgical, b)Respiratory therapy tion (CT performs

b)advisability for compression due which are basilar occlusion endovascular or if tracheostomy poorly in the 

intravenous or to cerebellar parent vessels b)Angioplasty of medical intervention posterior fossa)

intra-arterial swelling of the vertebral or basilar b)Ventilatory support b)CTA/MRA/TCD thrombolysis and/or cerebellar stenosis in patients often necessary due necessary to identify 

c) anti-coagulation b)Ventriculostomy arteries with concomitant to pt’s inability to vascular stenoses/

for prevention of for obstructive (MRA and severe vertebro- protect airway or occlusion in progressive basilar hydrocephalus CTA often basilar flow ischemia of primary vertebrobasilarthrombosis or adequate) impairment respiratory centers arteriesartery to artery threatening

embolus basilar occlusion
25

Improving the Chain of Recovery for Acute Stroke in Your Community

Surgery: vascular/ Cerebral Neuroendovascular Intensive care ICU 

Stroke subtype Stroke expertise neurosurgery angiography intervention or NICU Neurorehabilitation MRI/MRA/CTA/TCD/CNICarotid territory 

Patient manage- a)Emergent carotid a)To assess a)Intra-arterial a)Intensive monitor- a)Motor, speech/ a)DWI and CT perfusion

infarction ment including: revascularization patency of thrombolysis ing for neurologic swallowing therapy demonstrate regions of(internal carotid, a)Decision-making by experienced carotid ter- for major artery deterioration in b)Respiratory therapy ischemic injury in the

middle cerebral, regarding intra- surgeon for pro- ritory vessels occlusion within patients with major if tracheostomy acute periodanterior cerebral 

venous and gressive stroke (MRA/CTA 6 hours of artery stenosis or b)CT, MR (SPECT) perartery occlusion intra-arterial due to carotid and ultra- symptom onset occlusion who are fusion imaging may be

or severe thrombolysis stenosis sound b)Stent/angioplasty candidates for endo- useful in delineatingstenosis) b)Planning b)Brain biopsy are often for carotid vascular, surgical or degree and distribusecondary for diagnosis of adequate stenosis medical intervention tion of abnormal

stroke cerebral vasculitis except for c) Angioplasty for b)Blood pressure sup- cerebral perfusionprevention c) Hemicraniectomy vasculitis) severe symptom- port for patients with c) MRA and CTA 

c) Preventing to prevent death atic intracerebral fluctuating symptoms identify intracanial 

neuro or due to malignant artery stenosis c) Post thrombolysis care vascular lesion

medical brain edema d)Management of d)MRA/CTA/CNI detect complications elevated intracranial extracranial stenosis

pressure in patients e) Serial CT needed to detect

with malignant malignant brain edema,brain edema degree of infarction

Small vessel a)Patient N/A N/A N/A a)Post-thrombolysis a)Motor, speech/ a)DWI often needed toinfarction management care if decision swallowing therapy demonstrate the small

b)Secondary made to treat with deep penetrator infarcts

prevention intravenous t-PA b)MRA /TCD/CTA needed

to rule out underlyingstenosis in Circle of 

Willis parent vessel

Venous sinus a)Patient a)Rarely a)Identify sites a)Cerebral a)Intensive monitor- a)Motor, speech/ a)MR venogram or CT thrombosis management decompressive of venous arteriogram to ing for neurologic swallowing therapy venogram to make 

b)Seizure hemicraniectomy occlusion make diagnosis deterioration diagnosis and follow 

management needed to prevent though b)Intra-sinus b)Management of state of the venous 

c) Management death due to MRV and thrombolysis or anticoagulation sinus

of brain edema brain edema CTV often direct thrombus c) Management of b)DWI often needed to 

d)Secondary substitute removal raised intracranial distinguish venous 

prevention pressure from arterial “infarct”

DWI: diffusion weighted MR imaging. MRA: magnetic resonance angiography, improved sensitivity and specificity by using bolus of intravenous contrast.

CNI: carotid duplex ultrasound. CTP: X-ray computed tomographic cerebral perfusion scan using bolus of intravenous CT contrast.

TCD: transcranial Doppler. Perfusion MR: magnetic resonance cerebral perfusion scan using bolus of intravenous gadolinium.CTA: X-ray computed tomographic angiogram using bolus of intravenous CT contrast. SPECT: single photon emission computed tomography cerebral perfusion scan using radionuclide.
26

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

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Professional Education

Professional Education

he objective of the Professional 

\ Education Task Force Report is to 

outline strategies to motivate physicians, other

health care providers, and health care organizations to learn and apply the principles of acute

stroke care. The report discusses current barriers 

to implementing recommendations for improved

acute stroke care and suggests how to overcome

them by using methods that engage the support 

of local and national organizations in the education process. It also discusses how to improve 

professional education for acute stroke care by

effectively incorporating educational materials

into continuing medical education (CME) programs, medical school and nursing school 

curricula, and residency programs.

Principles of Adult Education

Learning is defined as the acquisition of 

knowledge that leads to a change in behavior.1

To modify the practices of health care providers

responsible for delivering improved stroke care,

the principles of adult education must be incorporated into stroke evaluation and management

educational interventions. These principles are

summarized in Table 1. Most important, adults

must be motivated to learn. Motivation can result

from varied forces, both internal and external. 

The vast majority of health care providers possess

strong internal motivation to assimilate new

information in order to improve the quality 

of care they provide to patients. This internal

T ASK FORCE REPORT

Professional Education 

Patrick D. Lyden, M.D.

Task Force Chair

University of California at San Diego Medical Center

Susan L. Hickenbottom, M.D., M.S.

Task Force Co-Chair

University of Michigan Health System

Ann Arbor

Richard P. Atkinson, M.D.

University of California at Davis

Sacramento

Lisa Davis, R.N., M.S.N.

National Institute of Neurological Disorders and Stroke

Bethesda

Jeremy Golding, M.D.

University of Massachusetts Memorial Health Care System

Worcester

Judith A. Hinchey, M.D.

New England Medical Center

Boston

Kurt Kleinschmidt, M.D.

University of Texas Southwestern Medical Center 

at Dallas

Thomas G. Kwiatkowski, M.D.

Long Island Jewish Medical Center

New Hyde Park, New York

Christopher A. Lewandowski, M.D.

Henry Ford Hospital

Detroit

Colin C. Rorrie, Jr., Ph.D., C.A.E.

American College of Emergency Physicians

Irving, Texas

Edward P. Sloan, M.D., M.P.H., F.A.C.E.P.

University of Illinois at Chicago

Judith A. Spilker, R.N.

University of Cincinnati

Robert E. Suter, D.O., M.H.A.

American College of Emergency Physicians

Irving, Texas

Steven Warach, M.D., Ph.D.

National Institute of Neurological Disorders and Stroke

Bethesda

T
32

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

motivation to improve may be influenced by

major life events or may arise from a perceived

moral imperative to do what is best for the

patient. From a more practical standpoint, 

this internal desire to learn must be strong

enough to successfully compete with other 

time demands placed on people with already 

saturated schedules. On the other hand, external

factors, including direct supervisors, health system administrators, insurance organizations, 

and regulatory agencies, can also be very 

powerful motivators. Pressures from these 

entities can often promote learning even 

when internal motivation is lacking.

In general, adults may not learn purely 

for the sake of learning; they do so because 

they have a relevant use for the knowledge 

or skill being sought.2 Adults also tend to 

prefer learning concepts and principles rather 

than facts, and they are better motivated to 

learn if they can quickly apply what they have

learned.1,3 When new concepts are linked to 

existing knowledge and experiences, such as

through a problem-oriented teaching approach,

learning is enhanced. For example, case studies

focus learning on a common point and provide

opportunities for discussions.1 Adults prefer 

learning settings that involve straightforward

information, a “how to” focus, and singleconcept/single-theory courses.2 Conversely, 

information that is complex or conflicts with 

what is already held to be true is integrated 

more slowly into practice.

Moreover, adults prefer active, not 

passive, curricula that are focused on the 

learner. Thus they often prefer self-directed 

or self-designed learning projects over group

learning experiences, although interaction 

with other learners is still deemed important. 

In group learning sessions, adults want instructors to facilitate learning, not to dominate 

the process.2 Finally, adults like feedback to 

evaluate their own performance.3 Negative 

feedback is accepted more readily if some 

positive feedback is also used. Adults tend to 

take “errors” or bad outcomes personally and 

thus are less likely to try new approaches.2

For health care providers, this may be particularly compounded by the current 

medicolegal atmosphere. 

Inadequacies of Previous Professional

Education Efforts for Acute Stroke

Continuing education, in the form of 

meetings and journals, has been the timehonored method of transmitting new medical

information to practicing medical professionals. To date, most of the professional education

efforts aimed at improving acute stroke care 

have relied on this traditional approach.

Unfortunately, studies have shown that 

most continuing medical education (CME) 

aimed at physicians, usually in the form 

of didactic lectures, results in little if any 

change in physician behavior and practice.4,5

CME can be made more effective, especially 

if it is combined with other techniques to 

promote behavioral change. New information about acute stroke management must 

be conveyed to all those in the medical 

community, but traditional CME needs 

to be altered to recognize the limitations 

of didactic lectures. Table 2 outlines techniques that have been tested and their 

relative effectiveness. 

Table 1 Principles of Adult Education

Adult students —

 must be motivated to learn

 need a relevant use for the knowledge or skill 

being sought

 prefer learning concepts and principles rather 

than facts

 prefer an active curriculum that is learner-based

 like to receive feedback on their performance
33

Improving the Chain of Recovery for Acute Stroke in Your Community

Furthermore, previous educational efforts 

for acute stroke care may not have been well 

targeted. Many national and local stroke education programs have focused primarily on 

postgraduate physician education, but have 

not distinguished between those already familiar with the latest strategies for diagnosis and

management of acute stroke (e.g., neurologists 

or emergency medicine physicians) and those

who may have less exposure to these aspects 

of stroke care (e.g., primary care providers). 

In addition, non-physician learners may have 

different needs. For example, much of the 

current nursing school curriculum is based 

on a “foundational concept” approach. 

Because such curricula are driven by a healthpatterns model, nursing students are provided 

a foundation for providing care to patients 

with impairments in mobility, sensation, 

or communication. While this information 

clearly applies to a stroke patient, it is not 

often presented in the disease-focused model 

that drives continuing education. The portion 

of nursing school curricula that focuses on 

neurological diseases in general is limited, 

varying from 16 hours total for an associate’s

degree in nursing to 24-30 hours total for a 

bachelor’s degree or advanced practice nursing

specialties. As a result, nursing school graduates receive information about care needs 

of stroke patients indirectly at best. Continuing education efforts aimed at nurses should 

include information on disease-specific pathophysiology as an introduction to acute stroke 

care, as well as focusing on factors that have 

been found to effect change in clinical nursing

Table 2 Strategies for Changing Physician Behavior* 

Most effective strategies:

 Reminders (at point of need/services)

 Patient-mediated strategies

 Outreach visits

 Encouragement from opinion leaders

 Multiple, sequenced interventions sustained over time

Moderately effective strategies:

 Audit and feedback

 Educational material

Least effective strategies:

 Formal CME conferences or activities

*Adapted from Davis et al, 1995.5

Table 3 Factors Found to Effect Change in Clinical Nursing Practice* 

Most effective strategies:

 Well-timed education sessions with clinical application of care-specific interventions

 Demonstrations of obvious advantage to patients and positive patient outcomes

 Availability of clearly written agency policy and procedures manuals

 Access to opinions and support of other professionals

 Efforts to bring about changes that are compatible with nursing values

 Availability of simple-to-understand and easy-to-implement guidelines

 Promotion of changes that can be tested and evaluated, that quickly demonstrate results, and that are 

accompanied by effective plans for implementation

Barriers to change:

 Perceived lack of authority to institute changes

 Lack of physician and other administrative support

 Efforts to mandate change without proper training

 Absence of credible justification for change 

*Adapted from Clarke, 1995.6
34

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

practice6 (Table 3). Finally, some type of 

introductory instruction might be needed 

in undergraduate medical education or with 

others not as familiar with acute stroke care. 

Thus, a range of educational efforts is needed, 

and trying to create “one-size-fits-all” stroke 

courses may leave all attendees feeling dissatisfied, as educational expectations and 

needs are not met.

Finally, the content of previous acute 

stroke educational programs may have been 

too focused on thrombolysis to be of value 

to many learners. Because of variability in 

clinical resources, emphasis on this treatment

only may distract learners from retaining stroke

educational messages on the whole. Some physicians or other health care providers may have

very infrequent opportunity to use thrombolysis,

yet could still benefit from education about 

other aspects of acute stroke care. 

Environmental Barriers to Implementing

Professional Education

Over the past decade, there has been an 

explosion in the number of individuals seeking emergency care nationwide. In 2000 there

were 108 million emergency department visits, 

an increase of 17 percent over the number 

of visits in 1997. At the same time, many 

emergency departments are being closed.

Furthermore, many locations are experiencing a significant decrease in the number of 

on-call specialists maintaining a full complement of privileges. Hospital crowding, 

declining financial resources for the provision of health care, and medicolegal issues 

further complicate delivery of medical care.

The current national nursing shortage 

has increased the workload of emergency 

department and hospital nurses, and places 

limits on nurses’ opportunities to leave the 

bedside to attend in-service continuing education events. The nursing shortage has also 

created a deficit of administrative support 

by limiting the number of hospital-based 

educators or clinical nurse specialists and 

others who have traditionally been responsible for presenting innovative practice 

information to the bedside nurse. In times 

of acute staff shortages, most hospital nursing

leadership is focused on keeping beds open 

rather than on effecting behavioral change. 

The impact of these difficulties on the 

ability of a health care system to undertake 

any specialized education initiatives related 

to stroke is evident. This environment would 

not be conducive to special initiatives that 

require focused activity or new approaches 

to learning. 

Improving Professional Education 

for Stroke

Improving the quality and increasing the 

impact of educational interventions for health

care professionals is a worthy goal, as it should

improve acute stroke care and outcomes for 

stroke patients in the long run. While the 

problem is complex, several steps can be 

taken to work toward this valuable goal.

Incorporating Educational Theory 

into Practice

Whatever the method, target audience, or 

content of future educational programs for

improving stroke care, the interventions will 

need to incorporate lessons learned from 

educational theory. In order to maximize 

the potential for success, new interventions 

will need to (a) elucidate and focus on health 

care provider motivation to learn, (b) be relevant to those taking care of stroke patients 

in clinical practice, (c) emphasize concepts 

and principles of stroke care, rather than 

reiterating facts, (d) involve participants in 

active learning, and (e) provide feedback to 

learners. External motivation to improve acute
35

Improving the Chain of Recovery for Acute Stroke in Your Community

stroke care could be generated by garnering

involvement of quality improvement divisions,

marketing departments, or regional peer review

organizations of local institutions. In addition,

physicians and other health care professionals

would be highly motivated to learn about 

acute stroke care if it were an emphasized 

part of the skill set needed in order to practice.

Encouragement could come from employers 

(hospitals or medical groups), professional 

societies (American College of Emergency

Physicians, American Academy of Neurology, 

etc.), or certifying bodies through their various

exams (U.S. Medical Licensing Exam; American

Board of Emergency Medicine; American Board 

of Psychiatry and Neurology; American Board 

of Internal Medicine; American Board of 

Family Practitioners; neuroscience, critical 

care, or emergency nursing organizations; etc.). 

Changing the Approach to 

Continuing Education

Traditional continuing education activities will

need to be modified to include the above concepts. Several factors have been identified as 

most effective in preparing physicians and other

health care providers for change and learning. 

 Providers must recognize the need to change. 

 Educational tools must provide interaction

among learners with opportunities to 

practice the skills learned. 

 Education should use sequenced and 

multifaceted activities.7

Thus, options for improved CME programs on

stroke include the following:

1 Provide material or data that raises awareness of gaps in knowledge or performance.

Motivation to improve knowledge or 

performance can come from audit and 

feedback, benchmarking, registries, or any

technique that demonstrates gaps between

performance and guidelines. Behavior 

must first be measured before it can be 

successfully changed. Assessment of process

and outcomes can be promoted locally. This

may include the development of forms to 

collect specific information and allow feedback on compliance with the recommendations. Means to this end could include:

– Developing web-based, interactive 

individual and system assessment 

tools for stroke. These tools could 

offer case studies with multiple choice

answers and feedback, and downloadable model guidelines, orders, and 

pathways (both in PDF format and 

compatible with PDAs).

– Developing tests of knowledge and 

assessment of clinical practice about 

stroke before didactic lectures.

– Developing benchmarks of care so 

providers and systems can compare 

their practice to “best care.”

2 Provide interactive learning opportunities.

“Interactive” continuing education, requiring some response from the receiver, has

shown the best outcomes in studies of 

physician knowledge and practice patterns.8

Examples include workshops, small discussion groups, and individualized training 

sessions. More extensive use of personal 

computers, PDAs, and the Internet may 

revolutionize the field and make this a 

feasible and cost-effective evolution.9

Some interactive options include:

– Live or video lectures with local/regional/

national leaders who use an interactive

approach, such as a case study review.

– PDA-appropriate content about acute 

stroke management. This could include

information such as decision trees for
36

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

thrombolysis, blood pressure management, glucose issues, discharge medications for secondary stroke prevention, and

atrial fibrillation anticoagulation issues.

– A forum on the Internet for strokerelated management discussion through 

a moderated site (e.g., via the American

Academy of Neurology, the American

College of Emergency Physicians, or 

the American Stroke Association).

– Use of simulated stroke patients and 

mock “stroke codes.”

Self-assessment tools and interactive 

learning materials are under development 

or are available through many organizations, including the American Academy of

Neurology, the American Stroke Association,

and the Foundation for Education and

Research in Neurological Emergencies.

3 Provide sequenced and multimodal activities.

Because health care providers learn in different ways and several factors are involved in

changing behavior,10 the most successful

teaching techniques include using a combination of the methods shown in Table 2.5

Targeting Multiple Audiences 

with Interventions Appropriate 

to Knowledge Level

As noted above, it is important to design 

multifaceted educational programs that include

information targeted to learners from different

disciplines and at different levels of training. 

Since medical students, nursing students, and

medical residents are essentially a captive audience primed for learning, a major goal should 

be improving stroke-related curricula in medical

and nursing schools and residency programs.

Stroke-related components of nursing 

school, medical school, and residency curricula

should be evaluated for their currency and comprehensiveness. Because stroke is the third most

common cause of death in the United States,

physicians in all specialties are frequently confronted with patients at risk for stroke, or who 

are experiencing stroke symptoms. To address 

this medical need the American Academy of

Neurology is preparing a neurology residency 

curriculum with input from all the specialty 

sections of the Academy. Implementation of 

this curriculum, with current stroke information, should be a priority. In addition, national

organizations charged with overseeing undergraduate and graduate education for medicine,

emergency medical services providers, physician

assistants, etc., should incorporate stroke into 

their curricula.

Nursing education in stroke should be

reviewed and updated as follows:

 Undergraduate nursing education should 

be evaluated for content specifically relevant to stroke care across the health 

care continuum.

 Continuing education for nurses needs 

to be developed to effectively integrate 

baseline nursing knowledge of stroke 

care management into the multidisciplinary stroke system approach. For example,

continuing education strategies should

include nursing participation in caseconference discussions with physicians 

and other stroke care providers.

Education for other personnel who care for

stroke patients, including emergency medical 

services providers and physician assistants, should

also be reviewed and updated. Home health providers and those who deliver services to residents

in assisted living, nursing care, and other longterm facilities need specialized education in caring

for a population where pre-stroke functional disability, cognitive impairment, and co-morbidities

are common. This specialized education will help

ensure that this high-risk population is properly

evaluated for stroke symptoms and referred

promptly to hospitals when appropriate.
37

Improving the Chain of Recovery for Acute Stroke in Your Community

Expanding the Content of 

Acute Stroke Education

As noted above, new interventions for 

professional stroke education cannot focus 

only on the delivery of thrombolytic therapy.

Additional aspects of stroke care that need 

to be addressed in educational interventions

might include epidemiology, pathophysiology,

stroke syndromes, emergency care and stabilization, evidence for or against other acute 

therapies (heparin, temperature or glucose 

control, etc.), emerging therapies, diagnostic

workup including CT interpretation, inpatient

care, rehabilitation and recovery, quality of 

life issues, secondary prevention, systems 

of care, and quality improvement.

Moreover, there is a need for the 

development of consistent, easily accessible

“model” guidelines on stroke management 

and prevention for local adaptation and use 

in quality improvement projects. A recent 

study pointed out the variability of advice 

given in national guidelines regarding 

stroke prevention.11 Validated guidelines for 

medical and nursing management of stroke

patients should be developed using simple 

language and “how to” advice. These guidelines should be made available at all point-ofcare sites. Local health care providers could 

adapt these guidelines to fit their needs and 

environment, and quality improvement measurements could be created from them. 

