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A four-tier system of hospitals was endorsed by the American Heart Association (AHA)/American Stroke Association (ASA) in an updated policy statement on the organization of acute stroke care in the U.S.

Sitting between primary stroke centers (PSCs) and comprehensive stroke centers (CSCs) in terms of stroke care level are now thrombectomy-capable stroke centers (TSCs), newly designated hospitals that are alteplase- and thrombectomy-capable but not necessarily able to offer comprehensive care for the most complex stroke cases.

Occupying the lowest rung of the ladder, then, are nationally certified acute stroke-ready hospitals (ASRHs), or centers that are likely rural, alteplase- but not thrombectomy-capable, and lacking dedicated stroke units.

"The CSC, [PSC], TSC, and ASRH framework provides an appropriate platform for the data-driven development of hospital-based processes of care and outcome metrics. All certification systems should meet or exceed these standards," according to the writing group chaired by Opeolu Adeoye, MD, MS, of the University of Cincinnati, in the statement published in .

TSCs make sense in communities without access to thrombectomy, but where a CSC already exists nearby, they are more controversial, according to AHA president-elect Robert Harrington, MD, of Stanford University in California, in an accompanying editorial.

"A key issue will be what amount of extra travel time to access a CSC over a [PSC] or nearby TSC is acceptable. This will likely be a local decision based on the density of the population and distribution of resources until more research provides data needed for an evidence-based policy decision," he wrote.

"Ideally, when geography permits, locales will identify a CSC as the ideal choice for a suspected LVO [large vessel occlusion] patient if an ambulance needs to choose among several destinations, including [PSCs] and TSCs," Harrington added.

He predicted that the greatest challenges will be in urban and suburban areas, due to multiple municipalities governing emergency medical services, multiple competing hospital systems, and fluctuating traffic patterns, among other variables.

"The recommendation to prefer endovascular-ready hospitals just makes sense. I wish there was more data about how to factor in time but I know groups are working on models that will give us more information about this," commented S. Claiborne Johnston, MD, PhD, of The University of Texas at Austin.

Other new and revised recommendations in the AHA/ASA policy statement (its first update since 2005) include:

• Primary prevention: "A stroke system should develop support mechanisms to assist communities as a whole, patients, and providers in long-term adherence to primordial and primary preventive treatment regimens"

• Community education and engagement: "Innovative behavioral interventions addressing barriers to healthy behaviors, prevention adherence, and warning sign action with tools such as digital phenotype analysis, social network analysis, gamification, and machine learning offer opportunity for sustainable behavioral change, and research in these areas should be encouraged"

• Emergency medical services: "When there are several intravenous alteplase-capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity scale score suggestive of LVO. When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care"

• Acute stroke care at stroke centers: "Data suggest the benefit of more sophisticated imaging triage that assesses penumbral pattern in selecting patients for endovascular thrombectomy from 6 to 24 hours from last known normal. These data merit the broader adoption of this imaging technology in thrombectomy centers"

• Secondary prevention: "A stroke system should establish support systems to ensure that all patients discharged from hospitals and other facilities to their homes have appropriate follow-up with specialized stroke services when needed and primary care arranged on discharge"

• Rehabilitation and recovery: "A stroke system should ensure that all stroke survivors receive a standardized screening evaluation during the initial hospitalization to determine whether rehabilitation services are needed and the type, timing, location, and duration of such therapy"

"The guidelines recommend a number of community-wide interventions that could reduce the incidence and impact of stroke. Sadly, these are unlikely to be implemented in the U.S. given how dollars flow in our health system," according to Johnston.

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