The impact of establishing a stroke center at a community hospital on the use of thrombolytic therapy: the NINDS-Suburban Hospital Stroke Center experience
Background: One strategy that has been advocated to increase the percentage of stroke patients treated with thrombolytic therapy is the establishment of primary stroke centers in community hospitals. Methods: A stroke center was established at a 397-bed private community hospital in Bethesda, Maryland consistent with published recommendations (M. Alberts, et al, JAMA. 2000;283:3102). Following a 4 month pilot phase during which the stroke critical care pathway was introduced into hospital practice, around the clock coverage by the on-call stroke team was initiated on January 3, 2000. According to the pathway, the team was to be paged for any patient identified with a suspected new stroke and persistent deficits of less than 6 hours in duration (initial screening criteria). Observations of patient characteristics and times of key points in acute management are reported through July, 2000. Results: Sixty-four patients met the initial screening criteria (58 of these patients arrived at the hospital within 3 hours of onset of symptoms). Time in minutes to action (patient arrival at hospital to paging of neurologist, to arrival of neurologist, to scan) decreased over the first 7 months of stroke coverage (24 to 12, 28 to 16, 52 to 32, respectively, per 2-month average). Of 143 patients hospitalized with ischemic stroke during this period, 15 patients (10%) were treated with t-PA (10 IV, 5 IA). For the IV-treated patients, the median time to treat was 130 minutes and median door to needle time was 83 minutes, in line with benchmark values. During the same 7-month period of the year prior to the center initiation, only 3 patients were treated with t-PA at this hospital. Conclusions: A 5-fold increase in t-PA usage was observed in the first 7 months following the establishment of the stroke center (3-fold increase for IV t-PA use only). Establishment of a stroke center at a community hospital is feasible. Our experience to date suggests that a substantial increase in the frequency of patients receiving t-PA therapy for ischemic stroke may be achievable shortly after initiation of a community hospital stroke center.