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Acute Stroke Management: Brain Protection and Reperfusion

Cerebrovasc Dis 2009;27(suppl 1):140147 Published online: April 3, 2009


DOI: 10.1159/000200452

Relevance of Stroke Code, Stroke Unit and Stroke


Networks in Organization of Acute Stroke Care
The Madrid Acute Stroke Care Program
Mara Alonso de Leciana-Cases a Antonio Gil-Nez b Exuperio Dez-Tejedor c
Stroke Unit, Department of Neurology, a Ramn y Cajal University Hospital, b Gregorio Maran University Hospital,
and c La Paz University Hospital, Madrid, Spain

Key Words zational plans should also take into account the process be-
Acute stroke Stroke network Medical care Attention yond the acute phase, to ensure the appropriate application
chain Stroke code Care resources Stroke management of measures of secondary prevention, rehabilitation, and
chronic care of the patients that remain in a dependent state.
We describe here the stroke care program in the Community
Abstract of Madrid (Spain). Copyright 2009 S. Karger AG, Basel
Stroke is a neurological emergency. The early administration
of specific treatment improves the prognosis of the patients.
Emergency care systems with early warning for the hospital
regarding patients who are candidates for this treatment Care for the acute stroke patient has changed radical-
(stroke code) increases the number of patients treated. Cur- ly in the past few years. It continues to evolve to include
rently, reperfusion via thrombolysis for ischemic stroke and improvements not only in the scientific-technical re-
attention in stroke units are the bases of treatment. Health- sources for diagnosis and treatment, but also in working
care professionals and health provision authorities need to towards improving the systems of organization of care
work together to organize systems that ensure continuous with the objective of ensuring equitable access to these
quality care for the patients during the whole process of resources by all who need them. There are essentially two
their disease. To implement this, there needs to be an appro- reasons underlying this evolution. Firstly, stroke is a dis-
priate analysis of the requirements and resources with the ease with a high incidence and prevalence and is the main
objective of their adjustment for efficient use. It is necessary cause of incapacity in the adult. Secondly, it is well docu-
to provide adequate information and continuous training mented that it is a neurological condition that is amena-
for all professionals who are involved in stroke care, includ- ble to effective treatment; the earlier the patient is evalu-
ing primary care physicians, extrahospital emergency teams ated by a specialist and the earlier the specific treatments
and all physicians involved in the care of stroke patients are applied, the better the outcome. As such, stroke con-
within the hospital. The neurologist has the function of co- stitutes an important problem of public health, with ter-
ordinating the protocols of intrahospital care. These organi- rible consequences that can be palliated, at least in part,