Hospitals and payers could then pursue 

quality improvement in stroke care for their 

communities, tying current knowledge about

stroke management to easily measured hospital quality improvement projects. Potential

measures might include antithrombotic 

therapy use at discharge, proportion of 

ischemic strokes treated with thrombolytics, 

use of early swallowing assessments, and 

use of deep vein thrombosis prophylaxis 

in non-ambulatory stroke patients. 

Overcoming Other Barriers

Other chapters in this book will deal more 

fully with issues of implementing a systems

approach for acute stroke care, navigating the 

current medicolegal climate as it pertains to 

acute stroke care, and developing financial 

incentives for acute stroke care. However, it 

should be noted that these environmental 

barriers play a role in frustrating effective 

education. Behavioral change needs to occur 

within an organization, and organizational 

barriers to change must be removed for education to succeed. A fundamental way to 

begin to overcome organizational barriers 

at the local level is to form teams of health 

care professionals to encourage local implementation of guidelines.12 The use of local 

opinion leaders to deliver seminars has also 

been effective to encourage local change.13

As noted above, national specialty 

organizations, advocacy groups, regulatory 

agencies, and others should be approached 

to aid in the development and implementation of these proposals, to gain institutional 

“buy-in” for acute stroke education and care, 

and also to provide external motivation for 

behavioral change among health care providers.

Institutional motivation to bring about these

changes will be key in a successful educational

intervention. In addition to the desire to provide quality care, institutions can be motivated 

to provide or require professional education 

by ranking, certification, or regulation. These

approaches have been used effectively in 

stimulating overall institutional performance 

as well as specifically for cardiac and trauma 

care.14-17 Ranking institutional performance is

usually a function of a media outlet or advocacy

group. This function is not usually a function of

regulatory agencies, as these agencies view their

role as delineating minimum performance 

or adherence to standards. Promotion of an 

institutional ranking system through stroke 
38

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

advocacy groups and/or a major magazine 

that would take an interest in this area could 

be pursued. Certification systems could also 

serve to motivate institutions. Development 

of stroke center identification, mostly through 

the efforts of the American Stroke Association, could provide further impetus to apply 

current stroke management knowledge at 

hospitals throughout the country. Guidelines 

for the establishment of a “primary stroke 

center” were published in the Journal of 

the American Medical Association in 2000.18

A survey done in Southern California found 

that large numbers of hospitals believed 

they met these criteria, but when actually 

evaluated, a small percentage truly qualified

(Kidwell CS, personal communication, 2002). 

In a competitive health care market, such 

efforts can be expected to attract sufficient 

attention to improve professional education 

and stroke care, and educational materials 

with practical advice on how to develop 

and maintain a stroke center will be useful 

in this process. Finally, regulation is an 

efficient, if onerous, method of promoting professional education, but there are 

currently no examples of nationwide professional education required by regulation. 

Efforts to increase recognition of stroke 

and to compel immediate transport of 

the patient to an emergency department 

might be successful, and a national stroke 

registry is in prototype testing. These 

approaches could be areas worthy of 

further exploration.

Finally, financial support will be needed 

to develop, implement, and evaluate professional education for stroke. Programs for needs

assessment, validation of guidelines, measuring

adherence to guidelines, and assessing the 

effectiveness of educational interventions 

will all need to be supported through 

national funding initiatives.

Conclusions

The Professional Education Task Force members

summarized their recommendations to the 

educational community as follows:

 Develop comprehensive stroke curricula 

targeted at disciplines involved in providing stroke care.

 Deliver professional education in a multimodal, interactive manner, consistent 

with the principles of adult education.

 Increase funding for the development, 

implementation, and evaluation of 

professional education interventions.

References

1 Douglas K, Hosokawa M, and Lawler F. 

A Practical Guide to Clinical Teaching in Medicine. 

New York, Pringer Publishing Company, 1988.

2 Zemke R, and Zemke S. 30 things we know for 

sure about adult learning. Training 1988;25(7): 

pp. 57-61.

3 Whitman N, and Lawrence P. Surgical Teaching:

Practice Makes Perfect. Salt Lake City, University 

of Utah, 1991.

4 Davis DA, Thomson MA, Oxman AD, et al.

Evidence for the effectiveness of CME. A review 

of 50 randomized controlled trials. JAMA 

1992;268: pp. 1111-1117.

5 Davis DA, Thomson MA, Oxman AD, et al.

Changing physician performance: a systematic

review of the effect of continuing medical 

education strategies. JAMA 1995;274: 

pp. 700-705.

6 Clarke HF. Using research to make a difference 

in clinical nursing practice: the Nightingale 

legacy. Child Health 2000, International 

Pediatric Nursing Conference 1995 (http://

classweb.gmu.edu/rfeeg/ichna/clarke.html).

7 Mazmanian PE, and Davis DA. Continuing 

medical education and the physician as a 

learner: guide to the evidence. JAMA 2002;

288: pp. 1057-1060.
39

Improving the Chain of Recovery for Acute Stroke in Your Community

8 Davis DA, O’Brien MA, Freemantle N, et al. 

Impact of formal continuing medical education. 

Do conferences, workshops, rounds, and other 

traditional continuing education activities 

change physician behavior or health care 

outcomes? JAMA 1999;282: pp. 867-874.

9 Wiecha J, and Barrie N. Collaborative online 

learning: a new approach to distance CME. 

Acad Med 2002;77(9): pp. 928-929.

10 Allery LA, Owen PA, and Robling MR. Why 

general practitioners and consultants change 

their clinical practice: a critical incident study. 

BMJU 1997;314: pp. 870-879.

11 Hart RG, and Bailey RD. An assessment of 

guidelines for the prevention of ischemic 

stroke. Neurology 2002;59: pp. 977-982.

12 Cameron C, and Naylor CD. No impact from 

active dissemination of the Ottawa ankle 

rules: further evidence of the need for local 

implementation of practice guidelines. 

CMAJ 1999;160: pp. 1165-1168.

13 Gifford DR, Holloway RG, Frankel MR, et al.

Improving adherence to dementia guidelines

through education and opinion leaders. 

A randomized, controlled trial. Ann Intern 

Med 1999;131: pp. 237-244.

14 Dannenberg AL, Salive ME, Forston SR, et al. 

Board certification among preventive medicine 

residency graduates. Am J Prev Med 1994;10(5): 

pp. 251-258.

15 Gunn IP. Regulation of health care professions. 

Part 2: Validation of continued competence. 

Clinical Forum for Nurse Anesthetists 1999;10(3): 

pp. 135-141.

16 Livingood WC, and Auld ME. The credentialing 

of a population-based health profession: lessons

learned from health education certification. 

J Public Health Manag Pract 2001;7(4): 

pp. 38-45.

17 Parboosingh J. Credentialing physicians: 

challenges for continuing medical education. 

J Contin Educ Health Prof 2000;20(3): 

pp. 188-190.

18 Alberts MJ, Hademenos G, Latchaw RE, et al.

Recommendations for the establishment of 

primary stroke center. The Brain Attack 

Coalition. JAMA 2000;283(3): pp. 102-109.

Templates for Organizing 

Stroke Triage

Templates for Organizing Stroke Triage

ur health care systems need specialized 

physician expertise and in some cases 

above-average diagnostic capabilities with the 

current recommendations for management 

of acute stroke. Specialized care is particularly

important in the use of thrombolytic drugs, 

which ideally should be used by physicians 

with special expertise in acute stroke management and at facilities with organized stroke 

programs. This sentiment is supported by two 

successive articles focusing on the use of intravenous t-PA in stroke, which appeared in the

March 1, 2000, issue of the Journal of the 

American Medical Association. In the first 

article,1 which reported the results of the 

STARS1 study, the participating medical 

centers had well-established stroke programs 

and were in fact chosen from among centers

already enrolled in the ATLANTIS2 study.2

The favorable outcomes in acute stroke patients

achieved by the STARS investigators were comparable to the outcomes from the original NINDS

study, but with a reduction in the incidence of

intracerebral hemorrhage.1 The second JAMA

article presented data gathered from evolving

community programs at 29 mostly non-stroke

center hospitals in the Cleveland, Ohio, metropolitan area.3 In contrast to the STARS study, 

the Cleveland survey revealed a significant

increase in the mortality rate in acute stroke

patients receiving t-PA, with an almost threefold

increase in the intracerebral hemorrhage rate. 

T ASK FORCE REPORT

Templates for Organizing Stroke Triage

David Persse, M.D.

Task Force Chair

Emergency Medical Services

City of Houston

Richard C. Hinton, M.D.

Task Force Co-Chair

University of Texas Southwestern Medical School

Presbyterian Hospital of Dallas

Joe E. Acker III, M.P.H., E.M.T.-P.

University of Alabama

Birmingham

Todd J. Crocco, M.D.

West Virginia University

Morgantown

James V. Dunford, M.D., F.A.C.E.P.

University of California at San Diego Medical Center

James C. Grotta, M.D.

University of Texas Health Science Center 

at Houston 

Anne D. Leonard, R.N., M.P.H.

University of Texas Health Science Center 

at San Antonio

J.P. Mohr, M.D.

Columbia-Presbyterian Medical Center

New York, New York

Paul E. Pepe, M.D., M.P.H.

University of Texas Southwestern Medical Center at

Dallas and the Parkland Health and Hospital System

Michael R. Sayre, M.D.

Ohio State University

Columbus

Jane Wigginton, M.D.

University of Texas Southwestern Medical Center 

at Dallas

Paula Willoughby, D.O.

Emergency Medical Services

Chicago Fire Department

Daniel J. Worman, M.D.

Medical College of Wisconsin

Milwaukee

Judith R. Yates

Healthcare Association of San Diego and 

Imperial Counties

O
44

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

It is important to note that subsequently, when

quality improvement programs were applied 

to the same Cleveland hospitals, outcomes

improved significantly. This reinforces our 

conviction that acute stroke patients need to 

be treated by specialized physicians at designated stroke centers to assure optimal care, 

as well as to provide a safety net for potential 

complications. Furthermore, proper emergency

management of all stroke patients, even those 

not receiving t-PA, prevents complications 

and improves outcomes. Even after delivery 

of specialized care in the acute care setting, 

hospitals supporting a specialized inpatient 

stroke unit have documented an improvement in patient outcomes, as well as the 

added benefit of overall cost reductions.4

These considerations led the Brain Attack

Coalition to propose the establishment of 

stroke centers that could effectively deliver 

this specialized care and possibly duplicate 

the success of the trauma centers.5

This chapter is offered as a guide for 

setting up systems to facilitate delivery of 

specialized stroke care, including emergency 

medical services (EMS), and networks of 

stroke center hospitals. The information in 

this “how to” chapter has been supplied by 

individuals who have experienced first-hand 

the challenges and rewards of establishing 

these centers of excellence. The Appendices 

at the end of this report include additional

resources that may be of use to those establishing a new acute stroke program.

Hospitals should set a timetable of 

1 year following the publication of this document to assess their capacity to meet evolving

standards in order to qualify as a stroke center

and justify the triage of patients for specialized

care. Definitions for primary and comprehensive centers can be found in the Choosing Your

Level of Care section of this book, along with 

suggested requirements. It is important to

acknowledge that not all hospitals have the 

capability or desire to establish stroke programs,

just as many hospitals do not offer a trauma 

program. The decision to organize as a stroke 

center should be strictly voluntary. It is hoped 

that the information from these Task Force 

reports will induce more hospitals to join 

in this national effort and establish stroke 

programs. Hospitals not equipped to safely 

deliver t-PA should not be forced to offer this 

type of treatment to patients at their facility. 

It is expected that these non-participating 

hospitals would decide not to actively attract

stroke patients, and would cooperate with 

community efforts to triage appropriate patients 

to stroke centers. Most larger community hospitals have the proper training and facilities 

to correctly use t-PA, and hospitals that evaluate substantial numbers of stroke patients 

should consider becoming stroke centers.

Getting Started

Usually one or more physicians step forward 

to champion and guide the effort to establish 

a stroke center hospital or network of hospitals.

While not obligatory, such leaders are often 

neurologists. In some cities, emergency physicians have assumed the leadership role in this

regard. A physician leader must be convinced of

the importance of stroke centers as an enhancement to patient care. In addition, there must be 

a commitment to see the process through to 

completion, as there are many challenges and 

success will not come immediately. However,

leaders should be fortified with the knowledge

that the concept of stroke centers is a sound 

one, and that with perseverance success will 

usually follow. At a local level, the leader or 

stroke director will have the responsibility 

of transforming his or her hospital into a 

facility capable of quickly evaluating and 

treating stroke patients. At a network level, 
45

Improving the Chain of Recovery for Acute Stroke in Your Community

participating hospitals must be organized 

into an efficient system that provides access 

to specialized stroke care for all or most of 

the population in a community. 

The project cannot succeed without 

enlisting the assistance and support of many 

other interested parties, and it is important for 

the leadership to identify those likely to be 

helpful and those likely to benefit from the 

formation of stroke centers. These might be 

called stakeholders. At a hospital level, planning and execution must be a joint effort 

between physicians and hospital administrators. However, on a community-wide basis, 

other stakeholders might include medical 

societies, hospital councils, stroke survivors, 

people at risk for stroke in the community 

at large, state and national organizations, and

political bodies. At any level, the EMS system 

is an integral part of the process. The EMS system includes dispatch agencies, first responder

agencies, transport agencies, and medical control physicians and hospitals. Training programs

for EMS providers and dispatchers are essential.

Also, much thought and effort must be applied 

to designing a seamless communication link

between EMS provider groups in the field, 

hospital emergency departments, and acute 

stroke teams. In some cases a dispatch service 

provides this link and directs the transport 

according to pre-established algorithms.

Local Hospital Stroke Center Development

Physician Buy-In

It is usually important for the stroke director to

recruit other physicians to join in and shoulder

the responsibility of care. Considerations here

include arranging a stroke call schedule, as well 

as forming a stroke team. Depending on the 

size of the hospital, the stroke team might 

consist of neurologists, emergency medicine

physicians, radiologists, neurointerventionalists,

neuroradiologists, internists, and neurosurgeons.

A non-physician stroke coordinator, usually a

nurse or physician assistant, is also an extremely

important addition to the stroke team. These 

individuals may help with clinical responsibilities as well as data collection and outcome 

monitoring. It is always advantageous to have a

neurologist perform a neurological assessment

early in the process and to be closely involved 

in making the complex decisions regarding 

treatment. However, this is not always possible,

and other willing physicians must be trained 

to assess the patient neurologically, with phone

consultation from a neurologist if possible.

Emergency physicians are usually the first 

physicians to examine the patient and are 

sometimes the only physician initially involved.

Their complicity and partnership in the stroke

program is of course essential, and these physicians must be thoroughly familiar with the 

established emergency procedures and treatment guidelines, including transfer procedures, 

for stroke. Radiologists must be available to 

interpret imaging studies on an emergency 

basis. More advanced treatment is available 

at comprehensive centers, including interventional neuroradiology and up-to-date 

neuroimaging capabilities such as digital 

angiography. Patients with stroke frequently 

have significant underlying medical conditions, and emergency availability of internal 

medicine consultation is invaluable. Finally, 

neurosurgical expertise is called for in cases 

of subarachnoid hemorrhage, intracerebral 

hemorrhage, and thrombolytic-related 

hemorrhages. At other times, other specialty 

consults, such as cardiology, will be necessary. 

Tips for Obtaining Physician Buy-In 

Physicians may be reluctant to participate 

in the stroke team and to extend themselves 

on an emergency basis. This is particularly 

true of neurologists, whose practices are 

often office-based. Points to consider 
46

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

when recruiting neurologists include 

the following:

 Of all the specialties, neurologists are 

most capable of accurately assessing the

stroke patient and making the tough 

treatment decisions that are sometimes

required. Their input is very important 

for the delivery of quality care. It may 

be important to remind reluctant 

neurologists of this, and this realization might persuade them to make 

their expertise more available in the 

interests of patient care. 

 If the availability of neurologists on a 

hospital staff is limited, bedside emergency

consultations on a continuous basis may 

not be feasible. In this case, the emergency

physicians must develop expertise in 

stroke evaluation. 

 Radiology expertise may not be available 

on a continuous basis at some hospitals, 

and of course this is essential. However, 

the essentials of CT reading sufficient 

for t-PA patient selection can be learned 

by non-radiologists, especially neurologists,

neurosurgeons, and emergency physicians.

Teleradiology arrangements have in many

cases circumvented this obstacle, and 

remote interpretation of radiological 

tests is now very common. 

 If the barrier to physician participation 

is not a manpower issue, but is strictly 

the inconvenience of receiving an emergency call, hospital medical boards may 

apply pressure by requiring emergency 

call participation as a requirement for 

hospital staff privileges. 

 If a hospital is truly committed to 

attaining distinction as a stroke center, 

a hospital stipend for physicians agreeing to take emergency stroke calls can 

be an attractive incentive. For instance, 

it is not uncommon for hospitals to 

provide some financial incentive to 

surgeons involved in trauma calls.

 Convincing physicians that timely and 

quality acute stroke care, even apart from 

t-PA, results in improved outcomes will

encourage their participation.

 “Commando” systems are difficult to 

maintain. Ensuring appropriate financial 

and logistical support, adequate staffing, 

and renewal by training of younger stroke 

clinicians should help encourage and 

support the health care professionals 

involved in such efforts. 

Hospital Administration Buy-In 

An initial reticence from hospital administration is not unexpected, and it is important 

for stroke leaders to see the endeavor through 

the eyes of the administrators. Implementation of a stroke program at a hospital requires

considerable effort on the part of the hospital, 

as well as some expenditures. Upgrades to 

diagnostic imaging equipment may, in some 

cases, be necessary. Staffing of stroke services 

in many hospitals is not 24/7, thus hospital

administration may be faced with additional

staffing costs. In addition, t-PA itself is an 

expensive drug. Ideally, a stroke unit or 

neuro-ICU would be available, and this requires considerable allocation of resources.

Outcome monitoring is an important part 

of any stroke program, and continuing 

medical education must be provided for 

all involved. Creating a stroke program is 

no small task for a hospital. Nevertheless, 

with patience and tenacity, the hospital 

will often see the value to the institution 

and its patients and make the decision 

to become a partner in this. 
47

Improving the Chain of Recovery for Acute Stroke in Your Community

Tips for Obtaining Hospital Buy-In 

 Hospitals with large medical staffs and

advanced diagnostic capabilities are usually

able to offer specialized care in many fields. 

It is in keeping with their position in the

community for them to include excellence 

in stroke care in the services they offer, 

particularly if they wish to consider their 

institution a center of excellence. This 

argument may carry some weight in 

discussions with hospital administrators. 

 For all hospitals, the formation of a firstrate stroke program may enhance their 

image in a community, increase patient 

volume, and improve patient outcomes.

 The procedures developed for a hospital

stroke program often result in cost savings 

by reducing length of stay and minimizing

medical complications.4

 Increased staffing costs and functions 

may, in some cases, be shared with other 

programs, for example, x-ray technicians 

can be trained to operate CT scanners. 

 The members of the board of trustees may

have an ambitious long-range vision for 

the hospital and may, by virtue of having 

a keen sense of responsibility to the community, be very helpful to the stroke 

program effort.

Stroke Center Systems Serving 

a Community

Providing more complete access to expert 

stroke care for patients in a geographical 

area requires close cooperation between 

physicians and administrators of the participating hospitals. The following suggestions 

may be helpful to those leaders planning 

to establish a community-wide coalition 

of stroke centers.

 A steering committee or stroke council 

should be formed by the founding 

physicians and hospitals to oversee and 

monitor the activities of the network.

Representatives from all participating 

EMS provider agencies must be included 

on the committee as well. It is also prudent to include other stakeholders such 

as the local medical society, hospital 

council, etc. 

 In designing the triage transport system, 

the steering committee should make 

every attempt to offer services to all 

neighborhoods in a community.

 A quality assurance program should 

be in place to measure performance 

by participating hospitals and EMS 

provider agencies. 

 Outcome data should be shared among 

the participating hospitals and EMS 

providers; this will require resolution 

of any confidentiality issues. 

 An important function of the steering 

committee would be the development 

of basic qualifications for hospitals 

wishing to participate. The guidelines 

established by the Brain Attack Coalition 

might serve as a starting point.5 An 

invitation should go out to all hospitals 

in the community, and any hospital 

should have the opportunity to join 

in the effort at any time, provided it is 

sincere in attempting to comply with 

the standards established by the steering 

committee. The decision to become a 

part of the network should be a joint 

decision between the committee and 

the hospital candidate. The committee 

does, of course, have a responsibility 

to insist that the participating hospitals 

meet certain basic requirements in the 

interests of patient care.
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

 Non-participating hospitals should 

understand that transport of patients 

to a stroke center within the first few 

hours of symptom onset is unlikely 

to have a financial impact on them. 

This is because the percentage of 

stroke patients presenting within a 

short time of onset of symptoms is 

relatively small. 

