Three hospitals are the first in the country to receive The Joint Commission's long-awaited "comprehensive" stroke center designation, a high-performance credential that could result in new paramedic protocols that divert some stroke patients from other hospitals.
Stanford Hospital & Clinics in Palo Alto, CA, was the first to receive clearance two weeks ago, followed by OSF Saint Francis Medical Center in Peoria, IL, and Lehigh Valley Hospital in Allentown, PA, says M.J. Hampel, senior associate director for The Joint Commission's disease-specific care certification. More than 50 hospitals have requested the designation, but not all were able to pass its numerous and strict hurdles, Hampel told HealthLeaders Media.
The comprehensive review process is much more extensive and lengthy, requiring much more documentation, than what is required for the three-year accreditation survey process or what the organization now requires for the 1,000 hospitals in the nation that have received the lesser designation as primary stroke centers, she says.
Stanford's stroke team, as well as its executives, were elated when they heard the news, says Gregory Albers, MD, director of the Stanford Stroke Center. "The reviewers said in their closing meeting that they had been to a number of hospitals and found between 15 and 22 violations that prevented them from being certified, and we had zero.
"It was like a dream to hear that, because these [TJC] reviewers are not warm and fuzzy people. They asked probing questions, like, What is our procedure for handing off a patient from the emergency room to the cath lab and from the cath lab to the ICU. And then they asked multiple people the same thing, to look for consistency. They wanted call schedules for everything possible to prove that we know who's on call for a transcranial doppler at 2 a.m. on a Saturday night, and this coming Saturday," he says.
Additionally, the team asked for response times, Albers says, like "How long does it take your neurosurgeons to get to the operating room from the time they receive the phone call at home. ... And they don't accept, 'Well, I think it takes them 30 minutes.' They said, 'Show me where you recorded this data.'"
The rationale for a higher-tier stroke center credential is that, in addition to handling any stroke patient, comprehensive centers should be better equipped to deal with the toughest, most complex patients—those requiring neurosurgical and neuroradiological expertise for, say, complicated arteriovenous malformation (AVM) procedures, Hampel says.
These newly designated centers have higher standards for brain imaging capability as well as physician and stroke team expertise, she says.
Comprehensive designation is much more expensive for hospitals than primary certification, because it requires facilities to make available multidisciplinary teams of neurointerventionalists, neuroradiologists, neurosurgeons, and endovascular technicians. And more time is required for documentation and review.
The certification also requires that the hospitals and their operators have the latest high-tech surgical equipment for complex aneurism clipping and endovascular coiling techniques to find and remove clots.
For example, the comprehensive level stroke care requires the following:
- Catheter angiography available on site 24 hours a day, 7 days a week
- CT angiography available on site 24 hours a day, 7 days a week
- Extracranial ultrasonography
- MR angiography (MRA) available on site 24 hours a day, 7 days a week
- MRI, including diffusion-weighted MRI, available on site 24 hours a day, 7 days a week
- Transcranial Doppler
- Transesophageal echocardiography and transthoracic echocardiography.
The hospitals also must retain quality experts who meet monthly to monitor performance indicators. These centers also must treat a minimum number of certain types of patients, and staff must have baseline levels of training and procedural experience.
For example, facilities must perform at least 15 endovascular coiling or surgical clipping procedures per year.
These centers must also hold dedicated neuro-intensive care unit beds and maintain specific procedures for communicating with paramedic EMS teams. They have to be capable of evaluating two or more stroke patients simultaneously and perform specific follow-up tasks after discharge. They also have a requirement to enroll patients in clinical trial stroke research, use a stroke registry, and have certain peer review processes.
Albers acknowledges that the new stroke certification program may be a tough sell to other would-be referral hospitals. "This will not be popular among some of the primary stroke centers. They will say, 'Hey, we can do all these things and we don't want diversion.'"
In time, Stanford and other comprehensive stroke programs will have to convince potential referring hospitals that they can do a faster, better job for patients, by showing better outcomes resulting from their around-the-clock capabilities and because of their experience with tougher cases. That may be easier in Stanford's region, Albers says, because San Mateo County and Santa Clara County both have paramedic stroke diversion protocols in place, similar to a trauma system.
Many hospitals may wonder whether it's worth it to seek comprehensive designation. Albers says that's unclear, and certainly it won't be worth it for every hospital to try.
"It's very expensive because of all the time these people have to put into it, and the benefits—what's going to be the increased volume and how does that turn into revenue for the hospital—is unclear. But there are other benefits, such as reputational scores [reflected] in ratings like that published by U.S. News & World Report."
Patrick Lyden, MD, director of the Cedars-Sinai Medical Center's stroke program in Los Angeles, whose hospital had its comprehensive stroke center performance evaluation last week, says the designation "is superb, and a long time in coming, and TJC is doing it really well.
"They're going to a lot of places that want to be comprehensive and think they're comprehensive, and they're telling people, 'No, you're not up to snuff.'"
In the survey at Cedars last week, he says, the commission's review team "is assuring patient safety with a fine-toothed comb in every conceivable aspect of stroke care."
Lyden, who helped lead the clinical trial showing that tissue plasminogen activator (tPA) was effective at busting clots in stroke patients if they received it within three hours, says that certain difficult patients will see a benefit from better care at a comprehensive stroke center than at a primary stroke center.
"The beauty of this, for us and for patients, is really to make it very clear to the public who's qualified to be doing this sort of thing, and who's not. Today, you have situations where there are well-intentioned neurologists and surgeons who don't know what they're dealing with."
Hampel says more centers will be announced in the next few months. She does not know how many comprehensive stroke designations the country should have because it depends on each community's resources.
The Joint Commission's requirements for comprehensive stroke centers were developed with American Heart Association and American Stroke Association.