In June 1996, tissue-type plasminogen activator (t-PA; see alteplase) was the first drug to be approved by the US Food and Drug Administration (FDA) for the acute treatment of stroke. This drug has been shown to work only within the first 3 hours of onset of symptoms, making stroke treatment a true emergency.  The short treatment window requires rapid evaluation of patients who may have had a stroke. Stroke teams have been created for this purpose.
The members of a stroke team vary depending on the needs of the individual hospital, although code team personnel often include 1 or more neurologists and nurses.
To achieve maximal efficiency, the team must integrate itself with the services and facilities involved in the care of patients with acute stroke, including the local community, emergency medical services (EMS), the emergency department (ED), interventional radiology (IR), neurosurgery, nursing, computed tomography (CT) scanning, laboratory, pharmacy, rehabilitation, and inpatient units.
The team educates the public and care providers about stroke warning signs and the availability of stroke treatments, evaluates and streamlines services, provides stroke treatment rapidly, and continually monitors the efficacy of its work. This article examines the creation of the stroke team and the role of the Primary Stroke Center in improving the delivery and coordination of care in acute stroke. [2, 3]
Establishment of Primary Stroke Centers
Stroke center guidelines
The Brain Attack Coalition published a set of recommendations for the establishment of primary stroke centers, in 2000. [4, 15] These recommendations consist of 11 major elements that help an organization to achieve the level of collaboration among services required to rapidly identify and treat acute stroke patients. The Joint Commission also adopted these elements for their Disease-Specific Primary Stroke Center Certification.  The 11 elements consist of the following:
Hospital and administrative support
Acute stroke team
Written care protocols
Emergency medical systems
Stroke Team Organization
The first major element is the creation of an acute stroke team. The team is made up of 2 parts: (1) the code team members, who respond to a code pager and deliver urgent treatment, and (2) a task force that works daily to facilitate patient access to treatment.
Usually, the code team consists of a neurologist or, in some cases, an ED physician, and a nurse. The task force, which is frequently larger, may include members from many disciplines, including neurology, emergency medicine, neurosurgery, nursing, radiology, pharmacy, laboratory, physical medicine, and rehabilitation.
Hospital and Administrative Support
Development of the team often requires early input from the hospital's administration to enhance problem solving and integration between services. Designation of resources in the form of a specific individual, often an advanced practice nurse, to lead the initiative is beneficial for keeping the process organized and consistently moving forward.
Written Care Protocols
Creating a written care protocol is helpful (see the document below). This outlines what each member of the team is responsible for and helps to set time frames for what is to be accomplished. Devising separate sections for actions based on the duration of a patient's stroke symptoms is a useful organizational strategy (ie, < 3 h, 3-8 h, >24 h). See the PDF below.
Representatives from each discipline should take part in determining the content of the protocol. These discussions may seem time-consuming on the front end, but they can be extremely helpful on the back end, because all parties have come to a consensus on how the acute stroke patient is to be managed. Protocols should be reviewed and revised annually and can be used as part of quality improvement initiatives.
Prehospital Needs for Medical Response to Stroke
Public and care-provider education
Although many patients know the symptoms of a heart attack, few are aware of the signs and symptoms of stroke. Persons who are most at risk for stroke, the elderly, are the least likely to know the risk factors and warning signs of stroke. In addition, while a heart attack frequently causes discomfort that invites the patient to seek rapid medical attention, a stroke does not. These factors impede the early arrival of patients in the ED, preventing them from receiving treatment. Patient education regarding stroke symptoms and the need to call 911 for these symptoms is imperative.
Primary care providers also must be educated on the availability of therapy for acute stroke and the critical 3-hour time frame for treatment with intravenous t-PA and the window (up to 8 hrs) for intra-arterial t-PA or clot extraction maneuvers. Primary care providers should encourage patients' use of the EMS system.
Because primary care physicians see patients before they present with ischemic events, care providers in the community can identify patients at high risk for stroke and initiate preventive therapies.
Emergency medical services
EMS providers must be trained in the recognition of stroke and in prioritizing the patient with stroke for rapid transport to the hospital. The prehospital stroke scale used in Cincinnati defines 3 major physical findings to identify patients with stroke: facial droop, arm weakness, and speech abnormalities. 
EMS providers can assist the treatment process further by establishing the time of onset of stroke symptoms. They need to be aware of the time frames for intravenous and intra-arterial t-PA as well as clot extraction maneuvers, and they must know which facilities in their region are set up to provide these therapies. Although a variety of regional policies exist for the regulation of patient transportation, it is recommended that processes to enable rapid access to appropriate therapies be instituted. 
EMS staff members should be reminded not to overtreat high blood pressure in the stroke patient, in whom maintaining perfusion pressure to the brain is vital. Once a brief assessment has been performed, the time spent in the field must be minimized. Stroke patients should be transported to the hospital with the same level of urgency as those with myocardial infarction (sometimes referred to as "load and go"). Early notification of ED personnel can shorten the time to evaluation so that treatment can start as soon as the patient arrives in the ED.
Patients with strokes who arrive by EMS instead of private transport were more likely to receive brain imaging and physician interpretation of the imaging within recommended target times.  EMS arrivals with hospital prenotification had more rapid evaluations than those without hospital prenotification.
