Certification for Primary Stroke Center

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  1. Introduction
  2. Review of the Literature
  3. Recommended Leadership Style
  4. Recommended Communication Strategies
  5. Recommended Change Management
  6. Resolution Strategies
  7. Potential Costs and Anticipated Benefits
  8. Conclusion
  9. References

Introduction

The certification process for stroke centers (Table 1) was initiated following a unanimous statement evidenced in the Journal of American Medical Association of 2000. The Brain Attack Coalition played a significant role in the drafting of this essential landmark agreement in stroke care (Hassan et al., 2019). Since then, other consensus statements have been published detailing the need for different levels of stroke centers and their treatment capabilities. A good example of such centers is the primary Stroke Center (PSC). It is important to note that PSC falls under level two of certification (see the table below for details) (Chen et al., 2022). Certification for PSC offers care providers the needed capability to ensure reasoned and consistent referral. In fact, the treatment capabilities of these centers remain to be a major determinant for certification. Once certified, Primary Stroke Centers should have dedicated stroke beds, at least a 2-hour period available for neurosurgery and the presence of in-house medical management. Similarly, certification for Primary Stroke Center is significant since it recognizes the facilities that meet the set standards– it aims at improving quality care and better outcomes for stroke care (Chen et al., 2022).

Table 1: Stroke Centers

Level Type of Center
Level 1 Comprehensive Stroke Center (CSC)
Level 2 Primary Stroke Center (PSC)
Level 3 Thrombectomy-Capable Stroke Center (TSC)
Level 4 Acute Stroke Ready Hospital Certification (ASRH)

Review of the Literature

Several studies have been carried out to ascertain the benefits associated with PSC-certification. Multiple studies have indicated a direct relationship between the certification process and improvement in stroke care. Man et al. (2018) focused their research on discussing some of these advancements. They include a well-streamlined treatment process, an increase in thrombolysis rates and better outcomes. While this is the case, Man et al. (2018) maintained that only a few centers in the United States have achieved certification due to the many barriers associated with the process. These barriers include high costs, lack of “diversion of the patient to the right level, presence of leadership and shortage of neurological experts” (Man et al.,2018, p. 45).

In another article, the researchers were interested in examining whether improvements in acute stroke care at PSCs are associated with certification or factors intrinsic to the facility. To achieve this, Shkirkova et al. (2020) relied on the data obtained from Field Administration of Stroke Therapy. From this, their findings showed that hospitals with PSC “designation had a shorter time of door to first imaging” (Shkirkova et al., 2020, p. 34). For instance, in cerebral ischemia, PSC hospitals recorded a high rate of tPA use, specifically for those patients who met the criteria for thrombolytic treatment.

The findings indicated above were influenced by prior studies whose analysis demonstrated mixed results. In Almallouhi et al.’s (2019) study, the scholars found that centers certified as PSCs had a high patient outcome compared to non-certified facilities. Some of the end results studied by the Almallouhi et al. (2019) include in-hospital mortality, one-month mortality rate, and one-month readmission rate – all of them were found to be lower in certified facilities. However, this article failed to consider the severity of stroke which may end up affecting the outcomes. In addition to this, the Almallouhi et al. (2019) were not able to address the thrombolytic use in stroke. This led the authors to conclude that the “examination of cross-sectional analysis examining the benefits of stroke center certification have the potential to be bias if they fail to incorporate the differences” (Almallouhi et al., 2019, p. 173). A follow-up study by Baker et al. (2022) aimed at comparing the facilities with and without certification. The scholars focused mainly on the one-month risk standardization and readmission rates. Their findings indicated that 50 percent of PSCs had a lower mortality rate compared to 19 percent of non PSCs. They later concluded that certification did not necessarily indicate better performances and outcomes.

In a different article carried out in 2018, the researchers were interested in finding out whether stroke centers had an impact on mortality. From this, Man et al. (2018) observed a significant reduction in mortality rate in PSCs admitted patients compared to those in non-PSCs. More specifically, the authors managed to show that the existing outcome differences were in line with a diagnosis of stroke vs. acute myocardial infarction. A closer look at these findings it is clear that there is a major improvement in stroke care end results in certified PSCs.

Leadership plays a critical role in the delivery of high-quality services to patients in primary stroke centers. More specifically, the recommended leadership style for PSCs must be transformative in nature because these centers have been criticized previously for providing services that are poorly tailored to patients needs. With transformational leadership style, PSCs will overcome the challenge of setting up stroke services that has persisted for many years. For example, the adoption of this style will reduce the number of waits and delays witnessed in the care facilities. In a study undertaken by Duncan (2019), the author demonstrated how transformational leadership guided different centers in the Netherlands in the adoption of a prospective budgeting system. The centers were given budgets that were negotiated with sickness funds and private insurers. The budgets were intended to cover operating costs and capital costs for inventory. The leadership played an important role in centralizing price setting as well as decentralizing negotiations on volumes.