2009 S. Karger AG, Basel Maria Alonso de Leciana, MD, PhD


10159770/09/02770140$26.00/0 Unidad de Ictus, Servicio Neurologa, Hospital Universitario Ramn y Cajal
Fax +41 61 306 12 34 Ctra de Colmenar Km 9,100
E-Mail karger@karger.ch Accessible online at: ES28034 Madrid (Spain)
www.karger.com www.karger.com/ced E-Mail mariaalonsoleci@telefonica.net
if the appropriate treatments are administered in time. vide care for these dependent patients (cessation of pro-
This makes it necessary that the healthcare resources are ductive labor not only of the patient but of the family
organized efficiently, the objective being to ensure access member providing care, or contracting a nonfamily carer
to the treatments and their correct application. if necessary, adapting the home to the patients incapacity,
etc.) [911].
Hence, it would seem logical to invest in resources and
Stroke as a Public Health Problem in organization to improve the healthcare provision for
these patients in all possible phases of the disease. It is
Throughout the world, but especially in the industrial- important to implement measures of prevention and, as
ized countries, stroke is a very frequent disease. The rates well, to ensure adequate emergency access to the treat-
of incidence vary between 200 and 600 cases/100,000 cit- ment available in the acute phase. The objective is that all
izens/year, depending on the epidemiological studies in the patients who suffer a stroke have a better opportunity
different geographical areas. This implies that the disease of reducing the cerebral damage that they suffer and, as
is the second, or even the first, most common cause of such, the probability of suffering subsequent invalidity.
death in many of these countries [14]. In Spain, the cur-
rent data show rates of incidence of stroke between 140
and 169 cases/100,000/year in the case of women and be- Stroke as a Treatable Neurological Emergency
tween 170 and 364 cases/100,000/year in men [5, 6]. The
incidence increases with age, such that in women 165 Awareness of stroke as a neurological emergency is
years of age the incidence is 510/100,000/year and in men based on the demonstration that the application of ap-
it is 704/100,000/year [6]. These rates increase up to 1,493 propriate therapeutic measures improves the clinical
and 2,371 in females and males, respectively, above 70 evolution of the patients, and that these treatments are
years of age [5]. In Spain, the prevalence of stroke in indi- more efficacious the earlier they are administered [12,
viduals 165 years of age is approximately 6% in females 13]. The majority of advances have been developed in the
and 7% in males. Given the progressively aging Spanish field of cerebral ischemia, but hemorrhages, as well, can
population, it is forecast that, at the current rhythm, there benefit from appropriate management during the acute
will be 742,500 individuals affected by stroke by the year phase. Contrary to what has been thought for some con-
2030 and, by the year 2050, the level will reach 1,129,000; siderable time, cerebral damage after stroke is not instan-
a highly significant number, especially when taking into taneous, but rather develops progressively over a pro-
account that half of them will have a certain grade of re- tracted period. This offers the possibility of applying
sidual incapacity. Hence, with the increase in life expec- treatments directed towards inhibiting the different
tancy and an aging population, a progressive increase in mechanisms underlying the lesions in order to reduce the
hospitalization will occur as a consequence of stroke [7]. gravity of the consequences [1417]. These mechanisms
In Spain, stroke is the most common cause of death in are becoming better known not only with respect to the
women and the first or second most common cause of action but also to the time at which the damaging effects
death in men, depending on the different Autonomous are produced [18]. The inhibition of these mechanisms
Communities [7]. The mortality rates from stroke in the using different therapeutic strategies is described as neu-
year 2006 were 74,657/100,000 (63,675 in males and 85,248 roprotection [19]. This is a wide concept that brings to-
in females) compared to 84,169/100,000 from acute myo- gether different therapeutic aspects, from reperfusion of
cardial infarct and other ischemic heart diseases (97,615 the ischemic tissue to maintenance of tissue homeostasis
in males and 71,096 in females) [7]. Further, it is the high- and to the application of drugs with inhibitory action on
est cause of incapacity in the adult (up to 53% of patients the different steps in the cascade of cell death that is set
are left with a grade of dependence) and the second high- in motion after stroke. Of the treatments applied in the
est cause of dementia (between 30 and 50% of patients acute phase of stroke, two have been demonstrated to be
have cognitive deterioration after stroke) [8]. This implies beneficial with a class I evidence [20]: stroke units (SUs)
an important consumption of resources during the acute and intravenous thrombolysis with rtPA within the first
phase (approximately 4% of the healthcare budget) and 3 h from the onset of symptoms [12, 21, 22]. Recently it
subsequently, as well, in secondary prevention measures has been shown that reperfusion therapy with iv rtPA is
or rehabilitation. This does not include the long-term in- also beneficial when administered up to 4.5 h from onset
direct costs derived from the necessary measures to pro- of symptoms [23, 24]. Both of these treatments have been