 EMS providers are usually willing 

participants. They do need reassurance 

that patients transported to stroke centers 

will receive prompt and specialized care. 

It is important to involve them as much 

as possible in the planning stages, as 

they can offer helpful suggestions in 

the design of the triage system.

 All EMS provider agencies should have 

an opportunity to participate at any time 

if they are willing and able to comply 

with the policies established by the 

steering committee.

 EMS providers, through community 

education programs, can help dispel 

reluctance and embarrassment about 

calling 911.

 Opposition to the plan may come from 

hospitals, physicians, or sometimes other

groups. It is important to have open discussion with these dissenting voices, 

since the objections are often based 

on misunderstandings. 

 It is critical to obtain the endorsement 

of the local medical society or other 

physician representative organizations. 

These bodies usually recognize the value 

of stroke centers and are likely to offer 

enthusiastic support. They are particularly useful in neutralizing political 

obstacles among physicians and hospitals. If the medical society is firmly 

behind the effort and considers the 

idea an enhancement to patient care, 

it is more difficult for hospitals or 

individual physicians to erect barriers. 

 The American Heart Association has 

long been behind this national initiative 

and the local chapter can be a helpful 

catalyst in launching stroke center networks. The Association will soon introduce a new product, the Acute Stroke

Treatment Program, designed to guide 

hospitals through a step-wise process 

for establishing primary stroke center 

operations. The Program is based on 

and complements the recommendations for the establishment of stroke 

centers published in 2000.5 The 

organization also hosts educational 

activities and promotes community 

awareness of stroke symptoms. The 

National Stroke Association is also 

a useful resource.

 At a national level, organizations such 

as the American Academy of Neurology 

and the American Medical Association 

can urge Congress to allocate funds for 

the founding of stroke centers. 

 Media coverage is helpful, but only 

after the network is working smoothly 

and efficiently.

 Finally, organized stroke survivor groups 

may be helpful in lobbying efforts with 

various groups including hospitals 

and physicians.

EMS Stroke Triage Policies

Stroke Center System 

Coordination/Oversight

The key to effective stroke center/system 

development and implementation is to 

identify or create a single entity responsible 

for organizing the stroke system. The entity
49

Improving the Chain of Recovery for Acute Stroke in Your Community

should have the ability to cross geopolitical 

lines and coordinate all participants: 911 

centers, EMS response agencies, medical 

control physicians, and hospitals. The entity 

may be an organization already in existence 

or may be created for this sole purpose. 

The entity must be viewed as neutral to 

all parties and receive its policy direction 

from the steering committee. 

911 Call Center

Emergency medical dispatch and call-taking 

has improved greatly over the past decade.

Standards exist for emergency dispatching, 

there is a National Standard Curriculum in 

place, and there are several dispatch accrediting

agencies. Integral to effective stroke care is early

identification of potential stroke patients and 

subsequent prioritization of the dispatch. Most

EMS call-taking protocols allow for the caller 

to report what they believe the patient’s problem may be. While some callers may be astute

enough to correctly report that the patient is 

having a stroke, many stroke patients will 

initially be reported as being the victim of a 

fall or having altered mental status, diabetic 

problems, or cardiac problems. It is unrealistic 

to expect call-takers to accurately identify all

potential stroke patients. However, sophisticated call-processing protocols generally 

include key questions designed to identify 

potentially critically ill patients. These questions usually pertain to whether or not the 

patient is awake and breathing or speaking 

normally. The uniform use of these key 

questions for all reported emergencies 

allows the dispatch center to identify 

potentially seriously ill patients, including 

stroke patients, even if the caller misidentifies the patient’s actual medical problem.

When a caller reports that the patient’s 

problem may be a stroke, the prioritization

scheme of the dispatch center must reflect the

time-dependent nature of stroke care. Just like 

dispatches to patients with serious trauma 

or acute myocardial infarction, dispatches 

to potential acute stroke patients must be 

given high priority, above less critical and 

less time-dependent emergencies.

EMS Assessment of the Patient

Several studies have demonstrated that 

emergency medical technicians and paramedics are able to identify acute stroke 

patients with relatively good reliability. 

Prior to any specific stroke-identification 

training, San Francisco Fire Department 

paramedics correctly identified 61 percent 

of acute victims. Following a 4-hour training program on stroke and instruction on 

how to administer a modified NIH Stroke 

Scale, they correctly identified 91 percent of 

acute stroke victims.6 Other large EMS systems,

including those in Los Angeles, Cincinnati, 

West Central Florida, Birmingham, Houston, 

and Dallas, have designed prehospital acute 

stroke evaluation tools for use by their 

emergency responders (Appendix A).

Each of these stroke-screening processes

includes a brief and simple physical exam. 

The Cincinnati Prehospital Stroke Scale (CPSS)

consists of observation for a unilateral facial

droop when the patient is asked to smile; arm

drift from a position of the arms being held 

out in front; and slurring of words, use of 

incorrect words, or inability to speak when 

asked to repeat the phrase “you can’t teach 

an old dog new tricks”.7 The Los Angeles

Prehospital Stroke Screen (LAPSS) consists 

of a physical examination that evaluates 

smile, arm drift, and grip as well as five 

inclusion criteria (exclusion questions concern age, duration of symptoms, glucose 

level, and history of seizures).8 The LAPSS 

proved to be very accurate, with a sensitivity 

of 91 percent, a specificity of 97 percent, a 

positive predictive value of 86 percent, and 

a negative predictive value of 98 percent.9
50

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

In addition to the physical exam, each of

these prehospital stroke scales inquires about 

specific details of the patient’s medical history.

One of the most important parts of the history 

for the EMS caregiver to ascertain is the exact 

time of symptom onset. Paramedics and emergency technicians should be trained to use all

available information sources to determine 

as exactly as possible when the patient’s symptoms started. Patients are often unable to provide the time of onset as they have become 

confused or are frightened about what is 

happening to them. Family members or

bystanders may remember what events were

occurring when the patient began to develop

symptoms. This type of information can be 

used to help them recall the time of symptom

onset. A useful tool is to ask the bystanders 

what was on the television or what meeting 

had just started when the symptoms began.

Whenever possible, it can be helpful to bring 

family members and/or witnesses of the acute

event with the patient. This allows physician 

and nursing staff to obtain further historical

details and to address issues of consent and

advanced directives.

If there is a history of seizure disorder, 

and in particular if the patient has had a 

seizure in the past 24 hours, the diagnosis 

may be Todd’s paralysis rather than stroke.

Another co-morbidity to be considered is 

hypo- or hyperglycemia in diabetic patients. 

In addition to the rapid recognition of 

a possible stroke, EMS workers can benefit 

their patient by providing supplemental oxygen,

intravenous access, and cardiac monitoring while

expediting rapid transport to the nearest stroke

center. The intravenous fluid of choice should 

not include dextrose as it is well recognized 

that elevated levels of glucose are potentially

harmful to at-risk cerebral tissue. Hypertension

should not be treated in the field because it

heightens the risk of hypoperfusion to the 

penumbra. The patient should be transported 

in a laterally recumbent position on the affected

side to protect the affected limb, provided this

does not cause any respiratory compromise.

Finally, giving early notification to the destination hospital can be extremely beneficial 

by allowing health care personnel more time to

mobilize the necessary resources for patient care.

Decision-Making for Destination Selection

Once a patient is recognized as being a probable

acute stroke patient, the decision must be made 

to transport the patient expeditiously to the most

appropriate pre-identified hospital. Essential 

to the success of such a program is that the 

prehospital personnel know, with little or no

delay, which facilities are able to appropriately

care for the patient. In Houston, a criterion for

hospital participation in the stroke care system 

is resource availability 24 hours a day, 7 days a

week. In Dallas, on the other hand, four stroke

center hospitals are available but participate in 

a rotational system on a weekly basis. Regardless

of the system used, two important features must

exist: (1) the system should be easy to understand, and (2) EMS providers should routinely

and reliably know which hospital is the appropriate facility to receive the patient.

In the setting of rural prehospital care, 

it may be especially difficult to maintain a 

rotational system due to the time and distance

variables that this would involve. Additionally,

web-based hospital status systems may be 

difficult to maintain due to funding issues 

and the diversity of institutions that could 

potentially be involved. Consequently, innovative approaches may need to be adopted. For

example, expanding the role of EMS dispatchers

may allow confirmation of the destination hospital. After determining that an acute stroke 

has probably occurred, EMS personnel in rural

areas could recruit dispatch personnel to confirm a hospital’s availability and suitability to

receive the presumed stroke patient. Communication over long distances can be difficult 
51

Improving the Chain of Recovery for Acute Stroke in Your Community

from the field. For this reason, rural EMS systems should consider having their dispatch 

centers communicate patient care issues to the

destination hospital. This has the added benefits 

of (1) providing the receiving hospital with 

more time to mobilize necessary resources, 

(2) allowing time for alternative arrangements 

to be made during times of hospital crisis or

unavailability, and (3) determining bypass of

unavailable hospitals rather than relying on 

time-consuming transfer processes. This might

include air-medical transport.

As hospital and ED overcrowding continues 

to be an active issue for emergency care systems,

contingency plans must be developed by EMS 

and hospital providers. For example, if a participating stroke care hospital has determined 

the need to request diversion of incoming 

emergency patients due to ICU overcrowding,

does this affect the hospital’s ability to care 

for a new stroke patient? Many stroke patients,

even those receiving t-PA, do not require ICU 

care and can be managed in specialized intermediate care settings. Diversionary status for

stroke patients should be determined locally 

and independently of other diversionary conditions. EMS providers must have a way of 

knowing if a stroke care facility can continue 

to accept potential acute stroke patients if the

intended receiving facility has requested ICU

diversion. The same pre-planning must occur 

for ED diversion requests, trauma diversion

requests, etc. Also, how are EMS providers 

to react if all stroke care hospitals are at full 

capacity? Are they to take the patient to a nonstroke care hospital or are all the stroke care 

hospitals to be considered open and acute 

stroke patients divided among each of them 

in a rotation? The steering committee should 

also consider provisions relating to patients’ 

personal preferences about hospital destination.

In today’s health care financial landscape, patients

often find themselves unsure of the impact on

health care coverage if they are not taken to an 

“in-service” hospital. EMS care providers need 

to be adequately educated on this issue in 

order to correctly advise patients.

One city that has implemented such a 

system and measured the impact is Houston. 

Prior to the implementation of an EMS stroke

triage program, a local group of university-based

neurologists coordinated an aggressive stroke

treatment program in four EDs. Supported by 

an American Heart Association grant, each hospital in the city was asked to participate in the

program. Six of 29 invited hospitals agreed 

to share quality improvement data and offer 

acute stroke care 24 hours a day, 7 days a week.

Paramedics were then trained how to identify 

possible acute stroke patients using a stroke

screening tool. Prior to the start of the program, 46 percent of all acute stroke patients 

were being transported to one of four original

centers covered by the University of Texas stroke

team, with 50 percent arriving less than 2 hours

after symptom onset. After the paramedics 

were trained in the stroke screening assessment,

70 percent of all apparent acute stroke patients

were transported to one of the six stroke center

hospitals. The University of Texas team continued to cover the original four hospitals, 

and two new hospitals were added with their 

own in-house stroke teams. The most common

reason for a possible acute stroke patient to be

transported to a non-stroke center hospital was

patient insistence on transport to the non-stroke

center hospital. As a result of this effort, doorto-needle times decreased from a mean of 

68 ± 28 minutes to 54 ± 11 minutes across all 

six centers, and the proportion of stroke patients

receiving t-PA increased from 7.4 to 10.8 percent.

Model Systems for Stroke Response

One of the goals of this document is to provide

models for communities wishing to improve 

the care available to patients with acute stroke. 

A number of different locations across the 
52

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

United States have developed systems that 

address many of the issues identified as inhibiting effective emergency response to these patients.

Urban Settings

Change is occurring too slowly for many 

patients. Some communities may find it helpful to identify elements from the following

descriptions of stroke response systems that 

may be good models for them.

Houston

Area Leadership Team

In 1999, James Grotta, a neurologist at the

University of Texas Medical School in the 

Texas Medical Center, received a grant from 

the American Heart Association to develop 

a regional stroke system. The grant was titled 

“Can Paramedic Education Improve Stroke

Outcome?” The specific aim was to determine 

if a program of paramedic education, including

the identification of designated stroke center 

EDs, would result in improved urgent stroke 

management. The program was a collaborative effort between the stroke teams at the two

Houston medical schools — University of Texas

and Baylor — and the Houston Fire Department

EMS. The grant paid for a study nurse to recruit

hospitals to participate and help develop the 

paramedic and ED educational programs, and 

it provided funds to develop a paramedic educational program focused on acute stroke 

recognition and triage. Limited funds for 

hospital staff education were also provided. 

There were only two conditions for 

hospitals to join the system. The hospital had 

to offer advanced stroke care 24 hours a day 

every day, and it had to collect patient outcome

information and allow the study nurse to verify

quality improvement processes. All 29 hospitals 

in the area were invited to join the system. Six

agreed to participate. The organizers of the 

system tried, with limited success, to recruit 

hospitals to achieve a geographic balance. 

The local chapter of the American Stroke

Association’s Operation Stroke program 

endorsed the system. All area hospitals had 

representatives on the Operation Stroke task 

force, which included a variety of different 

professionals such as neurologists, emergency

nurses, and emergency physicians. Participating

EDs received recognition from this group as 

designated stroke centers, and recognition was

given to paramedics who brought to stroke 

centers two or more patients who got treated. 

An evening program with stroke survivors was

orchestrated by the American Stroke Association chapter and was attended by stroke center 

ED nurses, paramedics, EMS directors, and the

University of Texas and Baylor stroke teams. 

Receiving Hospital Designation System

Many hospitals that wanted to participate 

found they were unable to do so since they 

did not have the internal resources to collect 

data on numbers of patients treated, process 

control variables (door to CT time, etc.), and

patient outcome information. In some hospitals, emergency physicians wanted to participate but neurologists were not available 

for 24/7 coverage. 

Of the six hospitals that participated, 

two were the home hospitals of the two 

medical school stroke teams (Hermann and

Methodist). At three large community hospitals

(St. Luke’s, Memorial Southwest, and Memorial

Northwest), a hybrid system had been developed

during the NINDS study in which University 

of Texas stroke team neurologists responded 

to treat patients. In one remaining hospital, 

an internal stroke team, coordinated from 

the ED, responded to treat patients.

During the term of the American Heart

Association grant (1999-2002), the study nurse

verified the capabilities of the participating hospitals. After the grant ended, the Operation 

Stroke task force assumed that responsibility.

There is a well-organized system for collecting

process and outcome information from the 
53

Improving the Chain of Recovery for Acute Stroke in Your Community

six participating hospitals, including times 

to treatment, the proportion of stroke patients 

treated, and the accuracy of stroke assessment 

by EMS personnel.

EMS Triage Policy

The Houston Fire Department transports acute

stroke patients to whichever hospital the patient

or family designates, but paramedics routinely

encourage acute stroke patients to go to one 

of the six stroke treatment centers. The Houston

Stroke Scale, a variation of the LAPSS, is used 

to identify potential fibrinolytic treatment candidates. Paramedics call the medical control 

system when they recognize a possible candidate, and the paramedic at medical control 

pages the stroke team at the destination hospital.

Early stroke recognition and the stroke scale

was taught to paramedics during the first year 

of the grant, and the training is routinely reinforced at least twice yearly by the University 

of Texas stroke team at regularly scheduled 

meetings of all paramedics. 

Receiving Hospital Response System

The response system in each of the six hospitals

varies. In two hospitals, there is an internal 

stroke team and a neurologist responds to 

the ED to assess the patient. In those hospitals,

the emergency physicians are taking on increasing responsibility for assessing patients and 

initiating fibrinolytic therapy without a bedside

assessment by the neurologist. In three large 

community hospitals, the neurologist from the

University of Texas at Houston travels to the 

ED to assess the patient. Within each hospital,

there are specific systems to mobilize the CT 

scanner and other support services.

Cincinnati

Area Leadership Team

In the mid-1980s an emergency physician,

William Barsan, and a neurologist, Thomas Brott,

who worked at the University of Cincinnati

College of Medicine began to collaborate 

under the mentorship of a senior research 

neurologist, Charles Olinger, to develop an 

emergency treatment for stroke. They decided 

to develop a regional stroke response team. 

The key idea was that the clinical researcher 

who was going to be enrolling a patient into 

the t-PA stroke trial would travel to the patient

instead of having the patient travel to the medical center. Choosing that approach defused 

potential political opposition. Although the 

strategy added complexity for the researcher, 

it simplified emergency treatment of acute 

stroke patients. 

This single regional team, called the 

Greater Cincinnati Northern Kentucky Stroke

Team, was founded in 1987. Team members 

met with area neurologists to allay any concerns they might have about the program. 

The community neurologists were pleased 

that the patients would largely be cared for 

at community hospitals by the stroke team 

physicians for the first 24 hours and then 

have their care handed over to the communitybased neurologists. The team was available 

24 hours a day to assess and potentially treat

patients with acute stroke in EDs of any 

hospital in the metropolitan area. 

The Cincinnati stroke team researchers 

also obtained approval from institutional 

review boards at each of the receiving hospitals for clinical trials including the NINDS 

dose escalation and randomized trials. Once 

the original NINDS t-PA stroke trial ended 

and the results were known, the stroke team 

continued its commitment to patient care 

and began using t-PA to treat eligible patients 

outside the research process while still responding to more than 17 community hospitals in 

the region. The core group of treating clinicians

includes stroke-trained neurologists and emergency physicians who share call duties equally. 

A major advantage of this system is that a small

group of clinicians gains extensive clinical experience treating patients with acute stroke. 
54

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

The stroke team also holds weekly case 

review and quality improvement meetings in

which patient cases from the previous week are

discussed and new team members are trained 

in acute stroke treatment. Another benefit is 

that the emergency physician at the community

hospital never has to decide which neurologist 

the patient’s primary care physician wishes to 

use since there is only one group of clinicians

treating patients in the entire region. A single 

telephone number is used to access the system

from any hospital at any time, simplifying the

process for activating the team.

The team provides EMS agencies with a 

mechanism to activate the response system 

in which EMS contacts the regional on-line 

medical control at the university hospital and 

asks to have the stroke team paged for a patient.

The treating paramedic provides as much detail 

as possible about the stroke, including the time 

of onset, when known, and the estimated time 

of arrival at the receiving hospital. Then the 

medical control physician pages the stroke 

team and also notifies the receiving ED.

Receiving Hospital Designation System

Hospital participation is voluntary, and 

all acute care hospitals within the greater

Cincinnati area, with the exception of the 

Veterans Affairs Medical Center, participate. 

A de facto two-tiered treatment system has 

developed. In the base tier, patients are treated

with intravenous fibrinolytic therapy and then

remain at the community hospital for subsequent care. If the patient is thought to need 

specialized care such as intra-arterial treatment 

or the community hospital staff is not comfortable maintaining the patient after administration 

of intravenous fibrinolysis, then he or she is 

transferred to one of the two hospitals with 

stroke units.

Patients who are brought to the EDs by 

their families rather than EMS comprise about 

40 percent of the acute stroke patients in the 

area. They are cared for using the same system 

as patients who arrive by EMS. However, the 

system response for patients brought by family

members is not as efficient as it is for patients

brought by EMS, primarily because without 

EMS participation no real advance notification 

of the system takes place. On the other hand, 

the distributed delivery model developed by the

Cincinnati stroke team means that all patients,

regardless of their choice of hospital, will have

access to intravenous fibrinolytic therapy.

There is an ongoing epidemiologic study 

of stroke patients in the Greater Cincinnati 

area that measures a number of patient outcomes. Recently, stroke team researchers shared

data collected through the Ohio Paul Coverdell

National Acute Stroke Registry with all participating institutions and the community at large.

EMS Triage Policy

Local EMS agencies generally take patients to 

the hospital chosen by the patient or family 

members, unless that hospital is on ED diversion. Acute stroke patients are not routed 

preferentially to any particular hospital. The 

paramedics use mobile telephones to contact 

the local medical control physician at the 

university hospital or to make direct contact 

with the receiving hospital. Depending on 

the clinical status of the patient, the stroke 

team may be notified about the case before 

the patient arrives at the ED so that the stroke 

team physician can begin to respond to 

that hospital.

Receiving Hospital Response System

A neurologist or emergency physician who is 

a member of the stroke team responds to the 

ED upon the request of the treating emergency

physician. While responding to the hospital, 

the stroke team physician uses his or her 

mobile phone to mobilize hospital resources. 

The mobile telephone is programmed with 

the telephone numbers for various hospital

departments such as CT and pharmacy. The 

ED staff is also integral to the process and 
55

Improving the Chain of Recovery for Acute Stroke in Your Community

is responsible for making a room available 

in the ED and notifying the CT technician 

that an acute stroke patient is arriving.

