American Stroke Association Releases Updated Recommendations for Stroke Care Systems

The American Stroke Association (ASA) has published updated recommendations for stroke care systems (Stroke. 2019;50:00-00). The recommendations comprehensively review evidence evaluating stroke care systems and update previous ASA recommendations based upon advances in stroke care systems. Among such advances are stroke center certifications, remarkable improvement in endovascular therapy, neurocritical care, telestroke, mobile stroke units, and other innovations. All of this has occurred while the landscape of health care in the US has undergone large changes. The statement addresses prevention and recognition of stroke, emergency medical services (EMS) and triage, stroke center care, secondary prevention at hospital discharge, and postdischarge rehabilitation.

New recommendations, in brief, include:

• Support for communities and individuals to achive long-term adherence to stroke prevention and local and regional education to increase stroke awareness for the general population and populations at increased risk for stroke or poor outcomes after stroke. 
• Public education programs focused on seeking emergency care (by calling 911) and understanding stroke systems designed to reach diverse populations and monitoring of all community education and supports to determine efficacy for improving response to symptoms, treatment, mortality and other outcomes. 
• Innovative interventions (eg, gamification, machine learning, social network analysis) addressing barriers to healthy behaviors, prevention adherence, and warning sign action 
• Development of EMS triage paradigms and protocols to ensure rapid identification of persons with stroke using validated and standardized instruments. 
• Transport protocols such that transport is to the highest level of care center within a similar travel time and not bypassing an alteplase-capable center in favor of a thrombectomy-capable center more than 15 minutes away unless the stroke severity score is suggestive of LVO. 
• Prearrival notification by EMS that a stroke patient is en route in all cases.
• All levels of stroke centers should work within their region in an integrated fashion, providing and sharing best practice.
• Timely completion of parenchymal and arterial imaging (CT or magnetic resonance) to identify those who may benefit from thrombectomy. 
• Transfer protocols for hospitals without thrombectomy capability. 
• Rigorous tracking of patient flow at all time points from presentation to imaging to intervention to allow iterative process improvement. 
• Standards for certifying and monitoring endovascular training and treatment. 
• Secondary prevention focused on modifiable risk factors with supports to ensure all persons who have had a stroke receive appropriate follow up from stroke services and primary care professionals, including education for families of people who have had a stroke
• Comprehensive screening for postacute complications, individualized plans for care transitions, and referrals to community services for secondary prevention and self-management of modifiable risk factors
• Standardized screening evaluation regarding need for rehabilitation services including type, timing, location, and duration with long-term follow up arranged. Screening should include neurologic, psychologic cognitive and functional assessments, medical comorbidities, the level of family/caregiver support, likelihood of returning to community living, and ability to participate in rehabilitation.
• Periodic assessment of a stroke care system rehabilitation capacity that addresses current and future needs
• Use of technology and patient-reported outcomes to improve care transitions to refine these with continuous quality improvement measurement and methods. 
• Federal or other governmental institutions should enact policies that standardize the organization of stroke care throughout the continuum. 

It is the position of the ASA that programs to improve public health knowledge; encourage stroke prevention; advance therapy, secondary prevention and recovery; and address disparities in stroke care should be actively developed in a coordinated and collaborative fashion by providers and policy-makers at the local, state, and national levels.