Hospital Needs in Stroke Care
Once the patient arrives in the ED, ED personnel should perform a brief assessment of the patient and immediately contact the stroke code team. To make this as easy as possible, the code team is best reached through a single pager number. The efficiency of the ED evaluation and treatment can be enhanced by following the multidisciplinary written care protocol that outlines the role of each ED member and the steps to be followed.
The first step is to contact the stroke code team before the evaluation is complete. Full history, examination, CT scan, and other laboratory results may still be pending when the code team is called. The respective roles of the code team nurse and the ED nurse in performing such tasks as starting a second intravenous line, taking blood pressure, or mixing the t-PA, if it is to be administered, need to be defined. Standard orders may save valuable time and prevent omissions in the care of the patient with acute stroke. ED personnel can be helpful in locating family members who might have additional information about the time of onset of stroke and other issues concerning the patient. (See the PDFs below.)
Radiology, Laboratory, and Pharmacy
The stroke pathway or protocol in the ED should provide for diagnostic studies in every patient with stroke.  Of these, the most critical is the computed tomography (CT) scan. The procedure for obtaining the CT scan should be streamlined to ensure that the scan is obtained urgently (within 25 minutes of arrival). The CT scanner and someone to read the scan need to be readily available at all hours or arrangements must be made for transfer of the patient to another hospital with these facilities.
Code team members may need to transport the patient to the CT scanner if waiting for someone else to perform this service might delay the scan. Laboratory tests should be ordered and performed promptly so that the results are available within 45 minutes. A chest radiograph and 12-lead electrocardiogram (ECG) within 45 minutes is also helpful. If the drugs required for treatment, including t-PA, are not located in the ED, the procedure for obtaining them from the pharmacy after regular hours needs to be outlined and administration instructions should be easily accessible.
The protocol should include criteria for which patients will be admitted or transferred to another facility with more comprehensive stroke services available. (See Referring Stroke Patients (PDF).) 
Inpatient units receiving patients after the initial ED workup should have staff trained in the care of the acute stroke population. Multidisciplinary care protocols should be written outlining inpatient management in the critical care and acute care phase, as well as monitoring of the patient post–t-PA. (See the PDFs below.)
Preprinted order sets can help ensure predefined care elements are considered. (See the PDFs below.)
Facilities keeping these patients will need to develop a plan to have fully functional operating room facilities and neurosurgical staff available within 2 hours of the clinical need being recognized. If that is not possible, a transfer plan should be developed for those patients who are identified as needing neurosurgical services the facility is not able to provide.
Remote consults from a regional comprehensive stroke center can be very helpful in making these decisions.
Monitoring and Improvement of the Stroke Care System
Continual review of the entire stroke care system can help to improve its function.  In particular, delays in evaluation and treatment should be investigated and causes corrected. The stroke protocol can be used to assess outcome measures, such as the timeliness of interventions, patient recovery, and costs. Feedback given to the people involved in the patient's care, including EMS personnel and those in the ED, provides an educational opportunity and maintains interest in providing care to patients with acute stroke.
The Get With the Guidelines-Stroke database can be very helpful in driving quality improvement activities.  Demographic and clinical data are entered for each patient admitted with acute stroke (ischemic stroke, transient ischemic attack, intracerebral hemorrhage, or subarachnoid hemorrhage). Reports can be run to track performance on a variety of indicators, including 10 predetermined stroke performance measures. These 10 measures focus on early identification and treatment with t-PA, prevention of inhospital complications, and secondary stroke prevention. The performance measures are as follows:
Deep venous thrombosis (DVT) prophylaxis
Discharged on antithrombotics
Patients with atrial fibrillation receiving anticoagulation therapy
Antithrombotic medication within 48 hours of hospitalization
Screen for dysphagia (See the PDF below.)
Stroke education for patient/family
Tobacco cessation counseling for patient/family
Plan for rehabilitation considered
The Mobile Stroke Team and Hospital Network
In some cities, coordinating stroke treatment efforts among multiple hospitals has been helpful. [12, 13] In these cases, a single stroke code team is mobile and travels between the hospitals. The mobile stroke team allows specialized stroke care to be provided to hospitals that by themselves may not have such resources, while avoiding time delays and costs incurred through transfer of a patient to a single site.
Telemedicine technology can also expand the reach of stroke neurologist expertise to community hospitals and rural areas. Clinical outcomes have been demonstrated to be similar for intravenous t-PA guided through telestroke technology and that given at a tertiary stroke center. 
Rapid recognition and treatment for the patient with acute stroke can improve clinical outcomes  . A coordinated multidisciplinary effort is necessary to accomplish this goal. The establishment of a stroke team and adherence to the recommendations for a Primary Stroke Center can provide a clear framework for development of a successful program.
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- Establishment of Primary Stroke Centers
- Stroke Team Organization
- Hospital and Administrative Support
- Written Care Protocols
- Prehospital Needs for Medical Response to Stroke
- Hospital Needs in Stroke Care
- Monitoring and Improvement of the Stroke Care System
- The Mobile Stroke Team and Hospital Network
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