After the patient is assessed in the ED and 

the decision whether to treat with fibrinolysis is

made, the stroke team physician communicates

with the emergency physician and admitting 

neurologist. The stroke team physician will 

usually stay involved in the care of patients 

who receive fibrinolytic therapy for the first 

24 hours of hospitalization. After that initial 

period, patient care is the responsibility of 

the patient’s primary care physician and 

consulting neurologist.

Dallas

Area Leadership Team

In 1999, Richard Hinton and Hal Unwin, 

neurologists and members of a stroke committee of the local chapter of the American Heart

Association, began an initiative to establish 

a regional stroke response system in Dallas. 

James Atkins, then medical director of the 

Dallas EMS system, assisted them in this effort.

Presentations were made to various groups 

including the Dallas County Medical Society

(DCMS) and the Dallas-Fort Worth Hospital

Council. Eventually, all potential physician 

and hospital participants were invited to a 

meeting hosted by the DCMS. 

After receiving approval from the DCMS 

and enthusiastic support from EMS, all hospitals 

in the region were then invited to actively participate in a stroke center network. The purpose

was to provide access to expert stroke care for 

all patients in the Dallas County region. Four 

hospitals agreed to participate in this Dallas 

Area Stroke Network, and a rotational arrangement for the participating hospitals was established with the help of Paul Pepe, current 

medical director of the Dallas Metropolitan 

BioTel (EMS), and Ray Fowler, deputy medical

director for operations of BioTel and its EMS 

base station. A Dallas Area Stroke Council 

was formed to oversee this network. The council 

is composed of physicians and administrators

from the participating hospitals, with representation from BioTel, the DCMS, and the American

Heart Association. The network became operational on August 1, 2002. An open invitation

remains to any other hospital in the Dallas 

area wishing to participate. 

Receiving Hospital Designation System

There are four hospitals that are prepared 

to receive acute stroke patients from the 

EMS system. Each of these hospitals is a selfdesignated, comprehensive stroke service 

hospital. Two are in the northern part of 

Dallas and two are in the south. Hospitals 

alternate weeks being on-call, with one hospital in the north and one in the south on-call

each week. Then the other two hospitals take 

call for a week, although all four hospitals 

can care for acute stroke patients at any time.

Membership in the system is voluntary 

and other hospitals are still encouraged to 

join the network. According to their own 

stated capabilities, each of the four hospitals 

has a comprehensive stroke service. 

EMS Triage Policy

Paramedics quickly assess the patient with 

a short stroke scale, developed by Paul Pepe, 

to identify patients with possible stroke. If the 

last time the patient was known to be normal 

was within 31/2 hours of the arrival of the medics,

then the patient is considered for transport to 

a stroke service hospital. The 31/2-hour window 

was chosen in order to allow the opportunity 

for intra-arterial thrombolysis (available at all 

the participating hospitals under experimental

protocols) for patients presenting after the 

3-hour window for intravenous t-PA. As soon 

as the medics identify a patient fulfilling these 

criteria, the patient is given the choice of being

transported to a stroke service hospital or another

hospital. If the patient wishes to go to a stroke

service hospital, the paramedics contact the
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

regional base station (BioTel). BioTel confirms

with the EMS crews which hospital is on-call 

and prepared to receive the patient. In turn, 

the BioTel staff notifies the receiving hospital,

which then notifies its own stroke team. Even 

if the stroke service hospital is on EMS diversion because of overcrowding, stroke patients 

are not diverted.

Receiving Hospital Response System

Each of the four treating hospitals maintains 

its own acute stroke treatment team, available 

on a continuous basis regardless of their rotational status at any particular time. In most 

of the facilities, the stroke team membership

includes an emergency physician, a neurologist, 

a neuroradiologist, and an internal medicine 

hospitalist. Neurosurgery consultation is also

available on a continuous basis, if necessary.

Smaller Cities

Ann Arbor

A different treatment model is functioning 

in Ann Arbor, Michigan. Stroke research physicians at the University of Michigan developed 

a unique system for supporting emergency 

physician administration of fibrinolytic therapy 

at a number of hospitals in southern Michigan

without requiring the stroke expert physicians 

to travel to those hospitals. A system like this

could cover a large geographic area.

Area Leadership Team

Phillip Scott and William Barsan, both 

emergency physicians at the University of

Michigan, pioneered this approach in March

1996. Initially, the participating hospitals 

were four teaching hospitals affiliated with 

the University of Michigan.

A treatment guideline was developed with 

features specific to each of the participating 

hospitals. The guideline had a number of 

components such as inclusion and exclusion 

criteria for t-PA administration in acute stroke,

blood pressure control parameters, informed 

consent documents, dosing charts, and standard

ICU order sets. Emergency physicians, nurses, 

and other staff at the hospitals were trained to 

use the guidelines. All of the treating emergency

physicians were board certified in emergency 

medicine and the majority were members of the

teaching faculty at the University of Michigan/

St. Joseph Mercy Hospital emergency medicine

residency. Regional stroke team members were

available for emergency telephone consultation,

but contact with the team was initiated at the 

discretion of the treating emergency physician. 

CT scans were interpreted in real time by 

radiologists at each of the treating hospitals.

Receiving Hospital Response System

Membership in the program is voluntary. Since

this is a distributed system, all patients are able 

to be cared for whether they come to the hospital

by EMS or private vehicle; about 30 percent of 

the treated patients come by private car. During

the initial 18 months of the program, about 

60 percent of the treated patients received 

either an in-person or telephone neurology 

consultation before treatment was initiated.

This system has the advantage of developing under the auspices of a regional stroke

research team, and therefore outcomes were 

measured. One-year mortality among the first 

124 patients treated in this distributed system

between March 1996 and April 2001 was 27 

percent, which is equivalent to the 24 percent 

1-year mortality in the NINDS trial cohort.

Birmingham

Area Leadership Team

The process of organizing stroke care began in

1997 when Camilio Gomez, a neurologist, and

Joe Acker, executive director of the Birmingham

Regional Emergency Medical Services System

(BREMSS), agreed to serve as co-chairs of a 

stroke task force sponsored by the local chapter 

of the American Heart Association. Neurology,
57

Improving the Chain of Recovery for Acute Stroke in Your Community

emergency medicine, EMS, hospital administration, nursing, public health, politicians, 

and stroke survivors were all at the table. After 

the task force developed the plan, which covered

the six-county Birmingham, Alabama metropolitan area, it was approved by the local American

Heart Association chapter, the Birmingham

Regional Hospital Council, and other groups. 

The plan then became a part of the BREMSS

Regional Medical Control Plan which was 

adopted by the Alabama Committee of Public

Health. One key to achieving success was the

inclusion of stroke survivors on the committee.

Their presence served to inhibit economic selfinterest behavior by some participants.

Receiving Hospital Designation System

The system includes all hospitals that are 

willing to participate. Participating hospitals 

sign a contract with BREMSS. To be strokeready a hospital must have current availability 

of ED, x-ray, operating room, stroke ICU bed, 

neurologist, CT scan, and neurosurgeon (or 

transfer agreement). Each hospital notes its 

current availability within a computer network,

which is updated every 3 minutes or less. This

provides the hospital the availability to determine “stroke readiness” based upon available

resources. Twelve of 19 hospitals have been 

verified by a multidisciplinary site review 

team to receive stroke patients from EMS.

EMS Triage Policy

EMS routes patients only to stroke-ready 

hospitals unless the patient requests another 

hospital. EMTs use the Stroke Observation 

Scale (SOS) triage system to identify stroke

patients. The EMT then communicates with 

the Trauma Communication Center (TCC) 

and relays information on the patient. The 

TCC informs the EMT of the currently available

stroke hospitals. The EMT, in conjunction with 

the patient, chooses a destination hospital. The

chosen hospital is notified by TCC and a copy 

of the stroke patient report is electronically 

sent to the receiving hospital. An education 

program and a train-the-trainer process educated more than 2,500 EMTs and personnel 

from all EDs in the region. 

The BREMSS performs quality improvement

and reviews system, hospital, and prehospital 

performance. Through their contract with 

BREMSS, participating hospitals provide the

required outcome and process data. A feedback

loop to the EMT who placed the patient in the

stroke system and the TCC communicator who

handled the call is also performed. Each EMT 

and communicator learns the outcome for 

each patient entered in the stroke system.

Stroke patients who arrive at a hospital 

ED by non-EMS means are not entered into the

stroke system. However, if a non-participating

hospital initiates an interhospital transfer, the

stroke system assists with this process.

Receiving Hospital Response System 

Each of the 12 hospitals that receive patients 

from the stroke system has its own internal 

stroke team that is responsible for the care of

acute stroke patients within that institution.

Rural Settings

Morgantown

Area Leadership Team

The rural area surrounding Morgantown, 

West Virginia, has developed an effective 

stroke treatment system. The champion of 

the system was David Libell, who serves as 

director of the Comprehensive Stroke Unit 

at West Virginia University (WVU). WVU’s 

primary teaching hospital is Ruby Memorial,

which is a large tertiary care center and the 

only university hospital in the state.

Receiving Hospital Designation System

Within the city of Morgantown, there is only 

one other hospital. Patients who arrive at that

hospital with symptoms suggestive of acute 

stroke are routinely transferred by ground 
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

ambulance approximately 1 mile to the WVU

Medical Center. Participation in the system is 

voluntary. Ruby Memorial Hospital spent about

$250,000 on a marketing campaign during the

year 2000 to inform the public and rural hospital

personnel that acute stroke treatment was available. When a patient with acute stroke arrives 

at a rural hospital, the referring emergency 

physician contacts medical control for the air

medical service to facilitate patient transfer. 

The referring emergency physician speaks 

with the emergency physician on duty at Ruby

Memorial to verify that the patient is possibly a

candidate for either intravenous or intra-arterial

stroke therapy. About two-thirds of the stroke

patients cared for at Ruby Memorial arrive by

ground EMS, while 17 percent are delivered 

by air medical transport, 15 percent are brought 

by friends or family, and 2 percent have some

other mode of arrival.

There is no organized system for verification of stroke treatment capability at hospitals 

in West Virginia. There is a stroke unit at Ruby

Memorial Hospital, and there is a hospitalbased stroke care committee that includes 

representatives from hospital administration 

as well as all disciplines caring for stroke 

patients during the entire hospitalization. 

The committee meets quarterly and reviews 

quality improvement activities. Reports from 

the hospital are made available to EMS.

EMS Triage Policy

Paramedics generally use either the Cincinnati

Prehospital Stroke Scale or the LAPSS to identify

patients with acute stroke. These patients are 

then transported to Ruby Memorial Hospital. 

If the patient or family insists on transport 

elsewhere, they will be accommodated if the 

facility is within reasonable distance. The paramedics contact medical control at Ruby Memorial

about a potentially treatable stroke patient. The

medical control paramedic activates the stroke

response system if there is an obvious stroke. 

The medic can consult the emergency physician

on duty to get advice as needed.

Receiving Hospital Response System

Calling a single pager number sets off a group 

of pagers and activates the stroke team. Pagers 

are carried by the emergency medicine attending

physician, an ED charge nurse, a stroke neurology

attending physician, a pharmacist, laboratory 

personnel, the CT technician, and a “stat” nurse.

In the mid-1990s, a telemedicine demonstration project was in place for about a dozen

hospitals throughout West Virginia. John F. 

Brick, who is chairman of the department of 

neurology at WVU, championed this effort.

Medical professionals at WVU can use the 

system to evaluate patients remotely using 

cameras and audio equipment. Histories and

physicals can be performed using the system.

While CT scans can be read remotely using 

the system, acute stroke patients have not 

been treated using this system alone. Since 

this technology infrastructure remains in 

place, its increased role in the remote management of acute stroke patients is targeted 

for further study. 

Summary

The task force envisions the development 

of local, and eventually state and national, 

guidelines for stroke care delivery, including 

prehospital stroke care. In anticipation of 

these developments, this document has been 

created to help communities begin to pursue

these goals. 

The task force urges that, within 1 year 

of publication of this document, each community should: 

 Evaluate its stroke care system capabilities

regarding:

– Public awareness of the signs and 

symptoms of stroke
59

Improving the Chain of Recovery for Acute Stroke in Your Community

– Prioritization of potential stroke 

patients within EMS dispatch 

protocols

– Training of EMS professionals in 

recognition and treatment of stroke

– Uniformity of prehospital stroke 

care protocols among all EMS 

provider agencies

– Uniformity of transportation 

algorithms and destination 

protocols for stroke patients

– Identification of hospital resources 

regarding stroke care 

 Identify or create a community 

organization to implement and 

oversee the stroke care system. 

 Ensure competency for all components 

of the EMS system and participating 

hospitals in assessing and treating 

patients with acute stroke.

 Prioritize dispatch of acute stroke 

patients similar to that assigned to 

patients with major injury and acute 

myocardial infarction. 

 Develop triage protocols for preferential

stroke patient transport (including interhospital transfers) to designated stroke 

center hospitals. 

 Collect, analyze, and share EMS and 

stroke center hospital data among 

participating EMS systems and hospitals 

for purposes of quality improvement 

and patient outcome. 

 Develop local guidelines for stroke 

care delivery, including prehospital 

stroke care. 

References

1 Albers G, Bates V, Clark W, et al. Intravenous 

tissue-type plasminogen activator for treatment 

of acute stroke. Standard Treatment with Alteplase

Reverse Stroke (STARS) study. JAMA 2000;283: 

pp. 1145-1150.

2 Clark WM, Wissman S, Albers GW, et al.

Recombinant tissue-type plasminogen activator

(Alteplase) for ischemic stroke 3 to 5 hours 

after symptom onset. The ATLANTIS study: 

a randomized controlled trial. JAMA 1999;282: 

pp. 2019-2026.

3 Katzan I, Furlan A, Lloyd L, et al. Use of 

tissue-type plasminogen activator for acute 

ischemic stroke: the Cleveland area experience.

JAMA 2000;283: pp. 1151-1158.

4 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.

5 Alberts MJ, Hademenos G, Latchaw RE, et al.

Recommendations for the establishment of 

primary stroke centers. JAMA 2000;283: 

pp. 3102-3109.

6 Smith WS, Corry MD, Fazackerley J, et al. 

Improved paramedic sensitivity in identifying 

stroke victims in the prehospital setting. 

Prehosp Emerg Care 1999;3: pp. 207-210.

7 Kothari RU, Pancioli A, Liu T, et al. Cincinnati 

prehospital stroke scale: reproducibility and 

validity. Ann Emerg Med 1999;33: pp. 373-378.

8 Kidwell CS, Saver JL, Schubert GB, et al. Design 

and retrospective analysis of the Los Angeles 

Prehospital Stroke Screen (LAPSS). Prehosp 

Emerg Care 1998;2(4): pp. 267-273.

9 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.
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

APPENDIX A

Prehospital Stroke Screening Systems from Different Communities

 Cincinnati Prehospital Stroke Scale

Assess for the unilateral presence of at least one of the following:

Item Description

Facial droop Ask the patient to smile. Watch for weakness on one side of the face.

Arm drift Ask the patient to hold both arms out with palms up and eyes closed for 10 seconds.

Watch for a drift of one side. A positive result is present if there is weakness in one arm.

Weakness in both arms or normal strength is a negative test result.

Slurred speech Ask the patient to repeat a simple sentence such as “The sky is blue in Cincinnati.”

Inability to repeat the words correctly and intelligibly is a positive result.

 Los Angeles Prehospital Stroke Scale

Criteria Yes Unknown No

1 Age > 45 □□□

2 No history of seizures □□□

3 Symptoms < 24 hrs □□□

4 Not wheelchair-bound or bedridden at baseline □□□

5 Glucose 60–400 □□□

Assess symmetry in facial movement, hand grip, or arm strength

Normal Right Left

Facial smile/grimace □ □ Droop □ Droop

Grip □ □ Weak □ Weak

□ None □ None

Arm strength □ □ Drifts □ Drifts

down down

□ Falls □ Falls

rapidly rapidly

Yes No

6 Based on exam, patient has only unilateral weakness □ □

Items 1-6 all Yes or Unknown, then LAPSS criteria are met. If LAPSS criteria are met, then call the receiving

hospital with a “code stroke”; if not, then return to the appropriate treatment protocol. (Note: the patient

may still be experiencing a stroke even if the LAPSS criteria are not met.) From 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: pp. 71-76.
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Improving the Chain of Recovery for Acute Stroke in Your Community

 Dallas Area Stroke Council Stroke Evaluation Sheet

Yes No Unknown

1 Age 18 years old or older? □□□

2 Symptom(s) onset 3.5 hours or less? □□□

3 Are any of the following symptoms present? □□□

a) Facial droop e) Sudden abnormal speech

b) Sudden asymmetry in neurological exam f) Sudden imbalance in walking

c) Weak grip or loss of grip g) Acute arm and/or leg weakness

d) Arm drift h) Sudden loss of vision

If the answers to questions 1, 2, and 3 are all “yes,” the patient is considered to be having an acute stroke

event under this protocol. If the answer to any of these 3 questions is “no” or “unknown,” then the patient

should be transported to the closest appropriate facility or to the hospital of the patient’s choice.

 BREMSS Stroke Observation Scale

Level of consciousness Alert – 0

Requires stimulation – 2

Visual function No deficit – 0

Any deficit – 2

Facial function Symmetrical movements upon smiling – 0

Any lateralization – 2

Arm/leg movements Normal symmetry – 0

Arm or leg weaker than contralateral – 2

Verbal function Normal communication skills – 0

Abnormal articulation or language content – 2

Entering a patient into the Stroke System

1 Call the Trauma Communication Center (TCC) as soon as practical.

2 Identity yourself and your agency by name and number. If on-line medical direction is necessary, the

receiving stroke hospital becomes medical direction. TCC will help coordinate on-line medical direction

with a physician immediately.

3 Give location and request any additional resources needed.

4 Give age and sex of patient (patient name is not necessary).

5 Give criteria of entry.

6 Give vital signs — BP, P, R, GCSS or AVPU, glucometer reading.

7 TCC will offer available stroke hospitals based on information given above.

8 Give transportation type/provider.

9 Give PCR number and time of transport.

The receiving stroke hospital should be updated by the transporting unit 5–10 minutes out. This update

need only consist of any patient changes and patient’s current condition. A repeat of information used to

enter the patient into the stroke system is not necessary, as this information will be relayed by the TCC to

the receiving stroke hospital.

After the patient is delivered to the stroke hospital, the transporting provider should call the TCC with

Patient Care Report times.
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

 West Central Florida EMS

STROKE ALERT AGENCY________________

Date:_________/Time:__________ Rescue Unit #:_____________ Age_________ Male: □ Female: □

Pt. Name __________________________________________ Incident #________________________________ 

CINCINNATI STROKE SCALE (FAST)

(check if abnormal)

□ F-(face) FACIAL DROOP: Have patient smile or show teeth. (Look for asymmetry.)

Normal: Both sides of the face move equally or not at all.

Abnormal: One side of the patient’s face droops.

□ A-(arm) MOTOR WEAKNESS: Arm drift (close eyes, extend arms, palms up).

Normal: Remain extended equally, or drifts equally or does not move at all.

Abnormal: One arm drifts down when compared with the other.

□ S-(speech) “You can’t teach an old dog new tricks” (repeat phrase).

Normal: Phrase is repeated clearly and correctly.

Abnormal: Words are slurred (dysarthria) or abnormal (aphasia) or none.

□ T-TIME of SYMPTOM ONSET:___________________________________!

EVENT WITNESS NAME_________________ Cell Phone_____________ Home__________ Pager________ 

CLOSEST RELATIVE NAME (if different)____________________________________________________________

Cell Phone _______________________ Home _________________________ Pager ______________________

STROKE ALERT criteria met – Transport IMMEDIATELY. 

Determine if destination facility can handle an acute stroke (see below). 

PERTINENT HISTORY/SYMPTOMS EVALUATION:

SpO2______ % Glucose _____ mg/dl

TREATMENT:

Head Elevation > 30 (unless hypotensive)

IV NaCl (2 sites preferred, draw labs)

O2 @ 2 L/min (unless hypoxic then high flow)

Drug Therapy ______________

Other_____________________

□ Cardiac Arrhythmias

□ Weakness/numbness

□ Dizziness

□ Headache, Nausea/

Vomiting, Neck Pain*

□ Visual Disturbances

□ Other___________

*HEADACHE ONSET: If present, was onset that of a classic “explosive” headache that is the 

“worst of the patient’s life”?: □ YES □ NO (if yes, consider aneurysm) 

Vital Signs: P: _______________ R: _______________ BP: Lt: __________________ Rt: __________________

Destination: Onset < 2hours, Transport to facility capable of IV thrombolytics within 3 hour window

Onset 2-4 hours, Consider transport to facility capable of Intra-cerebral thrombolytics

* For suspected aneurysms or

** When lytics are potentially contraindicated: consider transport (including aeromedical) to Neuroendovascular/

Neurosurgical facility 

Hospital Destination:_____________Time Stroke Alert called:__________

Name of hospital contact person:_________________________________ Time arrived at hospital_________ 

□ Head trauma at onset**

□ Seizure at onset**

□ On Coumadin (Warfarin)**

□ Recent or current bleeding,

trauma, surgery, or 

invasive procedure**

□ Bleeding Disorder**

□ Pregnancy**
63

Improving the Chain of Recovery for Acute Stroke in Your Community

APPENDIX B

Primary Stroke Center Assessment*

Hospital Name________________________________________________________________________________

Address ______________________________________________________________________________________

Patient Care

1 Does EMS pre-notify your emergency department of potential stroke patients?

□ Yes □ No 

If yes, is there a protocol in place to notify the stroke team?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

2 Do you have an agreement with local EMS for consistent transport of stroke patients to appropriate 

hospitals using high priority coding?