Organization of Acute Stroke Care Cerebrovasc Dis 2009;27(suppl 1):140147 141


well documented as being efficacious in improving the the center capable of administering these treatments.
clinical evolution of patients who suffered an ischemic One of the main reasons for excluding the thrombolytic
stroke. treatment option is the delay in transferring the patient
Thrombolysis is a cost-effective treatment. There is no to the specialist care unit (the therapeutic window has
significant increase in the costs of managing the acute lapsed by the time the patient is seen by the neurologist).
process and the probability of becoming incapacitated is This is also related to the patient not seeking emergency
reduced. The patient has a better quality of life and there attention as a consequence of not knowing and not rec-
is a reduction in the long-term healthcare costs [25]. How- ognizing the symptoms of stroke and not being aware of
ever, thrombolytic treatment is restricted to patients with the seriousness of the disease [34, 35]. Lack of awareness
ischemic stroke, and of these, only a small percentage of is very easily resolved via information campaigns for the
around 1015% [12, 26, 27] can benefit from the treatment. general population. A good example is the celebration of
This is due, in part, to the contraindications and risks, but a National Stroke Awareness Day an initiative pio-
also because the therapeutic window is very narrow and neered in Spain where this day is celebrated annually
there are often delays in the patients transfer to, and treat- since the year 1999 with several activities organized that
ment at, centers capable of administering this treatment. raise awareness in the communication media.
The SU offers a benefit to the majority of patients as Once the clinical assistance is solicited, it is necessary
the treatment offered in this type of specialized care unit that the extrahospital emergency services react quickly
improves morbido-mortality and reduces the probability in coordination with the assigned hospital centers that
of suffering complications and dependency, together have all the resources necessary to attend to patients with
with a favorable cost-efficacy balance. This benefit is de- stroke in the acute phase. The acute-phase stroke needs
rived from noninvasive neurological monitoring and to be recognized as urgent so as to identify those patients
from the application of protocols of general care directed who may be candidates for specific treatments, and to
towards maintaining homeostasis, and the essential ob- assign consensus protocols that place the patient in the
jective is to ensure a nonpharmacological neuroprotec- best situation for the latest treatment. The prehospital-
tion as well as the correct application of specific treat- ization procedure is based on the knowledge of the emer-
ments [2831]. gency, the objective being to organize transport of the
However, it is clear that these efficacious treatments patient to the center with the appropriate capability (neu-
are not available for the whole patient population. A vari- rologist on call, SU and the competence to apply specific
able percentage of the patients who suffer a stroke do not treatments such as thrombolysis) which, together with
have access to these facilities and are dependent on the alerting the emergency services and on-call neurologist
geographic zones in which they reside. This phenomenon to facilitate rapid attention for these patients, is termed
has been described as a postcode lottery. Some hospitals the extrahospital stroke code. This code reduces the time
that deal with stroke patients do not fulfill the minimum to patient care and the delay in administering specific
requirements to conduct thrombolytic treatment. These treatment [3639]. Also, the hospital emergency service
include the lack of specialists trained in the management needs to be organized to attend to this type of patient to
and treatment of stroke, and/or the technical resources reduce the delay as much as possible. The protocols di-
for an appropriate diagnosis and care of the possible com- rected towards this objective are termed intrahospital
plications that could arise. Many have neither dedicated stroke code and have also been shown to be very effica-
SUs nor a minimum level of the necessary healthcare re- cious [27].
sources such as cranial computed tomography during the
first 24 h, or an on-call neurologist [32, 33].
SU, Stroke Team and Stroke Comprehensive Centers

The Importance of Urgent Transport to the Hospital: Once the patient is in the hospital, it is necessary to
The Stroke Code rapidly evaluate his/her neurological status with the ob-
jective of applying the appropriate diagnostic-therapeu-
It is important to attend to stroke patients early be- tic protocols in the hyperacute phase, which would max-
cause the appropriate treatment needs to be applied as imally reduce the cerebral damage produced after stroke,
early as possible if a good outcome is to be achieved. as well as clarifying the etiology so that the strategy of
Hence, it is important to urgently transfer the patient to secondary prevention and rehabilitation may be imple-

