At a glance
State laws that address policy interventions with “best” evidence are expected to have the greatest potential for a positive health impact and an associated economic impact.
Pre-hospital
Includes all emergency medical care provided to the stroke patient prior to the handoff of the patient from EMS providers to staff at the acute care facility.
Stroke Pre-Notification of Receiving Facility by EMS Providers
States can encourage emergency medical services (EMS) providers to pre-notify receiving facilities of a suspected stroke patient. For example, by incorporating pre-notification into EMS protocol algorithms and checklists, including pre-notification as a component of EMS training and continuing education, and reviewing the use of pre-notification as a part of continuous quality improvement activities within stroke systems of care.
State law example: A Wyoming regulation requires EMS providers to issue a “Notification of Stroke Alert” to the receiving Stroke Center as soon as possible for patients with a positive F.A.S.T. (Facial droop; Arm droop; Slurred speech; and Time to call for help) assessment.
EMS Triage and Transport to Most Appropriate Stroke Facility
EMS providers play a vital role in the rapid triage and transportation of suspected stroke patients. Pre-hospital EMS care protocols for triage and transport to the closest stroke facility by ambulance may improve outcomes for patients. (Analyses included ground transport studies only.)
State law example: In collaboration with the District of Columbia Fire and EMS Department, the Department of Health is to establish standardized pre-hospital care protocols for stroke triage assessment, treatment, and patient transport to the closest most appropriate facility. This could be an Acute Stroke Ready Hospital (ASHR), Primary Stroke Center (PSC), or Comprehensive Stroke Center (CSC).
Air Medical Transport to Most Appropriate Stroke Facility
Air transport of stroke patients allows for shortening the time to treatment, improving patient survival rates, potentially lowering the incidence of stroke, and improving access to interventional stroke care in rural settings. States could authorize air medical transport in stroke transport protocols.
State law example: A Missouri rule establishes protocols for “transporting suspected stroke patients by severity and time of onset to the stroke center where resources exist to provide appropriate care.” Suspected stroke transport protocol requirements include mandatory use of the state protocol (with some exceptions) by all ground and air ambulances. This assesses three factors: first, if all ground and air ambulances use the state protocol (with some exceptions). Second, it assesses the presence of life-threatening conditions for stabilization prior to transport to stroke center. Third, it assesses timing of symptoms and therapeutic window for transport to level I, II, III, or IV and out-of-state facilities is also assessed.
Inter-Facility Transfer to Most Appropriate Stroke Facility
Such policies encourage: (1) written inter-facility transfer agreements to ensure appropriate, timely acute stroke care at appropriate facilities; (2) strategies to improve efficiency including “drip and ship” protocols to allow tPA infusion immediately before or during transport to endovascular-capable centers; and (3) reimbursement that covers costs for both transferring and receiving facilities. (Analyses included ground transport studies only.)
State law example: The Louisiana Emergency Response Network Board and the Department of Health and Hospitals are required to recognize four levels of stroke facilities: CSC, PSC, ASRH, and non-stroke hospitals. An ASRH is expected to provide timely acute stroke care in areas where transportation and access are limited using “drip-and-ship”, telemedicine, and other delivery models. A non-stroke hospital is authorized to accept suspected stroke patients only when clinically necessary, provided it has written transfer agreements with an ASRH, PSC, or CSC.
In-hospital/post-hospital
Includes the treatment of an acute stroke patient at the appropriate stroke hospital(s) and all the long-term, rehabilitative care received by the patient after they are discharged from the hospital.
Telestroke to Initiate Treatment On-Site
Telemedicine involves the use of technology to provide health care, monitor health status, and share health information remotely. Telestroke involves using telemedicine to initiate treatment for acute stroke care and provide access to acute stroke specialists in medically underserved, rural, and geographically remote areas.
State law example: An Arizona statute requires all insurance contracts provided to subscribers by certain “hospital service corporations” and “medical service corporations” issued, delivered, or renewed on or after January 1, 2018 to provide coverage for stroke telemedicine services “if the health care service would be covered were it provided through in-person consultation… to a subscriber receiving the service in Arizona.”
State-Level Continuous Quality Improvement Registry
A statewide continuous quality improvement (CQI) program, process, and/or plan is needed to ensure that stroke care delivery across the state applies to evidence-based national standards and best practices. As part of CQI, a state-level stroke database, data system, or registry helps to track nationally recognized consensus stroke care metrics.
State law example: All hospitals designated at any level by the Georgia Department of Public Health (DPH) as a stroke center must participate in the Georgia Coverdell Acute Stroke Registry. Such hospitals must also submit a minimum set of data elements to the Registry as required. DPH may suspend or revoke designation of non-compliant hospitals.
Nationally Certified Primary Stroke Centers
PSCs certified by nationally recognized accrediting bodies must have infrastructure and demonstrated ability to stabilize and treat acute stroke patients. This includes timely provision of intravenous thrombolytic therapy utilizing alteplase, neuroimaging capabilities, and the management of intracranial pressure.
State law example: The Illinois Department of Public Health is authorized to designate hospitals as PSCs with proof of certification from a Department-approved nationally recognized certifying body using “current nationally recognized, evidence-based stroke guidelines.”
State Standards for Primary Stroke Centers
A state can designate a facility as a PSC or the equivalent when the facility meets specific standards set by the state. Standards could include: hospital-based emergency department and EMS staff education in acute stroke prevention, diagnosis, and treatment; hospital stroke CQI and submission of stroke data to the Department of Public Health; and EMS pre-hospital stroke notification.
State law example: As of April 2017, a Massachusetts regulation allows hospitals to apply to the Department of Public Health for designation as a Primary Stroke Service (PSS) provider. Such hospitals provide emergency diagnostic and therapeutic services to acute stroke patients through a multidisciplinary team approach, available 24 hours per day, seven days per week.