□ Yes □ No 

3 Do you have written care protocols (standing orders) for emergency care of stroke patients?

□ Yes □ No 

If yes, are the orders: 

Specific for t-PA? □ Yes □ No

General stroke orders? □ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

4 Are the emergency department personnel trained in diagnosing and treating acute stroke?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

5 Are dedicated, trained, stroke health-care providers (stroke team) available to evaluate a suspected 

stroke patient within 15 minutes of the patient’s arrival 24 hours a day, 7 days a week?

□ Yes □ No

If yes, define the members of your stroke team by specialty:

______________________________________________________________________________________

______________________________________________________________________________________

Comments_________________________________________________________________________________

__________________________________________________________________________________________

* From the Acute Stroke Treatment Program. Used with permission from the American Stroke Association, a division of the

American Heart Association.
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

6 What is your typical “door to needle” time for ALL suspected stroke patients from time of arrival at

emergency department?

□ Less than 60 minutes

□ 60 to 120 minutes 

□ More than 120 minutes 

Comments_________________________________________________________________________________

__________________________________________________________________________________________

7 Is t-PA for stroke patients available in the emergency department 24 hours a day, 7 days a week?

□ Yes □ No

Intravenous t-PA? □ Yes □ No

Intra-arterial t-PA? □ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

8 Does your hospital have physicians experienced in the administration of thrombolytic therapy for stroke

on-site or on-call 24 hours a day, 7 days a week? 

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

9 Is a CT scan or MRI performed and interpreted by an attending or staff radiologist or neurologist within

45 minutes of the arrival of a potential candidate for t-PA therapy 24 hours a day, 7 days a week?

□ Yes □ No 

Comments_________________________________________________________________________________

__________________________________________________________________________________________

Support Services

10 Do you have the following staff available or on call 24 hours a day, 7 days a week? 

Neurologist □ Yes □ No

Neurosurgeon □ Yes □ No

Designated stroke/neuro nurse □ Yes □ No

Diagnostic neuroradiologist □ Yes □ No

Interventional neuroradiologist □ Yes □ No

Designated medical director of stroke unit? □ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

11 Do you have neurosurgical services available 24 hours a day, 7 days a week and ready within 2 hours? 

□ Yes □ No

If no, are you prepared to transfer the patient to a hospital that does?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________
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Improving the Chain of Recovery for Acute Stroke in Your Community

12 Are hospital personnel trained in the National Institutes of Health Stroke Scale (NIHSS)?

□ Yes □ No

If yes, please list staff by specialty (ED Physicians, ED Nursing, etc):____________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

If no, what scale do you use?_____________________________________________________________

12a Are any of those staff (and therefore the ability to use the NIHSS) available 24 hours a day, 7 days 

a week? 

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

13 Are stroke-relevant blood work (coagulation, CBC, basic metabolic panel, etc.), x-ray, and EKG 

completed with results back within 45 minutes?

□ Yes □ No 

Comments_________________________________________________________________________________

__________________________________________________________________________________________

14 Do you operate a stroke unit with written care protocols, continuous telemetry, or ICU staffed by 

physicians and nurses trained and experienced in caring for acute stroke patients? 

□ Yes □ No

If no, are you prepared to transfer the patient to a hospital that does?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

15 Does your hospital have a critical pathway, care-map, or collaborative pathway for stroke patients 

during their inpatient stay? 

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

16 Does your hospital utilize a stroke rehabilitation decision guideline or pathway?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

17 Does your hospital track any of the following in a database or stroke registry?

a. Elements of the stroke timeline for treatment with t-PA:

Door to first physician contact? □ Yes □ No

Door to CT scan read? □ Yes □ No

Door to needle? □ Yes □ No

If yes, what treatments (drugs)?_________________________________________________

b. Number of stroke patients seen □ Yes □ No

c. Type of stroke □ Yes □ No
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

d. Stroke patient outcomes □ Yes □ No

Graded examination □ Yes □ No

Disposition □ Yes □ No

Other — please explain________________________________________________________ 

____________________________________________________________________________

18 Does your hospital provide the following diagnostic procedures?

a. Diffusion imaging MRI □ Yes □ No 

b. MRA □ Yes □ No

c. CT □ Yes □ No

d. CTA □ Yes □ No

e. Cerebral angiography □ Yes □ No

f. Transcranial Doppler □ Yes □ No

g. Transthoracic echo □ Yes □ No

h. Transesophageal echo □ Yes □ No

i. Ultrasound □ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

19 Does your hospital provide the following surgical endovascular procedures?

a. Carotid endarterectomy □ Yes □ No

b. Intracranial balloon angioplasty □ Yes □ No

c. Intracranial stenting □ Yes □ No

d. Extracranial stenting □ Yes □ No

e. Intracarotid balloon angioplasty □ Yes □ No

f. Intracarotid stenting □ Yes □ No

g. Aneurysm clipping □ Yes □ No

h. Aneurysm coils □ Yes □ No

i. Treatment of vasospasm (transcatheter) □ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

20 Does your hospital participate in any of the categories of stroke care programs below?

a. Secondary prevention □ Yes □ No

b. Rehabilitation □ Yes □ No

c. Other □ Yes □ No

If other, please describe__________________________________________________________________

______________________________________________________________________________________

21 When patients are discharged, are they given a standard packet of information and materials and 

counseled about next steps and follow-up?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

22 How long does your hospital track stroke patients after discharge?__________________________________

__________________________________________________________________________________________
67

Improving the Chain of Recovery for Acute Stroke in Your Community

23 Does your hospital provide at least 2 community outreach education programs annually?

□ Yes □ No

If yes, please describe____________________________________________________________________

______________________________________________________________________________________

24 Do you provide a minimum of 8 hours of continuing stroke education for hospital staff annually?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

25 Has your hospital provided a stroke education and training program for staff in the past year?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

26 Does your hospital have continuing education criteria for each member of the stroke team? 

□ Yes □ No

If yes, does this include emergency department personnel?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

27 Does your hospital sponsor a stroke support group?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

28 Do you have telemedicine capabilities (use of remote video technology) to provide stroke treatment in 

your facility?

□ Yes □ No

Comments_________________________________________________________________________________

__________________________________________________________________________________________

Name of person(s) completing the assessment:

Print Name__________________________________________________

Date_____________________ Title_____________________________________________

Indicate all names of persons contributing information; note which responses they provided:

Name/Numbers completed (example: 1,2,3,16,22)

Thank you for taking the time to complete this assessment. 

AHA Contact_______________________________ Phone number_____________________________
68

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

APPENDIX C

Example of Emergency Response Evaluation Form*

Fire department or private ambulance company ___________________________________________________

Total number of EMS personnel ______________

Name of person completing survey ______________________________________________________________

Phone _____________________________ E-mail ___________________________________________

Emergency Medical Calls

Do you receive 911 calls directly? □ Yes □ No

If not, from where do you receive them? _________________________________________________________

Does the public ever contact you directly with medical emergency calls (pertains to private ambulance

companies)? 

□ Yes □ No

Is this a private number or via 911? ______________________________________________________________

Do you require your dispatchers to be trained in Emergency Medical Dispatching (EMD)? 

□ Yes □ No

If no, is your department considering requiring dispatchers to be trained in EMD?

□ Yes □ No

Are you aware of any advocacy efforts to promote EMD funding in your service area?

□ Yes □ No

If yes, please explain. __________________________________________________________________________

_____________________________________________________________________________________________

What are the barriers to implementation, e.g., support, funding?______________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

If someone calls 911 for a cardiac arrest victim, will the dispatcher provide him CPR and AED instructions

over the phone?

CPR □ Yes □ No

AED □ Yes □ No

If someone calls 911 and says that he is experiencing numbness and weakness, will the dispatcher suspect

that he is having a stroke and code this call as a high priority/expeditious transport?

Suspect stroke □ Yes □ No

Code as high priority/expeditious transport □ Yes □ No

* From the Acute Stroke Treatment Program. Used with permission from the American Stroke Association, a division of the

American Heart Association.
69

Improving the Chain of Recovery for Acute Stroke in Your Community

Please provide the name and contact information of the person who is in charge of dispatch. 

_____________________________________________________________________________________________

Are there any other dispatch key-decision makers? □ Yes □ No

If yes, please provide name(s) and contact information. ____________________________________________

_____________________________________________________________________________________________

Addresses

Do some areas of your service area have inappropriate or no address labeling — e.g., route and box 

numbers instead of street names and numerical addresses? □ Yes □ No

Approximately what percentage of your service area has inappropriate or no address labeling? _______%

Has the local governing body considered addressing the issue? □ Yes □ No

What are the barriers to implementation — e.g., support, funding? ___________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please provide the name(s) and contact information for the person(s) who are responsible for appropriate

addressing. ___________________________________________________________________________________

______________________________________________________________________________________________

Defibrillation Capability

1 How many BLS response vehicles do you have? (do not include personal vehicles that a volunteer 

EMT may use) _____

2 How many ALS response vehicles do you have? _____

3 Are you aware of any non-EMS or non-law enforcement vehicles that respond first to a medical 

emergency call? (i.e., a security vehicle at a manufacturing plant or in a mall) □ Yes □ No

If yes, please list and provide contact information.

___________________________________________________________________________________________

___________________________________________________________________________________________

4 What percentage of the time do the following units arrive first to a medical call? 

_____ Fire department ambulance _____ Police

_____ Fire truck _____ Sheriff 

_____ Private ambulance _____ Individual Volunteer EMTs (personal vehicle)

_____ Other, please list. __________________________________________________________________
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

5 Of the following who would be available for a typical call, how many would have an AED available? 

(i.e., 2 of 2 ambulances means all ambulances have an AED; 1of 4 fire trucks means only 1 fire truck 

in the department has an AED)

____of ____ambulances ____of ____police cars

____of ____fire trucks ____of____sheriff cars

____of ____individual volunteer responders (EMTs)

Are there plans to equip all first line ambulances, fire trucks, police and sheriff cars with defibrillators?

□ Yes □ No _____ 100% of first line emergency vehicles are equipped with AEDs

If no, what are the barriers to implementation?__________________________________________________

___________________________________________________________________________________________

Stroke 

1 Do patients with signs and symptoms of stroke receive the same priority response and transport as 

heart attack and other life-threatening emergencies? □ Yes □ No 

2 Do your EMS personnel pre-notify the emergency department of a potential stroke patient? 

□ Yes □ No 

3 Are all of your EMS personnel trained to properly assess for stroke according to the American Heart

Association’s Guidelines 2000 (e.g., use of the Cincinnati Stroke Scale, recognition of stroke signs and

symptoms and establishing time of symptom on-set)? □ Yes □ No

If all are not trained, how many are trained? __________

4 Is your department willing to increase stroke training? □ Yes □ No

5 What is the name of the person who is responsible for EMT training for your department?

___________________________________________________________________________________________

___________________________________________________________________________________________

6 Who conducts EMT refresher training for your department?

_____ Your department _____ MATC _____ WCTC

_____ Other, please list: ______________________________________________________________________
Incentives for 

Enhancing Stroke Care

Incentives for Enhancing Stroke Care

ealth care providers strive to provide 

optimal treatment for their patients.

However, medicine is becoming more complex

and is practiced in a multifaceted environment

that includes an array of potential barriers to

effective acute stroke care. The identification 

of appropriate incentives to overcome these

impediments is critical to advancing the 

overall level of stroke care in the country.

Emergency Department

The emergency department (ED) plays an 

important role in achieving optimal care 

of the stroke patient. It provides immediate 

accessibility, integration with the emergency 

medical services (EMS) system, and access to 

a hospital’s resources. A stroke patient’s initial

contact with hospital-based personnel is 

generally in the ED. 

Until the advent of treatment with intravenous t-PA, ischemic stroke was considered 

not reversible even by aggressive emergency 

care. The goals of acute treatment were to 

avoid complications and reduce the risk of 

recurrence. Some of the barriers to optimizing acute stroke care are related to general 

challenges faced in this care setting. The ability to deliver optimal care can be affected by 

limited available resources. For example, a 

sudden increase in patient volume can make 

it difficult to meet the immediate needs of all

patients. Because stroke patients often present

with limited readily available background 

history (e.g., pre-existing conditions, current 

medications, etc.), hospital personnel must 

take the time to gather this important information. A single patient requiring aggressive 

treatment and the attention of multiple staff

members can exacerbate this problem. 

T ASK FORCE REPORT

Incentives for Enhancing Stroke Care

Sandra M. Schneider, M.D.

Task Force Chair

Strong Memorial Hospital

University of Rochester Medical Center

Larry B. Goldstein, M.D.

Task Force Co-Chair

Duke University Medical Center

Durham, North Carolina

James G. Adams, M.D., F.A.C.E.P.

Northwestern University

Chicago

Kenneth L. DeHart, M.D., F.A.C.E.P.

Carolina Health Specialists

Myrtle Beach, South Carolina

Andrew M. Demchuk, M.D.

Foothills Medical Center

Calgary, Alberta, Canada

Anthony J. Furlan, M.D.

Cleveland Clinic Foundation

Michael D. Hill, M.D.

Foothills Medical Center

Calgary, Alberta, Canada

Michael T. Rapp, M.D., J.D.

George Washington University

Washington, DC

Joseph P. Wood, M.D., J.D.

Mayo Clinic Hospital

Phoenix

H
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Compounding these problems, nearly 

70 percent of ED care is delivered in “off-hours”

(i.e., evenings, nights, weekends, and holidays),

times when consultative support is even more

limited. Therefore, the emergency physician 

must often evaluate patients with neurological

complaints without the benefit of consultation

with a neurological specialist. This can be a 

particular barrier to the delivery of therapies 

with a narrow therapeutic index such as 

intravenous thrombolysis. Similarly, radiology

resources in many hospitals can be overloaded

during the off-hours when technicians and 

radiologists are often in short supply. Smaller 

EDs may not have immediate imaging resources

available at any time. These types of challenges

have increased over the past few years because 

of ED overcrowding. More than 90 percent of 

ED directors perceive that their departments 

are either at or over capacity,1,2 and available 

data indicate that this perception is well 

founded. According to a recent American 

Hospital Association poll, 62 percent of hospital EDs are at or over capacity. An ED point

prevalence study done on a typical spring evening found there were 1.1 patients per treatment 

space, 4.2 patients per registered nurse, and 

9.7 patients per physician.3 This overcrowding introduces stress in the system that can 

interfere with the optimal delivery of care.

Given the nature of emergency care, 

emergency physicians must frequently rely 

on consultation with physicians from other 

specialties. These physicians assist in evaluation and treatment and assume the care of

patients requiring hospital admission. The importance of consultative services to a smoothly

functioning ED is recognized in the EMTALA

(Emergency Medical Treatment and Active 

Labor Act) statute that requires hospitals 

to identify specific physicians with on-call 

responsibilities. This has become more difficult 

in recent years (see below, Neurology section). 

Using intravenous t-PA as an example 

of the problems associated with the use of an

innovative therapy with a potentially narrow 

therapeutic index, most emergency physicians

have been unwilling to accept sole responsibility for a decision to administer the drug 

without adequate consultative and administrative support. Concerns focus on the need for

expert CT scan interpretation and detailed 

neurological examinations with continuing

patient reassessments. These concerns are 

heightened in the increasingly hectic and 

crowded ED environment. In addition, relative lack of extensive experience with the use 

of t-PA leads most emergency physicians to 

seek the opinion of a neurologist prior to 

drug administration, or even to require 

that the neurologist order the treatment. 

In contrast, ED physicians are quite willing 

to independently administer t-PA for myocardial infarction. Unlike CT scan interpretation,

identifying ST elevation on an EKG is one of 

an emergency physician’s basic skills. The 

indications for t-PA for myocardial infarction 

are more straightforward, the frequency of its 

use in this situation is greater, the risk to the

patient with treatment is less, and there is 

less controversy regarding its use. 

In the United States, the problems of lack 

of space, personnel, technological resources, 

and support from subspecialty consultants 

are formidable, and the situation is much the

same in Canada. These barriers can be partially

addressed through development of efficient 

prehospital and ED triage systems, increased 

funding to support the availability of needed 

technological resources in hospitals caring for

patients with acute stroke, and the development

and adoption of care pathways including predetermined orders to facilitate the use of potentially hazardous stroke therapies by emergency

physicians. However, these approaches do not

address the need for consultative support.
75

Improving the Chain of Recovery for Acute Stroke in Your Community

Neurology

As reflected above, a perceived or actual lack 

of consultative support is viewed by emergency

physicians as a barrier to the provision of potentially risky therapies, such as thrombolytics for

acute ischemic stroke. As compared to acute 

cardiac emergencies, many emergency medicine physicians are not sufficiently trained in 

neurology to feel comfortable using new stroke

therapies that have the potential to cause harm.

Although stroke is one of the most common

inpatient problems confronting neurologists,

many neurologists subspecialize and do not 

provide care for stroke patients on a regular 

basis. Beginning in 1996, most neurology 

residency programs in the United States began

including some training related to intravenous 

t-PA for acute stroke. Nonetheless, many neurology residents have little experience or confidence in the use of intravenous t-PA.4 Surveys 

in Texas5 and by the American Academy of

Neurology6 suggest that no more than 50 percent of American neurologists have given intravenous t-PA for acute stroke. Less than one 

third (30 percent) of the neurologists found 

the evidence for t-PA efficacy “very convincing,”

with the majority (67 percent) finding the 

evidence of efficacy “somewhat convincing.”

Many neurologists felt the drug was “too risky,”

and 62 percent were “very concerned” about

intracerebral hemorrhage.

In addition to uncertainty about the 

efficacy of new therapies, most general neurologists see patients in outpatient settings. 

The economics of clinical practice dictate a 

tightly scheduled day. Interruptions to evaluate a patient with acute stroke can take several 

hours. Given the limited financial reimbursement associated with this activity (see below,

Financial Reimbursement section), there is a

strong disincentive to leaving a crowded office 

to provide emergency consultative services. 

The acute stroke time targets developed at 

the first NINDS National Symposium in 

1996 included “access to stroke expertise” 

within 15 minutes of ED arrival.7 The phrase 

“access to stroke expertise” was purposefully 

used because neurologists are not immediately

physically available in many community or 

rural hospitals. Therefore, the recommendation

anticipated telephone consultations, telemedicine, and the fact that in many situations it 

may be impossible to have a neurologist 

physically present in the ED before emergency

therapies such as t-PA are started. Although 

consultants are legally liable for advice given 

over the telephone, there is no financial reimbursement for telephone consultation. Therefore, many neurologists refuse to give advice

about intravenous t-PA over the telephone. 

Finally, when radiologists are not immediately

available, neurologists interpret radiographic 

studies such as CT scans to guide treatment.

However, they are rarely financially reimbursed

for these activities. Given this reality, it is not 

surprising that emergency medicine physicians

cite a lack of neurological support as a barrier 

to acute stroke treatment.

Medicolegal Concerns

The introduction of t-PA for acute stroke led 

to several legal theories that could provide 

a basis for a claim for medical malpractice,

defined as violation of the accepted standard 

of care causing harm to a patient. Similar 

theories could apply to other innovative acute

stroke therapies. The primary basis for any 

malpractice claim is a bad outcome. With 

a bad outcome, the task from the plaintiff’s 

perspective merely becomes relating the outcome to a deviation from the standard of care.

Evidence of the standard of care is provided 

by the opinion of expert witnesses, with arbitration by a judge and jury. One physician 

with minimal qualifications expressing an 

opinion that certain conduct violated the 
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

standard of care can be sufficient to have a 

jury consider the case and award damages to 

compensate for the bad outcome.

In the case of any innovative stroke treatment, the starting point is often a bad outcome

(because the patient had a stroke). The first 

theory available to a plaintiff’s attorney would 

be to argue that failure to administer t-PA was 

a violation of the standard of care, and that, 

had it been used, the outcome would have 

been the elimination of the patient’s neurological deficits. The latter is hard to prove 

scientifically, but easy to establish in a court 

of law since it merely requires the opinion of 

a qualified witness. A second theory available 

to a plaintiff would be to argue that the administration of t-PA was either not indicated or 

that the drug was improperly administered, 

leading to a bad result (either hemorrhage 

or perhaps simply failure to be cured). Finally,

there is the doctrine of informed consent. 