142 Cerebrovasc Dis 2009;27(suppl 1):140147 Alonso de Leciana-Cases /Gil-Nez /


Dez-Tejedor
mented. Specialist attention is required during the entire ically delineated SU structure and without continuous
disease process. The SU has been demonstrated to be the monitoring. The ST is an alternative for centers that do
organizational model for most of the efficacious stroke not have their own SU due, mainly, to the low require-
care provision [2831]. ment and low volume of patients which does not justify
SUs are geographically restricted structures. They de- the costs of setting up a dedicated SU in an economic en-
pend on the neurology service and are dedicated to the vironment in which resources are limited. Nevertheless,
specific care of patients with stroke. They need to be co- these hospitals do receive stroke patients, and therefore
ordinated and staffed by neurologists who are experts in quality care needs to be provided [45, 46].
cerebrovascular disease and who rely on the collaboration Finally, some techniques for diagnosis and/or treat-
with other related clinical specialties (cardiology, vascu- ment are particularly complex and costly and, as such,
lar surgery, neuroradiology, neurosurgery, rehabilitation, cannot be made available in all hospitals/centers, but all
emergency medicine, etc.). Also, there needs to be a col- patients should have access to the facilities in the better
laborating physiotherapist and social worker so that early equipped Stroke Comprehensive Centers via protocols
physiotherapy/rehabilitation can be initiated. There needs established in their own hospitals [46].
to be continuous noninvasive monitoring by a trained
nurse. The recommended nurse-to-patient ratio is 1: 6.
Personnel and diagnostic services need to be available Strategies of Health Provision Organization to
24 h a day, together with protocols and clinical routes for Improve Stroke Care
the evidence-based management of the patients. The num-
ber of beds in the SU should be sufficient to accommodate The Declaration of Helsingborg of 1995 and its 2006
the needs of the hospitals catchment population [40]. update [47, 48] are consensus documents developed by
The best results of the SU in relation to the attention experts of different scientific societies which established
provided in conventional clinics are due to better adher- the recommendations for Europe. The recommenda-
ence right from the start to the protocols of care, and to tions state that all patients with stroke should have easy
continuous monitoring. The consequences are early de- access to treatments in the acute phase that have been
tection of complications and rapid therapeutic interven- demonstrated to be efficacious and, specifically, to the
tion, resulting in more efficacious neuroprotection. The care available in the SU, and to subsequent rehabilita-
admission of the patient to the SU decreases mortality tion and secondary prevention strategies. Also, the con-
and morbidity, and/or functional dependence. The ben- sensus established specific objectives to be achieved in
efit persists after adjustment for age, gender, severity of relation to the improvement in the clinical evolution of
neurological deficit at admission, and differences in etio- the patients, and the measures necessary to achieve
logical subtypes of stroke [41]. Apart from the clinical them. This document has a great potential to influence
advantages related to improvement in the clinical evolu- the politics of healthcare provision of the different coun-
tion of the patients, the care provided in the SU improves tries, given the trustworthiness of the different scien-
the indicators of care quality (mean hospital stay, hospital tific societies that were signatories to the document and
readmission, mortality, and the need for institutionaliza- the level of evidence that backs the recommendations.
tion) and significantly reduces the economic costs of Hence, many countries and/or communities have al-
stroke care provision [4244]. ready commenced the planning of healthcare networks
In relation to the SU, the stroke team (ST) is the basic with the objective of ensuring appropriate and equitable
model of specialist neurological care oriented towards as- health care for all patients, adapted to the strategies,
sessment and specific treatment of the patients with characteristics and necessities specific to each popula-
stroke who, because of their clinical characteristics, do tion [46, 4952].
not necessarily depend on complex technologies, but One of the reasons why scientific-technical advances
nevertheless benefit from evidence-based protocols and in the field of medicine are not sufficiently well imple-
continuous follow-up. The ST is defined as a multidisci- mented and effective in populations is the lack of organi-
plinary group of specialists with a specific organization- zational structures to facilitate their application and
al function, which collaborates in the diagnosis and treat- equal access for all those needing the treatment, indepen-
ment of stroke patients coordinated by a neurologist with dent of socioeconomic level or place of residence. It is
expertise in the field of cerebrovascular disease, and uses necessary to have these advances brought to the attention
systematized stroke care protocols outside of a geograph- of those responsible for healthcare administration. This