In line with the above, transformational leadership is best suited to PSCs because it facilitates collaboration to develop relationships within the organization. Collaboration is critical in these centers as it increases the team’s awareness of each others’ type of knowledge and skills which improve decision-making as far as stroke services are concerned. Adeoye et al. (2019) observed the importance of teamwork in primary stroke centers – it ensures members are working together for the good of the patient. Additionally, this style is recommended because it creates a sound patient culture within the healthcare facility. Adeoye et al. (2019) further noted that transformational leadership inspires employees to act beyond their own needs and interest –for the greater good of the patient. Similarly, the leaders that exercise this style understand the organizational needs and will constantly work towards changing the culture to benefit the facility.

There are several communication strategies that, if implemented, could improve stroke patient care. The first strategy is the Background, Assessment, Recommendation (SBAR) structured communications. SBAR aim at improving patient safety by ensuring information is accurately shared between healthcare providers. As explicated by Dalky et al. (2020), SBAR has proven effective for nurse to nurse communications during shift change. This strategy exists to ensure structured conversations – the information shared across becomes accurate and efficiently transferred. SBAR is also useful in ensuring in ensuring the care providers reflect upon what they are about to communicate beforehand. This approach, in the end, ensures all the critical is information is shared.

The second recommended strategy is the Background, Affect, Troubles, Handling, Empathy (BATHE) protocol which focuses on communication between the care provider and patients. According to Chengappa et al. (2020), effective communication with patients is critical as it allows relaying of important information as well as ensuring the message is understood. BATHE has been found to improve patient experience and satisfaction. Therefore, BATHE is essential in PSCs as it allows the service providers to establish rapport with patients as well as helping them feel comfortable. However, it is important to note that the main aim of BATHE is not to solve patients’ problems but to reassure them that they will receive the best care. This strategy works well especially in outpatient settings whose performances are based on patient experience and satisfaction scores.

The last communication strategy for consideration is patient-teach back. This approach can be utilized by nurses and physicians to make sure essential information is effectively shared and understood by the patients (Hong et al., 2020). In most cases, patients may claim they have understood what they are told even when they are not aware of what has been said. Therefore, patient-teach back strategy ensures important information has been communicated and understood. It therefore follows that this approach is helpful in primary stroke centers as it strives to prevent readmission and reduce delays. Health care providers are encouraged to ask the patients, after communicating information to them, to repeat back what they have been told.

The recommended change management from the organization revolves around the need to establish a coordinated system of care that incorporate preventive and treatment services and, at the same time, promote patient access to high-quality care. The fragmented approach to stroke care that is currently being used is associated with suboptimal treatment, delays and safety concerns. As explicated by Bam et al. (2022), the fragmented system provides “inadequate linkages and coordination among the fundamental components of stroke care” (Bam et al., 2017, p. 722). Therefore, the recommended system will coordinate and promote patient care services such as treatment, rehabilitation, and stroke prevention.Similarly, more emphasis should be directed at ensuring there is a direct link between the activities and services of providers. In an effort to achieve this, the system should be a single entity that “is responsible for organizing the stroke system and should have the ability to cross geopolitical lines and coordinate all participants through emergency response call centers” (Bam et al., 2017, p. 729).

The recommended system, unlike the fragmented approach, ensures PSCs complete three key functions. Firstly, the system will ensure effective interaction and collaboration among the care providers as well as all the people involved in providing prevention, transformation and treatment services to stroke patients. Secondly, the system, once implemented successfully, will promote the use of a well-organized and standardized approach in the delivery of acute stroke care for patients in the rural areas. Lastly, the system will identify the most important performance measures related to process and outcome that will inform the provider the areas that require improvements. Similarly, a coordinated system will provide the care providers a mechanism with which to evaluate the effectiveness of the system as it continue to evolve.

Resolution Strategies

As organizations strive to implement a coordinated system of care for stroke services, the focus should also be on identifying key resolution strategies to address emerging challenges. These challenges are attributed to the following factors: geography, system resources, government priorities and funding programs. Therefore, the integration of community education and awareness strategy on primary stroke prevention, symptoms recognition and response algorithms will help resolve these challenges. On education, the organization should tailor its messaging around age groups, ethnic demographics, employees within the facility and multigenerational families. Prevention efforts must be a shared responsibility between primary care physicians and advanced practice practitioners. The organization may opt to develop campaign programs that focus on stroke symptom recognition, preparedness and health literacy. The aim here is to ensure the new stroke system addresses the existing knowledge gap. For example, public awareness campaigns can help the organization educate the members about health-related topics. In fact, many efforts at the local, regional, and global levels have occurred in the recent past to promote stroke awareness following the establishment of PSC certification standards in 2003. These efforts have informed the need for care providers to monitor cultural and behavioural attitudes towards recovery and system-related outcomes.