In this case, a plaintiff’s attorney could argue 

that the patient should have been informed 

of t-PA as an available treatment including 

its risks and benefits. 

The Food and Drug Administration 

approved intravenous t-PA as a treatment 

for acute ischemic stroke in 1996. Shortly 

thereafter, its use was advocated in a scientific

statement from the American Heart Association

and an almost identical practice parameter 

from the Quality Standards Subcommittee 

of the American Academy of Neurology.8,9

Editorials were published and educational 

campaigns were launched, aimed toward 

educating physicians and patients alike. 

The popular press, magazines, newspapers, 

and media of all types heralded the new 

treatment for stroke. 

These efforts in part created a fertile field 

for malpractice litigation related to the use of

intravenous t-PA. The plaintiffs’ bar recognized

that a new potential cause of action existed.

Advertisements and websites for malpractice 

attorneys highlighted the “alarmingly low” 

use of t-PA for patients with acute stroke, 

“especially for African Americans”.10 Solicitations educated patients, “If you suspect that 

a loved one should have received t-PA but did 

not, or that t-PA was administered improperly, 

it may be important to contact an attorney”.11

Legal solicitation continued as medical 

scientific debate and physician education was

ongoing. Legal scrutiny was noted even before

there was national consensus among specialties. With such a threat present, establishing

national consensus to undertake a timesensitive, technically demanding, high-risk 

therapy was unlikely. The scientific evidence 

was argued to be insufficiently convincing, 

the operational challenges enormous, and 

the complication rate worrisome. The perception was that any effort to further advocate 

for the use of thrombolytics could increase 

legal risk. The counterargument was that a 

higher threat existed from failure to administer thrombolytics.

There are several ways to deal with highrisk medicolegal situations, such as those 

involving t-PA. From the standpoint of emergency physicians, appropriate consultative support for treatments with a narrow therapeutic

index is viewed as important. The development 

of institutional policies for the use of a specific

treatment also reduces medicolegal risk. For 

example, an institutional policy decision could

define the circumstances in which a treatment

could or could not be safely administered. Such

advance policy decisions, if reasonable and if 

followed, can provide protection against the 

opinion of a plaintiff’s expert. Support may 

also be obtained from guidelines or policy 

statements by professional organizations. When 

a real difference of opinion exists within the 

medical community, an expert’s adoption of 

one view does not lead to legal liability.
77

Improving the Chain of Recovery for Acute Stroke in Your Community

Emergency physicians indicated to the

American College of Emergency Physicians 

that they were facing litigation for failure 

to administer t-PA for acute stroke. Given 

the perceived medicolegal risk, the American 

College of Emergency Physicians developed a 

policy on the matter.12 Similarly, the Canadian

Association of Emergency Physicians published 

a policy indicating that current evidence did 

not support the use of t-PA in acute stroke as 

a “standard of care.” The American Academy of

Emergency Medicine was the first professional

association in the United States to note that 

“evidence...is insufficient to warrant [t-PA’s] 

classification as standard of care.” This announcement served as powerful advocacy and welcome

support for emergency physicians who felt great

medicolegal threat, even while trying to provide 

the highest levels of service to patients.13

The experience with t-PA may be viewed 

as a model of what can be expected for other

emerging acute stroke therapies in the future.

Proponents of the use of innovative therapies 

for acute stroke must frame a convincing scientific stance and ensure the high levels of system

supports that will reliably achieve timeliness 

and safety. Promulgation of new, potentially 

hazardous acute stroke therapies before health

care providers and institutions have been educated about appropriate organizational changes

and support mechanisms will likely bring about

challenges similar to those facing t-PA use.

Financial Reimbursement

Appropriate financial support for consultative

services and stroke systems has been discussed 

as important to the provision of optimal stroke

care. In addition, indigent care must be supported. Because there may be different payers for 

acute and long-term care, even if an acute treatment is cost-effective from a societal standpoint, 

it may increase the costs to those providing 

the treatment. Other health care systems avoid

this conflict through global health care budgeting. The financial disincentives to the use of 

intravenous t-PA would be similar for other 

innovative approaches. For example, hospital 

and physician reimbursement is the same 

whether or not t-PA is administered to an 

acute stroke patient. Unless payers recognize 

the added value of implementing an acute 

stroke response system, many hospitals will 

be unable to dedicate the resources needed 

to consistently provide rapid, state-of-the-art 

care to acute stroke patients.

Surprisingly, only a minority of neurologists listed low reimbursement as a reason 

for not giving t-PA. This contradicts the 

common knowledge that neurologists consider reimbursement for intravenous t-PA 

inadequate, especially when they must go to 

the hospital in the middle of the night, on 

weekends, or during a busy daytime practice.

Many neurologists are unfamiliar with 

optimal current procedural terminology (CPT)

billing for thrombolytic therapy. The American

Academy of Neurology has published a Stroke

Coding Guide, which advocates using CPT 

Codes 99223 (initial hospital care, high complexity), 99291 (critical care, first hour), and

99292 (critical care, subsequent half hour) 

for initial treatment of acute stroke patients 

with thrombolytic therapy. The average national

payment in 1997 using these three CPT codes 

was $394.77; in 2002, the average payment

increased to $447.43. Although there is a 

CPT code for intravenous t-PA for acute stroke

(37195), the work relative value unit (RVU) for

this code is 0! This reimbursement rate provides

little incentive for neurologists to interrupt an

otherwise busy workday or to respond during

evenings, weekends, or holidays. Recognizing 

that it is unlikely that the emergency physician

and neurologist will both be fully reimbursed

when they bill under the same codes for the 
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

same patient, there is little financial incentive 

to establish a highly functional team approach. 

Adequate financial resources to promote 

optimal stroke care and to support physician 

leadership for the direction of a multidisciplinary

stroke team is critical. A significant opportunity

exists to amend the current system to create 

meaningful incentives in the provision of 

contemporary stroke care.

From the institutional standpoint, governmental payers such as Medicare compensate 

facilities based on a diagnosis related grouping

(DRG) methodology. This DRG methodology

largely reflects overhead costs calculated from

“case data” with little recognition of the expense

and higher resources involved in contemporary

thrombolytic or evolving neurological therapies

and technologies. Commercial payers typically

compensate acute care and rehabilitation facilities on a per diem basis, with denied payment

inconsistency occurring for services involving 

progressive stroke care. These reimbursement 

limits create a disincentive to the provision 

of optimal stroke care. New compensation 

levels must reflect three essential elements: 

1) the increased costs involving present and 

evolving thrombolytic and novel interventions;

2) the cost in providing uncompensated care; 

and 3) resources to develop and support medical leadership and system analysis.

The support of a “stroke team” and team

leader is particularly important. Traditionally,

medical directorships have been developed for

care that typically involves specific units within 

a given hospital. Stroke care, however, occurs 

in many locations within the hospital. It will 

be difficult, if not impossible, to nurture an 

optimal approach to care without financial

resources to properly encourage physician 

leadership and system development with 

meaningful clinical quality review.

Incentives must also be developed for 

those providing primary bedside care. One 

opportunity involves amendments to the 

current nomenclature involving the CPT-4 

codes used by physicians and ancillary 

providers to describe the care provided to stroke

patients. A second opportunity involves the 

development of new CPT codes to accurately

reflect new services in progressive stroke care.

The CPT-4 published by the American

Medical Association is the prevailing nomenclature in the United States used to describe

provider services to patients and it includes 

evaluation and management visit services, 

observation services, and critical care services.

However, “concurrency of care” limitations 

in the provision of services occur when they 

are simultaneously provided by multiple 

physicians from multiple specialties. 

These types of restrictions undermine an 

integrated multidisciplinary approach and 

must be discontinued. 

CPT codes presently exist that could 

be helpful in promoting an integrated team

approach. They include: 1) 99360, physician

standby service, requiring prolonged physician

attendance, each 30 minutes; and 2) 99371, 

telephone call by a physician to a patient, for 

consultation or medical management, or for 

coordinating medical management with other

health care professionals (e.g., nurses, therapists,

social workers, nutritionists, physicians, pharmacists). Other existing codes include: 1) 99371, 

simple-brief, e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other

health professionals into the medical treatment

plan, or to adjust therapy; 2) 99372, intermediate, e.g., to provide advice to an established patient

on a new problem, to initiate therapy that can 

be handled by telephone, to discuss test results 

in detail, to coordinate medical management of 

a new problem in an established patient, or to 

initiate a new plan of care; and 3) 99373, complex or lengthy, e.g., lengthy counseling session
79

Improving the Chain of Recovery for Acute Stroke in Your Community

with anxious or distraught patient, detailed or

prolonged discussion with family members

regarding seriously ill patient, or lengthy communication necessary to coordinate complex 

services of several different health professionals working on different aspects of the total

patient care plan.

The majority of third-party payers in the

United States, including Medicare, do not 

typically recognize these physician services for

payment. Efforts should be directed to securing

specific descriptive language amendments in 

these codes in order to support the development of multidisciplinary teams and to recognize the challenges in providing consultative 

services to acute care providers and patients.

The second opportunity for developing 

incentives exists through the creation of new 

and innovative language within CPT-4 to specifically describe acute resuscitative and chronic

stroke care. This descriptive nomenclature for

acute care could be global in scope and analogous to the present Critical Care 99291 or the 

CPR 92950 codes. As an example, an entirely 

new CPT code could be developed that more

accurately and fairly captures the physician

resources in the provision of stroke care.

Some of these financial incentives have

already been implemented in Canada over 

the last 3-5 years. For example, there has been 

a general move toward payment for on-call 

services, with several provinces providing 

stipends for either neurology call (including 

acute stroke) or acute stroke only. Payments 

range from $150 a day (neurology including 

acute stroke care) in Manitoba, to $300 a day

(stroke call) in Alberta, to $500 a day (stroke

only) in Ontario, to as high as $740-$850 a 

day (neurology including acute stroke care) 

in British Columbia. In addition to billing 

for their usual consultation fee, most bill 

for an additional 30-90 minutes for the 

time required for t-PA administration.

A coordinated stroke reimbursement 

strategy by patient advocates and professional

organizations may be the most effective way to

change the reimbursement system to facilitate

quality stroke care. Nationally, the Centers for

Medicare and Medicaid Services (CMS) regularly

reviews reimbursement levels for specific conditions and physician payments and invites 

public comment. Locally, carrier review 

committees can be similarly approached.

Health Systems

Systems approaches to stroke care are central 

to many of the identified resource issues. Studies

show that having an organized system of stroke

care improves outcomes, reduces complications,

shortens hospitalizations, and reduces costs. However, current reimbursement systems in the United

States do not support this approach. In addition,

reimbursement levels have not accounted for the

added expense involved in the use of new therapies. For example, DRG14 (stroke) was created

before intravenous thrombolysis was introduced.

Stroke quality assessment was recently 

discontinued by the CMS. As a result, there is 

currently little incentive for hospital systems to 

monitor the quality of their stroke care. Programs

to identify stroke centers are being discussed, and

CMS is planning to reintroduce stroke quality

indicators in its next scope of work. This should

help in gaining institutional support to enhance

stroke process improvement programs and provide

a consistent mechanism for giving feedback to all

caregivers, including emergency care providers.

Incentives to Improve Acute Stroke Care

 Develop and maintain stroke care systems.

 Provide acute stroke consultative support

(especially neurological and radiological

expertise) for ED physicians and nonspecialist care providers through in-hospital
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

protocols and systems approaches, including

telemedicine consultation and teleradiology

as appropriate.

 Develop a coordinated stroke reimbursement strategy involving patient advocates 

and professional organizations.

 Define medicolegal issues to reduce 

physician liability risk related to the 

provision of innovative acute stroke care.

 Support outcomes assessment programs 

to inform process improvement efforts 

and dissemination of best practices.

 Assure that appropriate education 

is conducted and that consensus is 

achieved as new therapies are introduced.

Educational priorities include emergency 

caregivers, neurologists, and nursing staff.

 Provide forums for constructive dialog 

among emergency physicians, neurologists,

and other key stroke care providers.

 Continue to refine and advance the level 

of stroke care through clinical research.

References

1 Derlet R, Richards J, and Kravitz R. Frequent 

overcrowding in U.S. emergency departments. 

Acad Emerg Med 2001;8: pp. 151-155.

2 The Lewin Group. Emergency departments. 

An essential access point to care. AHA Trendwatch

2001;3: pp.1-8.

3 Schneider SM, Gallery ME, Schafermeyer R, et al.

Emergency department crowding: a point in time.

Ann Emerg Med 2003 (in press).

4 Cucchiara BL, and Kasner SE. Graduating neurology

residents’ experience with IV tPA for acute stroke.

Neurology 2001;57: pp. 1729-1730.

5 Villar-Cordova C, Morgenstern LB, Barnholtz JS, 

et al. Neurologists’ attitudes regarding rt-PA 

for acute ischemic stroke. Neurology 1998;50: 

pp. 1491-1494.

6 Katzan IL, Sila CA, and Furlan AJ. Community use

of intravenous tissue plasminogen activator for

acute stroke. Stroke 2001;32: pp. 861-865.

7 Marler JR, 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.

8 Adams HP, Jr., 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. Stroke

1996;27: pp. 1711-1718.

9 Report of the Quality Standards Subcommittee of

the American Academy of Neurology. Thrombolytic

therapy for acute ischemic stroke — summary 

statement. Neurology 1996;47: pp. 835-839.

10 Cirignani and Associates, The Medical-Legal Law

Firm. “Medical Developments.” November 2002

(www.cerebralpalsylegalhelp.com/cerebral/

developments.html).

11 Injuryboard.com. “TPA.” November 2002

(www.injuryboard.com/view.cfm/ID=655/

Type=News/Article=254).

12 American College of Emergency Physicians. 

ACEP Policy Statement: Use of Intravenous 

tPA for the Management of Acute Stroke in 

the Emergency Department. March 26, 2002

(http://www.acep.org/3,5006,0.html).

13 American Academy of Emergency Medicine.

Position statement on the use of intravenous 

thrombolytic therapy in the treatment of acute

stroke. November 2002 (www.aaem.org/

positionstatements/thrombolytictherapy.shtml).
Provider Support 

Systems for 

Acute Stroke

Provider Support Systems for Acute Stroke

he phrase “provider support systems” 

describes the organization of human and

material resources necessary to solve a clinical

problem. Developing support systems is an 

integral step in the second phase of translational

research. In the first stage, the principal focus is

on bringing new therapeutic approaches from 

the laboratory to clinical trials. In the second

phase, the problem is to move from the clinical

trial setting to accepted clinical practice.

Why Develop Support Systems?

Provider support systems have proven remarkably

effective in improving medical care in numerous

areas in the United States. Regional trauma systems emphasizing the “golden-hour” have led 

to improvement in the outcome of patients 

suffering injury.1,2 Systems effective in reducing 

door-to-needle times in patients with myocardial

infarction receiving thrombolytic therapy have

also led to improved outcomes.3 Similarly, the

T ASK FORCE REPORT

Provider Support Systems for Acute Stroke

Phillip A. Scott, M.D.

Task Force Co-Chair

University of Michigan

Ann Arbor

Sidney Starkman, M.D.

Task Force Chair

UCLA Stroke Center

John Y. Choi, M.D.

University of Texas Health Science Center at Houston

Brian F. Connoly, M.D.

State University of New York at Buffalo

Karen L. Furie, M.D.

Massachusetts General Hospital

Boston

J. Stephen Huff, M.D.

University of Virginia Health System

Charlottesville

Walter N. Kernan, M.D.

Yale University School of Medicine

New Haven, Connecticut

Marian LaMonte, M.D., M.S.N.

University of Maryland School of Medicine

Baltimore

Dennis M.D. Landis, M.D.

University Hospital of Cleveland and 

Case Western Reserve University

Cleveland

Steven R. Levine, M.D.

Mount Sinai School of Medicine

New York, New York

David B. Matchar, M.D.

Duke University

Durham, North Carolina

Brett C. Meyer, M.D.

University of California at San Diego 

Medical Center

Debra G. Perina, M.D.

University of Virginia Health System

Charlottesville

Jeffrey L. Saver, M.D.

UCLA Stroke Center

Lee H. Schwamm, M.D.

Harvard Medical School and Massachusetts 

General Hospital

Boston

T
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

progressive testing of chemotherapeutic agents 

in a systematic, sequential fashion has substantially improved quality of life and survival in

patients with cancer.4

Clinical trials have demonstrated that 

interventions exist to reduce the morbidity and

mortality from stroke. These include primary

treatment (thrombolysis in acute ischemic

stroke5) and prevention of secondary complications of stroke (deep vein thrombosis, aspiration pneumonia, decubitus ulcer formation, 

etc.). The use of other interventions, such as 

specialized stroke care units, is supported by 

evidence of improved long-term survival and

independence for stroke patients treated in 

such settings compared to patients treated in 

a standard hospital setting.6 The widespread 

application of these disease management

approaches is limited by various barriers, 

some of which can be overcome through 

effective support systems. 

While it is not reasonable to expect every

physician and health care institution to manage every aspect of stroke care, it is reasonable 

to expect pre-established plans to deal with 

stroke patients falling outside the expertise of 

an individual provider or health system. These 

systems should serve to enhance the providers’

and facilities’ own capabilities while providing 

for patients needing additional resources, 

thus improving the delivery of care for all 

stroke patients.

Every health care delivery system providing care for patients with acute stroke has a

responsibility to develop and implement plans 

for meeting the requirements of each phase of

stroke care. The burden of stroke, for individuals

and society, compels us to develop effective 

support systems to deliver the optimum care 

to every patient with stroke. This document 

identifies multiple support systems to accomplish this task.

Specific Challenges for Support Systems

The use of thrombolytic therapy for acute

ischemic stroke poses an especially difficult 

challenge in the development of support systems. Ischemic stroke is a clinical diagnosis 

based primarily on patient history and physical findings. Unlike cases of acute myocardial

infarction or trauma, there are no immediately

available confirmatory studies for stroke.

Guidelines derived from successful clinical 

trials call for treatment when the diagnosis 

is established by a person with expertise in 

stroke; however, the vast majority of patients 

present to hospitals without specialized stroke

teams, and are instead seen by frontline medical

providers, such as emergency medical services

(EMS) personnel, emergency physicians, family

practitioners, and internists, who have limited

expertise in diagnosing stroke and/or using

thrombolytics in patients with stroke. 

Even when physicians who are comfortable 

in diagnosing stroke are available, there may be

other substantial barriers to treatment. Patients

often fail to seek medical support in the initial

hours of ischemic stroke, therefore delaying 

initial presentation. In-hospital delays may exist,

including impediments at triage, during initial

physician evaluation, and in obtaining required

CT and laboratory studies. Given the potential

obstacles encountered, it is not surprising that

more than 7 years after the initial NINDS t-PA

publication overall utilization rates are estimated

in the 1 to 2 percent range for all patients with

acute ischemic stroke.7 Even at centers with 

specialized stroke capability, only 7 to 9 percent of all acute stroke patients undergo 

thrombolytic therapy.8

The barriers encountered in the development of systems to deliver hyperacute therapies 

to stroke patients highlight many of the obstacles

to effective care for patients with either ischemic

or hemorrhagic stroke in complex health-delivery
85

Improving the Chain of Recovery for Acute Stroke in Your Community

systems. By developing support systems to 

overcome these barriers, it is anticipated that 

care of stroke patients in general will improve. 

It is encouraging that recent evidence suggests 

that development of support systems for 

providers serves to increase the use of 

thrombolytic therapy in stroke.9

Areas for Support System Development

From a chronological perspective, there are 

multiple points during the care of acute stroke

where pre-established systems should exist to

enhance patient care. In some locations, all 

the resources for a given phase may be present.

More often, however, institutions and caregivers require additional resources to provide 

optimum neurologic care. These resources may 

be as simple as advice over a telephone or as 

complex as automated image interpretation.

Regardless of the precise details, it is usually 

possible to predict the resources required, and 

to plan in advance the manner in which the 

necessary resources will be obtained.

Presently, optimal stroke care requires 

rapid evaluation and management in the first 

few hours after the onset of clinical symptoms.

The phases of stroke care for which advanced

planning is required include:

 Prehospital care

 Hospital-based care

– Diagnostic assistance

• Radiologic and imaging expertise

• Stroke diagnostic expertise 

– Management assistance

 Systems implementation and evaluation 

Moreover, each health care delivery system

must monitor the success of its plans and be 

prepared to change, as necessary, to improve. 

As staff change over time, an institution should

develop protocols and plans for training new 

personnel in the resources and techniques 

that have proven feasible at that site.

In general, knowledge used by medical 

personnel in the acute setting falls into at least

three categories: training acquired in advance,

information and training available upon 

demand, and information obtained in the 

acute care setting. Training and continuing 

education are discussed in more detail elsewhere (see chapter on Professional Education,

page 29); the following discussions will emphasize the range of support systems and resources

that may be used in the acute care setting. A 

list of suggested sites for additional information appears in the Appendix on page 95.