Organization of Acute Stroke Care Cerebrovasc Dis 2009;27(suppl 1):140147 143


could be in the form of evidence-based guidelines of clin- Table 1. Stroke code protocol
ical practice, and by ensuring a coordinated working re-
lationship between administration and healthcare pro- Objectives
Time from the start of the symptoms to the hospital no
fessionals. The objective would be to assess the require- longer than 2 h
ments resulting from putting the recommendations into Time from notification to the hospital less than 1 h
clinical practice and to ensure assignment of resources Greatest alacrity possible under all circumstances
and budget of the hospitals that provide attention for Criteria for inclusion
these patients according to those requirements. Time from the start of the symptoms to the hospital <6 h
As commented earlier, stroke is a frequent and devas- Baseline status of the patient: modified Rankin Scale score 2
tating neurological disease and thus generates high social Neurological focal deficit present at the time of diagnosis:
presence of any symptom suspicious of stroke
and healthcare costs. However, the severe consequences
1 Numbness, weakness or marked one-sided paralysis of the
of this disease could be reduced if the available appropri- face, arm or leg
ate treatments were applied. As such, it is a good example 2 Difficulty in speaking or understanding
of the need to establish efficacious systems of healthcare 3 Sudden loss of vision in one or both eyes
provision that ensures emergency attention for all pa- 4 Intense headache, marked and without apparent cause,
associated with nausea and vomiting (not attributable
tients in centers with the specialist facilities for appropri-
to other causes)
ate care over the whole process of the disease. 5 Difficulty in walking, loss of equilibrium or coordination
Criteria for exclusion from the stroke code
1 The diagnostic criteria of ictus not fulfilled
Acute Stroke Care Program in the Community of 2 More than 6 h of symptom evolution
Madrid 3 Coma <9 on the Glasgow Scale
4 Poor general clinical status with hemodynamic instability
An analysis of the resources available for stroke care refractory to basic support measures
5 Terminal disease and/or dementia
in the Community of Madrid (CM) showed that in the
year 2004, there were only 4 SUs, which implies that
3,391,932 citizens did not have an SU available (58.43% of
the total population), i.e. only a minority of the Madrid
population (41.57%) had access to this highly efficacious
healthcare resource. An on-call neurologist was only The extrahospital stroke code was established in the
available in 50% of the 14 public hospitals providing care year 2006 by the Healthcare Council of the CM under the
for acute stroke patients. This implies that 1,465,924 citi- central coordination of the Emergency Medical Service
zens, i.e. 25% of the CM population, received attention in of Madrid (SUMMA-112). The established structure was
hospitals in which there was no on-call neurologist and rationalized with respect to the existing resources so as
did not have access to emergency specialist attention to enable patients with stroke to receive attention in the
[53]. healthcare centers that had SU available (table 1) [54].
When a cost-effectiveness analysis compared the situ- The Healthcare Council, following the recommenda-
ation of the 4 existing SUs with that of an alternative or- tions of the General Directorate of the Madrid Health
ganizational strategy that contemplates the setting-up of Service and the Sub-Directorate of Specialist Care, and in
10 SUs in specific hospitals in the CM, the results showed collaboration with a panel of expert neurologists of the
that the alternative strategy would cost EUR 28,789,170, Stroke Forum of the Madrid Association of Neurology,
while the existing setup costs EUR 33,994,169, i.e. a sav- developed a Plan for Stroke Care. This integrated plan
ing of EUR 5,204,999 would be produced each year. The incorporates all the aspects necessary to ensure correct
alternative model would avoid 103 deaths and 277 depen- care for all patients who suffer a stroke, and to make
dencies a year while gaining 380 independencies. The available all the healthcare resources and measures nec-
cost of avoiding one death is EUR 50,432, that of avoiding essary in an equitable manner. The plan begins with in-
one dependency is EUR 18,788, and the gain of one inde- formation provided to the patients, doctors and health-
pendency is EUR 13,689, i.e. the model indicates that the care professionals of the primary care service, extrahos-
new proposal is cost-effective; these outcomes were main- pital emergency services, hospital emergency service, and
tained throughout the sensitivity analyses conducted neurology departments of the hospitals that are respon-
[53]. sible for the care of the stroke patient. Included in the plan

144 Cerebrovasc Dis 2009;27(suppl 1):140147 Alonso de Leciana-Cases /Gil-Nez /


Dez-Tejedor
are the emergency transport systems to the hospital and code, be transferred to a hospital with an SU in which the
the management of the emergency service (Extra- and necessary facilities are available. Those patients with a
Intrahospital Stroke Code). Different levels of healthcare longer time since the stroke event, or those who are not
provision are established (hospital with STs, hospital amenable to the complex therapies but nevertheless re-
with SUs, and referral hospital) with a plan for inter- quire specific care, will be transferred to hospitals with
change or sharing of resources, i.e. a network of stroke ST, i.e. the strategic plan puts in place interhospital pro-
care provision. The plan also incorporates patient man- tocols for those patients who would benefit from them.
agement after the acute phase and includes measures of After the acute phase, the resources necessary for the sub-
prevention, rehabilitation and social reintegration [52 sequent care of the patient need to be organized to ensure
55]. that appropriate measures of secondary prevention are
The plan is already in the developmental stage. In implemented and that there is outpatient follow-up by the
2007, the 4 existing SUs were updated and a new SU was specialist as well as by the primary care physician. There
created. It is envisaged that in the year 2008, 3 more SUs needs to be access to rehabilitation centers for those pa-
will be created, bringing the total to 8. Under consider- tients who need this assistance, and centers for chronic
ation is the establishment of STs in the rest of the Madrid care or home help for those patients who are in a state of
hospitals that are not equipped with SU so as to establish dependence. The implementation of these coordinated
a good network of healthcare cover for acute stroke in the systems of health care requires that all the healthcare pro-
whole of the CM. fessionals involved are properly informed and trained in
Implementing an overall strategic plan in a specific order to achieve a correctly functioning network that
healthcare area, the function of which is to coordinate continues to provide care for the stroke patient in all stag-
each section of the health provision network, ensures pa- es of the disease.
tient access to specific care according to the specific clin-
ical requirements in each stage of the disease. Patients
Disclosure Statement
with !6 h since the stroke event, and particularly those
within 3 h of the event who would especially benefit from None of the authors has any conflict of interest in relation to
reperfusion techniques, should, by activating the stroke the subject of this publication.

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