At the end of September, the Joint Commission released proposed requirements for certification as a Comprehensive Stroke Center. These new requirements build off of the exisiting certification program for Primary Stroke Centers (PSCs), which was launched in 2003 and has seen impressive growth since its inception.
To date, more than 800 hospitals nationwide have achieved this distinction, which signals a dedication to providing evidenced-based care for stroke patients in an efficient and high-quality manner. The Comprehensive Stroke Center program will certify hospitals that can provide advanced therapies for acute stroke patients, but can also provide enhanced long-term management of these patients. Assuming the final rules closely resemble the current proposed guidelines, it's possible that not many hospitals will be able to meet the extensive requirements. Few hospitals should be engaged in providing advanced stroke services, especially considering the intensity of resources needed and the complexity of care required.
The Joint Commission developed the proposed requirements along with The American Heart Association (AHA) and the American Stroke Association (ASA). Similar to PSC certification, the proposed requirements follow the Brain Attack Coalition’s recommendations—in this case the “Recommendations for Comprehensive Stroke Centers” that were first published in 2005—and provide detailed specifications on the capabilities, technology, physicians, and services needed to be considered a comprehensive program by the joint commission. A detailed account of the requirements can be found on the Joint Commission's website, but here we'd like to highlight some of the key aspects needed.
Physicians and staff
From a capability perspective, a major aspect of being a Comprehensive Stroke Center is the capability to provide advanced interventions for both ischemic and hemorrhagic strokes. Regular access to the physician specialists able to perform those procedures is necessary, and the Joint Commission has therefore proposed that 24/7 coverage from neuro-interventionalists and cerebrovascular neurosurgeons be available. Physician requirements, however, are not limited to the proceduralists involved in acute-care delivery; additional physicians required at comprehensive stroke program include:
- A medical director trained in neurology and cerebrovascular disease
- A physician with expertise and experience in neuro-rehabilitation
- Physicians with imaging experience in head CT or brain MRI
- Diagnostic radiologists
- Vascular surgeons
Other personnel requirements beyond physicians are also outlined, including advanced practice nurses (APNs) with stroke-specific training, a wide range of RNs (in the ED, Stroke Unit, ICU, and cath lab) with stroke-specific training, pharmacists with stroke expertise, nurse case managers and social workers with stroke expertise, physical therapists, occupational therapists, speech therapists, radiation technologists, and data analysts.
Stroke care management
Perusing the extensive set of proposed requirements, it's clear that the Joint Commission and its partners are not considering 'comprehensiveness' to be limited to the availability of advanced therapies. For the stroke admission, comprehensive centers would need to have access to intensive care units with experienced neuro-critical care staff, as well as 24/7 access to rehabilitation therapies. Both of those services make sense when thinking about providing stronger inpatient care, but in several areas the proposal lists' necessary capabilities cover a much more longitudinal management of stroke patients, hinting even at efforts to realize stroke prevention.
These new care management requirements start at discharge planning. The proposal requires centers to provide a much more detailed assessment to proactively identify issues that could impact the patient's post-acute hospitalization. Cognitive decline, behavioral health issues, and familial support issues are all expected to be measured to inform the coordination of post-hospital care. A range of community and hospital resources are expected to be identified for the patient, with referrals for everything from support groups to palliative care.
The implication here is evident. Comprehensive stroke programs will not simply be a destination center for patients that fall out of the treatment window for IV-tPA therapy. These programs will be expected to manage stroke patients effectively across multiple resources during the inpatient admission, and to be integrated with a wide range of providers in the post-acute setting to ensure that patients are adequately cared for post-stroke. Prevention will even be considered part of their function, as the current proposal requires comprehensive centers to sponsor two annual educational activities on stroke prevention.
Few hospitals may be able to meet all of these proposed requirements—our past estimates of unofficial 'comprehensive' programs put the number at less than 50. As it stands, we anticipate that few more would join that unofficial count when the official Joint Commission program goes live in July of 2012, likely ensuring that the distinction of being a comprehensive program will be reserved for only the most advanced stroke programs.