Prehospital Care Support

Prehospital recognition of the potential 

stroke patient is essential for rapid initiation 

of treatment. Evidence from prehospital studies

indicates that stroke patients accessing 911 emergency systems have significantly shorter times 

to physician evaluation and CT imaging of the

brain than patients arriving at the hospital via

other means.10 To exploit these benefits the 

following support systems are recommended 

for prehospital care.

EMS Training and Stroke 

Identification Support

Education on the signs and symptoms 

of stroke should be included in the initial 

and continuing education of all prehospital 

personnel. Since EMS providers function 

according to written guidelines developed by 

their medical directors, it is advantageous for 

such guidelines to contain a prehospital stroke

identification instrument, e.g., Cincinnati Prehospital Stroke Scale, Los Angeles Prehospital

Stroke Screen, or other similar scale.11,12
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Prehospital stroke identification instruments 

can be rapidly administered and they enhance 

the ability of EMS providers to accurately 

identify stroke and notify the receiving facility 

in advance. All EMS providers should be familiar

with such an instrument and employ it when

assessing suspected stroke patients to allow 

early hospital notification.

EMS Transfer Support Systems

Stroke patients should be transported without

delay to the closest appropriate facility. Guidelines for hospital destination decisions should 

be made in advance with the cooperation of 

area hospitals, emergency departments, EMS

agency administrators, and EMS medical 

directors. Such decisions should result in the

patient reaching a stroke-capable facility in 

the most timely manner. In cases where long

ground transport time to the receiving hospital 

is anticipated, consideration should be given 

to aeromedical evacuation to preserve the 

potential for thrombolytic, endovascular, 

neurosurgical, and/or investigational therapy 

in appropriate cases. Data suggest that aeromedical transfer of stroke patients may 

increase the opportunity for acute intervention and can be accomplished safely.13-15

Prehospital Management Support

While prehospital providers are knowledgeable about the symptoms of stroke, many 

are unaware of the appropriate use of supplemental oxygen, the potential detrimental 

effects of unnecessary dextrose administration, 

the need to avoid rapid lowering of blood 

pressure, and the presence of a therapeutic 

window for thrombolytic delivery.16 The development of EMS system guidelines requiring 

intravenous access and glucose measurement,

avoidance of interventions to lower blood 

pressure, and methods to assist in identifying 

the symptom onset time (e.g., transporting 

a family member or event witness with the

patient) and stressing the importance of early

treatment is recommended. 

EMS personnel routinely provide reports 

of individual patient assessment to local 

medical directors. Guidelines should exist 

to ensure that physicians at the receiving 

facility are made aware of the prehospital 

assessment of possible stroke, thus allowing 

internal hospital systems to prepare for rapid 

evaluation and treatment. Currently, such 

reports are given verbally; however, new technologies utilizing real-time video/still image 

linkages between ambulances and receiving 

centers may allow receiving physicians to 

remotely examine the patient during transport.

This type of communication may shorten the

decision-making process for acute therapies.

Hospital Care Support

Following arrival at the hospital, via EMS or 

other means, the stroke patient faces barriers 

within the hospital setting. These include 

many that are not amenable to hospital 

support system development: emergency 

department (ED) and intensive care unit 

overcrowding, reductions in hospital staff, 

and nursing shortages. A lack of access to 

consultants — particularly those with radiology and neurology expertise — is modifiable

through specific support system development

and is discussed in detail below. 

Radiologic Imaging

Rapid radiologic assessment is necessary 

to determine patient eligibility for thrombolysis, neurosurgical evacuation of intracranial

hematomas, and early treatment of aneurysmal

subarachnoid hemorrhage. Hospitals that 

provide acute stroke care but do not have 

available expert CT interpretation on-site 

must develop a plan for urgent and accurate 
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Improving the Chain of Recovery for Acute Stroke in Your Community

interpretation of brain CT scans. This may be

accomplished via use of local resources, remote

teleradiology systems, or patient transfer.

Teleradiology Support Systems

Teleradiology is a widely accepted practice 

for a variety of medical conditions. Traditionally, high-cost teleradiology solutions 

for CT interpretation have imported uncompressed brain images into a Picture Archiving 

and Communications System (PACS) workstation to be viewed on a 2K black and white

high-resolution monitor. Newer low-cost teleradiology systems are now available for the 

transmission of wavelet compressed DICOM

images.17 These images are compressed without loss of visual resolution and can be viewed

using an internet browser on a conventional 

PC equipped with a cathode ray tube or liquid

crystal display monitor.18-21 These systems 

allow local radiologists or neurologists to 

provide rapid interpretation of high-quality

images from their homes or offices, and allow 

outside physicians to provide interpretation 

services by contract. Because these systems 

handle much smaller datasets (a head CT 

scan is approximately 8 MGB, uncompressed)

they can be effectively transmitted at low to 

medium bandwidth rates that are widely 

available. The impact of integrating these 

technologies may be substantial at nonurban hospitals with a high likelihood of 

first medical contact.

Stroke Expertise

Rapid assessment, including neurologic 

examination, is necessary for optimum acute

stroke care; it is especially urgent in determining eligibility for thrombolysis. Patients in 

areas without local expertise may have limited 

access to these treatments. Hospitals providing

acute stroke care must have a plan for urgent 

and accurate patient evaluation. This may be

accomplished via use of local resources, remote

teleconsultation systems, or patient transfer. 

The delivery of rapid, efficient, and accurate 

neurological evaluation has been improved 

by the creation of “acute stroke teams” in 

various hospital settings. Centers that utilize 

such teams may have better outcomes compared with those administering t-PA ad hoc 

or to relatively few patients.22,23

Teleconsultation

Teleconsultation can allow a stroke expert 

to remotely evaluate a patient’s neurological 

condition, review brain images, and initiate 

a collaborative management plan with a referring physician. This location-independent 

infrastructure collapses barriers of time and 

distance to bring medical expertise to the 

bedside, potentially enabling delivery of 

care that would not otherwise be available.

Telemedicine for stroke, sometimes referred 

to as Telestroke, offers the potential for: 

 Improving diagnostic accuracy in the 

setting of stroke-mimics

 Facilitating delivery of thrombolytic therapy

to patients with identified acute strokes

 Enhancing referring physician education 

on acute stroke management

 Improving non-thrombolytic acute stroke care 

 Improving post-stroke management

 Allowing remote follow-up and monitoring

for secondary stroke prevention 

 Increasing standardization of acute stroke care

 Identifying patients for enrollment into 

acute treatment studies

Telemedicine has been shown to be a 

feasible and effective method of performing 

consultative services and delivering remote 

neurologic assessment and treatment to stroke
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

patients.24,25 Specifically, reasonably good 

inter-rater reliability of NIH Stroke Scale 

scores is preserved when performed over a

telemedicine video link.26 These preliminary 

data support the potential role of a remote

telemedicine link in the assessment and 

treatment of a patient’s neurologic deficit.

Available Technologies

Depending on the degree of information 

required, teleconsultation methods can range 

from telephone consultation to advanced 

hardware and imaging devices. At the simplest level, a telephone call to share clinical 

information can suffice, and this currently 

occurs in numerous settings where faceto-face acute evaluations are not possible.

Limitations of this method are the inability 

to personally visualize the degree of clinical

deficit, view the relevant neuro-imaging 

data, confirm the patient history, or have 

face-to-face interactions with patients, family

members, and the treating bedside physicians.

This method has been used to successfully 

support emergency physician delivery of 

t-PA in one model.27 Concerns remain, 

however, on the widespread acceptance 

of this strategy as an effective consultative 

mechanism in stroke. 

High bandwidth data transmission allows

real-time video consultation to support truly 

interactive patient evaluation and management. 

It can be performed with off-the-shelf commercially available systems that utilize integrated 

services digital network (ISDN) lines or digital

subscriber lines (DSL) with internet/intranet 

protocols for data transfer. These systems can 

generate 30-frames-per-second video resolution

and should support such features as remote 

pan/tilt/zoom to allow full remote control 

of the camera functions. These technologies 

have been tested and are currently feasible 

for the remote evaluation of patients.28

Today’s telemedicine systems serve 

point-to-point, hard-wired connections, but 

newer wireless and mobile systems are being

developed and evaluated. Software systems 

should be designed to facilitate the collection 

of critical patient data, assist in decision-support,

and create documents to meet medical, legal, 

and regulatory requirements. Further research

regarding these newer technologies should 

be addressed.

Teleconsultation Implementation 

Implementation of teleconsultation requires

installation of essential equipment, availability of the relevant telecommunications 

infrastructure, personnel training, technical 

support, and periodic maintenance. Teleconsultation must be integrated into the acute 

stroke evaluation process so that activation 

of the remote stroke team occurs in much the

same manner as that of a local stroke team. 

When a potential acute stroke patient presents 

in the emergency or hospital setting, an initial

evaluation by the bedside treating physician is

performed. If special expertise is indicated, but

not locally available, the remote system can 

be activated and the consultation can take 

place via telemedicine technologies. 

Multiple practical barriers have thus far 

limited the widespread use of teleconsultation

technology. The need for data transfer systems 

that can support high bandwidth transmissions

(LAN/ISDN/TCP-IP) has limited its use in 

some rural areas; however, this bandwidth is 

rapidly becoming ubiquitous. Current state 

medical board regulations define the site of 

health care delivery as the patient location, 

preventing physicians in other states from 

providing teleconsultation into states in which

they are not licensed. Some malpractice carriers 

are wary of the liability risks associated with 

teleconsultation and may impose restrictions 

to coverage. 
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Improving the Chain of Recovery for Acute Stroke in Your Community

Additionally, most third-party payers have

been slow to recognize these activities as eligible

for reimbursement, whereas others, such as the

Centers for Medicare and Medicaid Services, 

have provided reimbursement based solely 

on hospital location without reference to the

availability of resources specific to stroke. 

Because these teleconsultation methods are 

not yet widely accepted in acute stroke care, 

many practitioners obtain informed consent 

from patients or their designated caregivers 

prior to initiating these consultation services,

imposing additional time delays in the care 

of the patient with acute stroke.

Management Decision Support 

Clinical management decision-making is often

complex and involves the mechanics of health

care delivery as well as institutional policies,

regional practices, and referral patterns. The

process becomes even more difficult when 

time limitations are added. 

In stroke patients, once the initial neurologic assessment and diagnosis is established 

and radiologic interpretation obtained, the 

treating physician still faces fundamental 

issues regarding what, if any, interventional 

therapy is appropriate. Who is responsible 

for administering thrombolytics in eligible

patients? Which patients with intracranial 

hemorrhage would benefit from surgical 

consultation? Who will assume care of the 

patient following ED evaluation or treatment? 

The wide variability in stroke experience 

among individual physicians and limitations 

in local emergency/hospital stroke care delivery

systems — combined with the potential medicolegal risk of failure to treat or inappropriate

treatment — has impeded widespread 

adoption of thrombolytic stroke therapy. 

The availability of patient management 

support systems can assist the treating physician in achieving the essential care needed for

patients with acute stroke. The need for such 

support can clearly be found in the following

statement by the American College of Emergency Physicians regarding the use of t-PA 

in acute ischemic stroke: 

“There is insufficient evidence at this 

time to endorse the use of intravenous t-PA in

clinical practice when systems are not in place 

to ensure that the inclusion/exclusion criteria

established by the NINDS guidelines for t-PA 

use in acute stroke are followed. Therefore, 

the decision for an emergency department to 

use intravenous t-PA for acute stroke should 

begin at the institutional level with commitments from hospital administration, the 

emergency department, neurology, neurosurgery, radiology, and laboratory services 

to ensure that the systems necessary for the 

safe use of fibrinolytic agents are in place”.29

Options for management decision support

may be conceptually divided into systems or 

elements available locally to the treating physician; those located in off-site (remote) locations;

those facilitating patient transfer to a higher 

level of stroke care; and those providing 

patients access to clinical trial participation.

Local Decision Support

Local decision support identifies processes 

or elements which assist physician decisionmaking within a hospital or health care system.

Pre-planned guidelines developed by all involved

groups, such as family physicians, internists, 

neurologists, neurosurgeons, radiologists, and

emergency physicians, are a critical initial step 

for developing a standardized approach to 

acute stroke management. All stakeholders,

including nursing and ancillary services, 

should participate in their development. 

Potential options for delivering such 

support include web-based and PDA-based 

tools30 in addition to traditional paperbased formats. In the setting of emergent 
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

thrombolytic decision-making, these can 

assist with information on patient eligibility,

risk/benefit information for providers and

patients, dosing information, and care guidelines. The web- and PDA-based tools have 

the added potential of supporting interactive

management tools, allowing pre-programmed

algorithms to support treatment decisions in 

the acute setting. Such protocols, in certain 

settings, can empower emergency physicians 

to initiate interventional care in the most 

expedient manner possible. 

In circumstances requiring additional 

expertise in therapeutic decision-making, 

the most familiar approach is the use of 

“in-house” specialty consultation. The reasons 

for specialty consultation in stroke are numerous and include: understanding co-morbid 

conditions, providing effective communication on the current diagnosis and treatment 

plan, discussing preferred treatment options,

enlisting additional treatment assistance, and/

or enhancing completion of a recommended

course of action and disposition decisions.31

The use of standard consultation methods,

whether by phone or in person, can be effective in this setting27 but is dependent on 

specialist availability, technical capability, 

and experience. 

An extension of this standard consultation support is found in hospitals using 

the “code-stroke” or “brain-attack” strategy 

to activate multiple resources, including 

neurologists — who often assume both 

ED decision-making and inpatient care roles.

These teams have demonstrated effectiveness 

but are labor-intensive in resource utilization.

Development of such teams within a hospital 

has been outlined by several groups.8,32,33

Remote Decision Support

For facilities without the consistent local 

specialty consultation needed for a particular aspect of stroke care, processes must be 

in place to obtain off-site assistance. Such 

support might be as simple as telephone 

consultation with regional stroke centers34

or as technically complex as the telemedicine

solutions outlined earlier. The identification 

of regional stroke referral centers with access

information should be immediately available 

in the ED. Just as medical staff must obtain 

assistance in managing patients with multiple

trauma, so too must institutional and medical staff initiate pre-planning if time-limited 

interventional therapies are to be available 

to stroke patients. 

Transfer Protocol Support

Hospital managers need to identify in advance 

the closest stroke referral centers, along with 

the most expedient means to transport patients

needing a higher level of care. Protocols should

exist to enable rapid contact with staff at the

receiving institution, as well as ambulance agencies providing appropriate transfer level of care, 

so that little time is lost arranging acceptance 

and transport. Important administrative issues 

in patient transfer include:

 Obtaining patient transfer consent

 Completing and copying medical records

 Providing duplicates or originals of any 

radiographic studies

 Completing appropriate transfer forms

All of these items must accompany the 

patient during transport. Transfer forms 

must include signatures from the patient 

or next of kin to ensure compliance with the 

Emergency Medical Treatment and Labor Act 

(EMTALA) requirements. 

Clinical Trial Access

While developing systems for local and remote

support of clinical decisions, consideration 

should be given to encouraging participation 

in clinical trials for acute stroke. Facilities 
91

Improving the Chain of Recovery for Acute Stroke in Your Community

offering participation in clinical trials are 

more likely to implement new therapies 

if they are proven to be beneficial. Participation in clinical trial networks promotes a 

sense of community commitment to improve

delivery of acute stroke care. Clinical trials 

also provide the infrastructure to support 

acute stroke management and help highlight the importance of aggressive early 

care. Ideally, consideration of clinical trials 

should be integrated into clinical management algorithms, whether paper or electronic

based. An electronic system offers the advantage of using automatic flags to identify 

patients eligible for research protocols. 

Manual systems can replicate this with 

intensive education and advertising about 

clinical trial eligibility.

Implementation and System 

Evaluation Support

To be effective in reducing stroke morbidity 

and mortality, support systems must not only 

be created, they must also be implemented. 

As outlined previously, multiple barriers at 

all levels of the health care system lead to 

suboptimal recognition and early management of stroke. A concerted effort on the 

part of all health care workers and health 

care administrators will be necessary to 

overcome these barriers. 

Delivery System Analysis and Implementation

To successfully implement an effective 

support system for frontline providers, each 

component of the chain of recovery for acute

stroke must be reviewed. This process also 

creates the expectation of high-quality performance from the various stakeholders in the

delivery system. Recommendations for system

analysis include focus groups (for medical staff

and administrators) and the use of checklists,

patient simulations, and/or external reviewers.

Each of these processes can identify specific 

areas for improvement. A clearly identified 

local leader for the process may be instrumental in implementing a successful change 

in acute stroke management behavior.

Focus groups are effective in identifying 

barriers to delivery of stroke care and are commonly used in the ED setting to evaluate the 

level and consistency of care in other medical 

situations. It is a familiar process and requires 

few additional resources to conduct beyond 

a facilitator and staff time. Potential groups

include EMS personnel; ED nursing, physician,

and ancillary personnel; radiology technicians 

and physician staff; neurology, neurosurgery, 

and pharmacy staff; intensive care unit personnel; and cardiac arrest team representatives.

Independent of a focus group evaluation, 

checklists may be used to ensure availability 

of needed resources — triage assessment tools,

emergent care pathways, inpatient care plans —

for stroke patients.

Patient simulations using mock “Code 

Stroke” events offer the advantage of actually 

testing a system design and can be done for 

a variety of patient subtypes, including: 

 Altered mental status

 Transient ischemic attack

 Acute ischemic stroke

 Acute hemorrhagic stroke

The mode of patient arrival or location 

at onset may reveal important system status 

information and should be varied in these 

simulations to include:

 Arrival by ambulance

 Arrival by private vehicle

 Symptom onset in long-term care facilities

 Symptom onset in hospital inpatients 

 Symptom onset in an outpatient clinic
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

The benefits of such testing include 

identifying areas of suboptimal access to care 

and increasing the visibility of the therapeutic

options in stroke in multiple health care settings. Such test situations also offer an effective

means for regularly evaluating an established

acute stroke treatment system. Finally, external

review by individuals with acute stroke care

expertise may assist in improving system 

design and care delivery. 

Educational Programs

Following development and identification of the

support systems available to assist in the care of

the stroke patient, their existence must be communicated clearly to all involved personnel. This

can occur via regular staff meetings, mock drills,

in-service meetings, and new-hire training materials. The opportunity to utilize repetitive forms 

of communications for educational reminders 

is encouraged, particularly email. 

Additional physician education in the 

management of acute stroke will also be 

needed. In a 1999 survey of emergency medicine residents, 89 percent indicated their willingness to use t-PA with either telephone or 

bedside neurology consultation, while only 

8 percent would administer the drug without 

a consult.35 A recent survey of graduating neurology residents found only 73 percent comfortable giving t-PA for stroke independently.36

Thus, it is not surprising to find a wide variation in attending physician practice with respect

to the acute treatment of stroke. In addition to

strengthening residency training programs in

stroke care there is an additional need to provide continuing medical education materials 

to those already in practice.

Credentialing

The formal process of credentialing new staff 

and re-credentialing current staff is a potentially powerful tool in the effort to increase 

staff knowledge about stroke care pathways, 

algorithms, and resources. For physicians 

with a significant probability of caring for 

patients with acute stroke a clear attestation 

of their diagnostic and treatment capability 

is recommended. 

From an institutional perspective, all 

health facilities providing stroke care need 

to establish policies supporting the chain of 

recovery for acute stroke. Opportunities exist 

for such organizations as the Joint Commission on Hospital Accreditation to champion 

this cause as they have done for other health 

care issues. Requirements for evidence of a 

hospital’s stroke care plan should be established with criteria for outcome assessment 

and this should be linked to the institution’s 

quality assurance/improvement program.

Establishing Support System Effectiveness

Considering the functional specifications of 

optimal stroke care, and the variety of system

tools that can serve to fulfill those specifications,

it may seem self-evident what needs to be done 

to improve local acute stroke practice. However,

initial and ongoing assessment is indispensable

for assuring that the implementation approach

chosen is effective in achieving this goal. 

Stroke care systems need to maintain a 

mechanism for ongoing assessment of performance. This can follow the structure/process/

outcome formulation, focusing on aspects essential to satisfying the functional specifications of

optimal stroke care. An example of a structure

measure might be whether a person skilled in

reading head CT scans is available 24 hours a 

day, or whether a “care map” or other description of expected stroke management is accessible to relevant care providers. Process measures

could include the time from “door to needle” in

patients receiving t-PA, rate of t-PA use, referral 

to physical therapy within 48 hours, or appropriate assessment for carotid testing. Outcome

measures could potentially include blood 

pressure or functional status on discharge. 
93

Improving the Chain of Recovery for Acute Stroke in Your Community

Some form of database or registry is 

valuable for assuring that the hospital has 

captured the population of stroke patients for

whom stroke systems may be relevant. What is

less clear is whether a stroke registry can serve 

all the needs for ongoing assessment for the

majority of hospitals that do not have comprehensive electronic medical record systems. In 

the absence of an electronic medical record 

system, experience suggests that a specialpurpose stroke registry should have a minimal

number of data elements; the choice of elements should only be sufficient to guide the 

selection of a sample of patients for either 

a prospective evaluation or a retrospective 

chart review of a subset of patients. These 

may possibly be implemented through existing hospital quality assurance mechanisms.