Another resolution strategy for consideration is to ensure timely identification of stroke patients. Once identified, the patients should receive thrombectomy by qualified providers in their respective centers. The system must be designed in such a way that it offers neurosurgical and neurointensive care services for cerebellar ischemic stroke and hemorrhagic stroke. The 3-tier system of hospital certification will help with the identification process thus reducing mortality rates witnessed in care facilities. Overall, the organization should follow the existing guidelines and data matrix in ensuring the implementation of the system is simplified. Most importantly, improvement of stroke care is critical in making sure the system functions properly.

Potential Costs and Anticipated Benefits

The potential costs associated with implementing the system revolves around partner resources such as staff time. For large stroke centers partners the estimated value is $118,757 while for small center partners the cost is at $17,533. These resources were geared towards implementing the system as part of the partnership with Paul Coverdell National Acute Stroke Program (PCNASP). PCNASP aims at connecting healthcare professional across the system of care in an attempt to improve stroke care.

Once the system has been implemented successfully and all the challenges addressed accurately, the organization stand a high chance of benefiting from the system. For instance, the system will promote the use of evidence-based treatment options and effective use of the available healthcare resources. Similarly, the system will ensure early identification of stroke patients–they will be taken to the right care facilities that offer appropriate therapy.

Conclusion

The ultimate goal of primary stroke center certification is to improve the relationship of the facility with local hospitals, pre-hospital providers and governmental health organizations. The certification process, as discussed above, aims to standardize stroke patient care. Therefore, the initiative aims to give the centers the ability to provide care to patients with acute ischemic stroke. Once certified, the centers will be able to offer rapid assessment and imaging as well as administer evidence-based thrombolytic therapy. It also ensures the decision-making process in the stroke environment is guided by standardized care. The essential elements for primary stroke center include a defined stroke team, executive-level administrative support, written care protocols for diagnosis and treatment, and availability of stroke unit neurosurgical support.

References

Adeoye, O., Nyström, K. V., Yavagal, D. R., Luciano, J., Nogueira, R. G., Zorowitz, R. D.,&Jauch, E. C. (2019). . Stroke, 50(7), 87-210. Web.

Almallouhi, E., Holmstedt, C. A., Harvey, J., Reardon, C., Guerrero, W. R., Debenham, E.,& Al Kasab, S. (2019). . Telemedicine and e-Health, 25(8), 724-729. Web.

Baker, D. W., Schmaltz, S., Kolbusz, K., Messé, S. R., Jauch, E. C., &Schwamm, L. H. (2022). . Stroke: Vascular and Interventional Neurology, 15(8), 302-400. Web.

Bam, K., Olaiya, M. T., Cadilhac, D. A., Donnan, G. A., Murphy, L., & Kilkenny, M. F. (2022)..The Lancet Public Health, 7(8), 721-724. Web.

Chen, Y., Li, J., Dang, C., Tan, S., Ouyang, F., Li, J., & Fan, Y. (2022)..International Journal of Stroke, 17(5), 559-565. Web.

Chengappa, N., Honest, P. C. R., David, K., Pricilla, R. A., Rahman, S. M., & Rebecca, G. (2020). .Family Medicine and Community Health, 8(4), 99-150. Web.

Dalky, H. F., Al-Jaradeen, R. S., &AbuAlRrub, R. F. (2020)..Dimensions of Critical Care Nursing, 39(6), 339-347. Web.

Duncan, M. (2019). . British Journal of Community Nursing, 24(11), 538-542. Web.

Hassan, A. E., Shariff, U., Saver, J. L., Goyal, M., Liebeskind, D., Jahan, R., &Qureshi, A. I. (2019). .Journal of NeuroInterventional Surgery, 11(10), 984-988. Web.

Hong, Y. R., Huo, J., Jo, A., Cardel, M., &Mainous, A. G. (2020). . The Journal of the American Board of Family Medicine, 33(6), 903-912. Web.

Man, S., Zhao, X., Uchino, K., Hussain, M. S., Smith, E. E., Bhatt, D. L.,&Fonarow, G. C. (2018). .Circulation: Cardiovascular Quality and Outcomes, 11(6), 45-112. Web.

Shkirkova, K., Wang, T. T., Vartanyan, L., Liebeskind, D. S., Eckstein, M., Starkman, S.,&Sanossian, N. (2020). . Frontiers in Neurology, 10(5), 13-96. Web.

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