Improved resources to evaluate the impact 

of the cumulative effect of the above strategies 

in improving acute stroke care in the United 

States are recommended. Research into the 

optimum methods of creating medical care 

delivery systems to reduce morbidity and mortality from stroke is also encouraged. Effective

development, implementation, and monitoring 

of stroke support systems can improve the care 

of patients in the U.S. health system.

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4 Pearson HA. History of pediatric hematology 

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11 Kothari R, Hall K, Brott T, et al. Early stroke 

recognition: developing an out-of-hospital NIH

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12 Kidwell CS, Starkman S, Eckstein M, et al.

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13 Conroy MB, Rodriguez SU, Kimmel SE, et al. Helicopter transfer offers a potential benefit to patients

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air medical transportation after tissue plasminogen

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the delay in presentation and referral of stroke

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16 Crocco TJ, Kothari RU, Sayre MR, et al. A nationwide prehospital stroke survey. Prehosp Emerg Care

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20 Pysher L, and Harlow C. Teleradiology using 

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stroke: the Cleveland area experience. JAMA

2000;283: pp. 1151-1158.

23 Bravata DM, Kim N, Concato J, et al. Thrombolysis

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24 Sable CA, Cummings SD, Pearson GD, et al. Impact of

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25 Rogers FB, Ricci M, Caputo M, et al. The use of

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a retrospective analysis. Acad Emerg Med 1999;

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application of telemedicine for stroke. Stroke

1999;30: pp. 464-469.

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t-PA for the management of acute stroke in 

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stroke assessment: an NIH Stroke Scale and 

acute ischemic stroke management assistant 

for Palm or handheld computers. Acad Emerg 

Med 2002;9: p. 1060.

31 Guertler AT, Cortazzo JM, and Rice MM. Referral

and consultation in emergency medicine practice.

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approach to immediate evaluation and management of hyperacute stroke: experience at 

eight centers and implications for community 

practice and patient care. Stroke 1997;28: 

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33 Hill MD, Barber PA, Demchuk AM, et al. Building 

a “brain attack” team to administer thrombolytic

therapy for acute ischemic stroke. CMAJ 2000;162:

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34 Wang DZ, Rose JA, Honings DS, et al. Treating 

acute stroke patients with intravenous TPA: the 

OSF Stroke Network experience. Stroke 2000;31: 

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35 Kunnel B, and Heller M. Thrombolytics and stroke:

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residents’ experience with iv tPA for acute stroke.

Neurology 2001;57: pp. 1729-1730.
95

Improving the Chain of Recovery for Acute Stroke in Your Community

APPENDIX

Provider Support Systems: Suggested Sites for Additional Information

National Institute of Neurological Disorders and Stroke

http://www.ninds.nih.gov/

Brain Attack Coalition 

http://www.stroke-site.org/

List of Professional Society Guidelines for Stroke Treatment

http://www.stroke-site.org/guidelines/guidelines.html

American Stroke Association

http://www.strokeassociation.org/

The Internet Stroke Center at Washington University

http://www.strokecenter.org/prof/index.html

National Stroke Association, professional resources

http://www.stroke.org/

Foundation for Education and Research in Neurologic Emergencies

http://www.ferne.org/

eMedicine 

http://www.emedicine.com/emerg/NEUROLOGY.htm

Virtual Hospital, University of Iowa

http://www.vh.org/adult/provider/neurology/Stroke/index.html

American Academy of Neurology, stroke clinical assessment instruments

http://www.aan.com/professionals/patient/clinical.cfm

Steering Committee

Co-Chairs

William G. Barsan, M.D.

Professor and Chair

Department of Emergency Medicine

University of Michigan Health System

Ann Arbor

Paul E. Pepe, M.D., M.P.H.

Professor of Medicine, Surgery, Public Health 

and Chair, Emergency Medicine

University of Texas Southwestern Medical Center at

Dallas and the Parkland Health and Hospital System

Members

Marian A. Emr

Director, Office of Communications and Public Liaison

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Bethesda

Thomas G. Kwiatkowski, M.D.

Chair

Department of Emergency Medicine

Long Island Jewish Medical Center

New Hyde Park, New York 

Christopher A. Lewandowski, M.D.

Residency Program Director

Department of Emergency Medicine

Henry Ford Hospital

Detroit

Patrick D. Lyden, M.D.

Director, Stroke Center

Professor of Neurosciences

Chief, Clinical Neurology

University of California at San Diego Medical Center

Staff Neurologist, Veterans Administration Medical

Center at San Diego

John R. Marler, M.D.

Associate Director for Clinical Trials

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Bethesda

Lewis B. Morgenstern, M.D.

Associate Professor of Neurology and Epidemiology

Department of Neurology

University of Michigan Health System

Ann Arbor

David S. Nilasena, M.D.

Medical Officer

Centers for Medicare & Medicaid Services

Dallas

Arthur M. Pancioli, M.D.

Assistant Professor and Vice Chair

Department of Emergency Medicine

University of Cincinnati

Karen Rapp, R.N.

Certified Clinical Research Coordinator

University of California at San Diego Medical Center

Margo Warren

Chief, Public Liaison Section

Office of Communications and Public Liaison

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Bethesda

Steering Committee and Task Force Members
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A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Increasing Public Recognition and Rapid Response to Stroke Task Force

Alfred S. Callahan III, M.D.

Neurologic Consultants

Nashville, Tennessee 

Marc Eckstein, M.D.

Associate Professor

Department of Emergency Medicine

Keck School of Medicine of the University of 

Southern California

Los Angeles

Scott Kasner, M.D.

Associate Professor

Director, Comprehensive Stroke Center

University of Pennsylvania

Philadelphia

Russell V. Luepker, M.D.

Mayo Professor and Head

Division of Epidemiology

School of Public Health

University of Minnesota

Minneapolis

Karen Rapp, R.N.

Certified Clinical Research Coordinator

University of California at San Diego Medical Center

Chair

Lewis B. Morgenstern, M.D.

Associate Professor of Neurology and Epidemiology

Department of Neurology

University of Michigan Health System

Ann Arbor

Co-Chair

Wayne Rosamond, Ph.D.

Associate Professor

Department of Epidemiology

University of North Carolina

Chapel Hill

Members

Mark J. Alberts, M.D.

Director, Stroke Program

Department of Neurology

Northwestern University

Chicago

L. Kay Bartholomew, Ed.D., M.P.H.

Associate Professor of Behavioral Sciences

Associate Director of the Center for Health Promotion

and Prevention Research

University of Texas Health Science Center at Houston
99

Improving the Chain of Recovery for Acute Stroke in Your Community

Chair

Andy Jagoda, M.D.

Professor

Department of Emergency Medicine

Vice Chair for Academic Affairs and Residency Director

Department of Emergency Medicine

Mount Sinai Hospital

New York, New York

Co-Chair

Arthur M. Pancioli, M.D.

Assistant Professor and Vice Chair

Department of Emergency Medicine

University of Cincinnati

Members

Andrew W. Asimos, M.D.

Associate Medical Director, Stroke Program

Department of Emergency Medicine

Carolinas Medical Center

Charlotte, North Carolina 

William G. Barsan, M.D.

Professor and Chair

Department of Emergency Medicine

University of Michigan Health System

Ann Arbor

Kevin Baumlin, M.D., F.A.C.E.P.

Assistant Professor and Director of Informatics

Department of Emergency Medicine

Mount Sinai School of Medicine

New York, New York

William Dalsey, M.D.

Director, Emergency Medicine

Kimball Medical Center

Blue Bell, Pennsylvania 

Kathleen A. Delaney, M.D.

Medical Director

Parkland Emergency Services Department

Professor of Surgery and Medicine

University of Texas Southwestern Medical Center 

at Dallas

Edward Goldman, J.D.

Health System Lawyer

Health Systems Legal Office

University of Michigan

Ann Arbor

Margaret Gradison, M.D.

Chief of Family Medicine

Associate Clinical Professor

Department of Community and Family Medicine

Duke University Medical Center

Durham, North Carolina 

Markku Kaste, M.D., Ph.D.

Professor of Neurology

Chairman, Department of Neurology

Helsinki University Central Hospital

University of Helsinki

Helsinki, Finland 

Walter J. Koroshetz, M.D.

Associate Chief, Neurology and Stroke Services

Associate Professor of Neurology

Medical Director, Neurointensive Care Services

Massachusetts General Hospital

Harvard Medical School

Boston

Thomas G. Kwiatkowski, M.D.

Chair

Department of Emergency Medicine

Long Island Jewish Medical Center

New Hyde Park, New York 

Marc Mayberg, M.D., F.A.H.A.

Professor and Chair

Department of Neurosurgery

Cleveland Clinic Foundation

Choosing Your Level of Care Task Force
100

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Robert M. McNamara, M.D.

Professor and Chair

Department of Emergency Medicine

Temple University Hospital

Philadelphia

C. Crawford Mechem, M.D.

Assistant Professor of Emergency Medicine

University of Pennsylvania

Philadelphia

Daniel Morelli, M.D.

Professor of Clinical Family Medicine

Chief Medical Officer

Millard Fillmore Suburban Hospital

Williamsville, New York 

Hal Unwin, M.D.

Associate Professor and Vice Chair

Department of Neurology

University of Texas Southwestern Medical Center 

at Dallas

David Wang, D.O.

Director, OSF Stroke Network

Clincal Assistant Professor of Neurology

University of Illinois College of Medicine at Peoria

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

Assistant Professor

Department of Emergency Medicine Research Center

Assistant Director

Emergency Medicine Research Center

Emory University

Atlanta
101

Improving the Chain of Recovery for Acute Stroke in Your Community

Chair

Patrick D. Lyden, M.D.

Director, Stroke Center

Professor of Neurosciences

Chief, Clinical Neurology

University of California at San Diego Medical Center

Staff Neurologist

Veterans Administration Medical Center at San Diego

Co-Chair

Susan L. Hickenbottom, M.D., M.S.

Clinical Assistant Professor of Neurology

Department of Neurology

University of Michigan Health System

Ann Arbor

Members

Richard P. Atkinson, M.D.

Associate Clinical Professor of Neurology

University of California at Davis

Sacramento

Lisa Davis, R.N., M.S.N.

Senior Nurse Specialist

National Institutes of Health Stroke Team

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Bethesda

Jeremy Golding, M.D.

Associate Professor of Clinical Family Medicine 

and Community Health

Inpatient Services Director, Department of Family Medicine

University of Massachusetts Memorial Health Care System

Hahnemann Family Health Center

Worcester

Judith A. Hinchey, M.D.

Assistant Professor

St. Elizabeth’s Medical Center

Division of Clinical Care Research

New England Medical Center

Boston

Kurt Kleinschmidt, M.D.

Associate Professor

Department of Emergency Medicine

University of Texas Southwestern Medical Center 

at Dallas

Thomas G. Kwiatkowski, M.D.

Chair

Department of Emergency Medicine

Long Island Jewish Medical Center

New Hyde Park, New York 

Christopher A. Lewandowski, M.D.

Residency Program Director

Department of Emergency Medicine

Henry Ford Hospital

Detroit

Colin C. Rorrie, Jr., Ph.D., C.A.E.

Executive Director

American College of Emergency Physicians

Irving, Texas 

Edward P. Sloan, M.D., M.P.H., F.A.C.E.P.

Associate Professor

Department of Emergency Medicine

University of Illinois at Chicago

Judith A. Spilker, R.N.

Clinical Nurse Coordinator

Department of Emergency Medicine

University of Cincinnati

Robert E. Suter, D.O., M.H.A.

Board of Directors

American College of Emergency Physicians

Irving, Texas 

Steven Warach, M.D., Ph.D.

Chief

Stroke Diagnostic and Therapeutic Section

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Bethesda

Professional Education Task Force
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Chair

David Persse, M.D.

Physician Director

Emergency Medical Services

City of Houston

Co-Chair

Richard C. Hinton, M.D.

Chairman, Dallas Area Stroke Council

Associate Clinical Professor

University of Texas Southwestern Medical Center at Dallas

Director of Stroke Services at Presbyterian Hospital of Dallas

Members

Joe E. Acker III, M.P.H., E.M.T.-P.

Executive Director

Birmingham Regional Emergency Medical Services System

University of Alabama at Birmingham

Todd J. Crocco, M.D.

Department of Emergency Medicine

Health Sciences Center

West Virginia University

Morgantown

James V. Dunford, M.D., F.A.C.E.P.

City of San Diego EMS Medical Director

Professor of Clinical Medicine and Surgery

Department of Emergency Medicine

University of California at San Diego Medical Center

James C. Grotta, M.D.

Director, Stroke Program

Department of Neurology

University of Texas Health Science Center at Houston

Anne D. Leonard, R.N., M.P.H.

Coordinator, Stroke Program

Department of Medicine and Neurology

University of Texas Health Science Center at San Antonio

J.P. Mohr, M.D.

Sciarra Professor of Neurology

Director of the Doris and Stanley Tailanbaum 

Stroke Center

Neurological Institute of New York

Columbia-Presbyterian Medical Center

New York, New York

Paul E. Pepe, M.D., M.P.H.

Professor of Medicine, Surgery, Public Health and 

Chair, Emergency Medicine

University of Texas Southwestern Medical Center at

Dallas and the Parkland Health and Hospital System

Dallas

Michael R. Sayre, M.D.

Department of Emergency Medicine

The Ohio State University

Columbus

Jane Wigginton, M.D.

Assistant Professor of Surgery

Division of Emergency Medicine

University of Texas Southwestern Medical Center at Dallas

Paula Willoughby, D.O.

Medical Director

Emergency Medical Services

Chicago Fire Department

Daniel J. Worman, M.D.

Chair of Operation Stroke and Assistant Professor

Department of Emergency Medicine

Medical College of Wisconsin

Froedtert East Hospital

Milwaukee

Judith R. Yates

Vice President and Chief Operating Officer

Healthcare Association of San Diego and Imperial Counties

Templates for Organizing Stroke Triage Task Force
103

Improving the Chain of Recovery for Acute Stroke in Your Community

Chair

Sandra M. Schneider, M.D.

Professor and Chair

Department of Emergency Medicine

Strong Memorial Hospital

University of Rochester Medical Center

Rochester, New York

Co-Chair

Larry B. Goldstein, M.D.

Director, Center for Cerebrovascular Disease

Professor of Medicine (Neurology)

Duke University Medical Center

Durham, North Carolina 

Members

James G. Adams, M.D., F.A.C.E.P.

Professor and Chief

Division of Emergency Medicine

Feinberg School of Medicine

Northwestern Memorial Hospital

Chicago

Kenneth L. DeHart, M.D., F.A.C.E.P.

President and Chief Executive Officer

Carolina Health Specialists

Myrtle Beach, South Carolina

Andrew M. Demchuk, M.D.

Assistant Professor

Department of Clinical Neurosciences

Foothills Medical Center

Calgary, Alberta, Canada

Anthony J. Furlan, M.D.

Head, Section of Stroke

Cleveland Clinic Foundation

Michael D. Hill, M.D.

Assistant Professor

Calgary Stroke Program, University of Calgary

Department of Clinical Neurosciences

Foothills Medical Center

Calgary, Alberta, Canada

Michael T. Rapp, M.D., J.D.

Past President

American College of Emergency Physicians

Department of Emergency Medicine

George Washington University

Washington, DC 

Joseph P. Wood, M.D., J.D.

Mayo Clinic Hospital

Phoenix

Incentives for Enhancing Stroke Care Task Force
104

A NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE SYMPOSIUM

Chair

Sidney Starkman, M.D.

Professor of Emergency Medicine and Neurology

Co-Director, UCLA Stroke Center

University of California at Los Angeles

Co-Chair

Phillip A. Scott, M.D.

Assistant Professor

Department of Emergency Medicine

University of Michigan

Ann Arbor

Members

John Y. Choi, M.D.

Assistant Professor

Department of Neurology

University of Texas Health Science Center at Houston

Brian F. Connolly, M.D.

Clinical Associate Professor

Department of Family Medicine

State University of New York at Buffalo

Karen L. Furie, M.D.

Assistant Professor

Department of Neurology

Massachusetts General Hospital

Boston

J. Stephen Huff, M.D.

Associate Professor of Emergency Medicine 

and Neurology

Department of Emergency Medicine

University of Virginia Health System

Charlottesville

Walter N. Kernan, M.D.

Associate Professor

Department of Internal Medicine

Yale University School of Medicine

New Haven

Marian P. LaMonte, M.D., M.S.N.

Associate Professor of Neurology and Surgery, 

Division of Emergency Medicine

Department of Neurology

Director, The Maryland Brain Attack Center

University of Maryland School of Medicine

Baltimore

Dennis M.D. Landis, M.D.

Chair, Department of Neurology

University Hospitals of Cleveland

Case Western Reserve University

Steven R. Levine, M.D.

Professor, Department of Neurology

Director, Cerebrovascular Education Stroke Program

Mount Sinai School of Medicine

New York, New York

David B. Matchar, M.D.

Professor of Medicine and Director

Center for Clinical Health Policy Research

Duke University

Durham, North Carolina

Brett C. Meyer, M.D.

Assistant Professor, Department of Neurosciences

Co-Director, UCSD Stroke Center

University of California at San Diego Medical Center

Debra G. Perina, M.D.

Associate Professor

Department of Emergency Medicine

University of Virginia

Charlottesville

Jeffrey L. Saver, M.D.

Neurology Director, UCLA Stroke Center

Department of Neurology

University of California at Los Angeles

Lee H. Schwamm, M.D.

Assistant Professor of Neurology

Harvard Medical School

Associate Director, Acute Stroke Service

Department of Neurology

Massachusetts General Hospital

Boston

Provider Support Systems for Acute Stroke Task Force
Agency for Healthcare Research and Quality 

Air & Surface Transport Nurses Association

Air Medical Physician Association

Alliance for Aging Research

American Academy of Emergency Medicine

American Academy of Neurology

American Academy of Nurse Practitioners

American Academy of Physical Medicine 

and Rehabilitation

American Academy of Physician Assistants

American Association of Critical Care Nurses

American Association of Neurological Surgeons

American Association of Neuroscience Nurses

American Association of Occupational Health Nurses

American Board of Psychiatry and Neurology, Inc.

American College of Emergency Physicians

American College of Physicians

American College of Radiology

American Congress of Rehabilitation Medicine

American Geriatrics Society

American Health Care Association

American Hospital Association

American Neurological Association

American Nurses Association

American Pharmaceutical Association

American Public Health Association

American Red Cross

American Society of Emergency Radiology

American Society of Interventional and 

Therapeutic Neuroradiology

American Society of Neuroimaging

American Society of Neuroradiology

American Stroke Association, a Division of 

the American Heart Association

Association of American Medical Colleges

Association of Physician Assistant Programs

Association of Rehabilitation Nurses

Association of Schools of Allied Health Professions

Association of University Professors of Neurology

Canadian Congress of Neurological Sciences

Canadian Medical Association

Canadian Stroke Consortium

Canadian Stroke Network

Centers for Disease Control and Prevention

Child Neurology Society

Commission on Accreditation of Medical 

Transport Systems

Congress of Neurological Surgeons

Council of Emergency Medicine Residency Directors

Dana Alliance for Brain Initiatives

Emergency Nurses Association

Food and Drug Administration

International Association of Fire Fighters

Joint Commission on Accreditation of 

Healthcare Organizations

National Academy of Emergency Medical Dispatch

National Association of Emergency Medical Technicians

National Association of EMS Educators

National Association of EMS Physicians

National Association of State EMS Directors

National Black Nurses Association

National Committee for Quality Assurance

National Council of State Emergency 

Medical Services Training Coordinators

National Flight Paramedics Association

National Foundation for Brain Research

National Heart, Lung, and Blood Institute

National Hispanic Medical Association

National Medical Association

National Registry of Emergency Medical Technicians

National Stroke Association

Royal College of Physicians and Surgeons of Canada

Society for Academic Emergency Medicine

Society of General Internal Medicine

Society of Interventional Radiology

Society of Nuclear Medicine

Stroke Belt Consortium

Veterans Administration

Partners

The following organizations joined with the NINDS to develop agreement on how systems can be 

created and improved to benefit acute stroke patients in all communities.


Prepared by

Office of Communications and Public Liaison 

National Institute of Neurological Disorders and Stroke 

National Institutes of Health 

Department of Health and Human Services

Bethesda, Maryland 20892

NIH Publication No. 03-5348 

September 2003