Current Practices in Stroke Systems of Care: An International Survey of Progressive Stroke System Processes

Background and Aims Guidelines by the AHA/ASA recommend the development of stroke systems of care yet do not provide specifics as to how this should be done. As a first step in developing a regional stroke system of care in the “Stroke Belt” we sought to understand how high performing stroke systems across the world were organized in order to identify best practices and opportunities for meaningful system improvement. Methods An 81-question survey was developed to examine current practices in high-performing stroke systems. Twenty stroke centers worldwide were invited to participate. The survey encompassed all aspects of stroke systems of care from acute care and EMS practices to IT and discharge. Data analysis was conducted using REDCap internal analytic tools. Results Nine of 20 invited centers (45%) completed the questionnaire. Responding centers reported annual averages (median) of 750 ischemic strokes (range 350-1444) and 125 (100-501) hemorrhagic strokes, 150 (60-440) IV alteplase administrations, and 55 (12-130) endovascular thrombectomy procedures. At all 9 systems, EMS providers are trained in identifying stroke and utilize prehosptial stroke scales. Six (66.7%) reported destination protocols based on stroke severity involving bypass to endovascular thrombectomy capable (EVT-C) centers. All centers report expedited referral hospital transfer processes for neurointervention. Five (55.6%) centers reported patients with confirmed large vessel occlusions bypass the emergency department and are transported directly to the neurointerventional suite. Conclusions This international survey reveals useful practice patterns and processes used by progressive stroke systems. This information will be integrated into our regional system of care quality improvement program. ### Competing Interest Statement ME Ehrlich: Dr. Ehrlich discloses salary support from grant funding by The Medtronic Foundation, and Daiichi Sankyo. S Shah: Dr. Shah discloses salary support from grant funding by The Medtronic Foundation, and Daiichi Sankyo. BJ Kolls: Dr. Kolls discloses salary support from grant funding by The Medtronic Foundation. M Roettig: no disclosures L Monk: no disclosures C Graffagnino: Dr. Graffagnino discloses salary support from grant funding by Medtronic Foundation; medical consultancy and clinical trial support from Daichi Sankyo; medical consultancy for Portola and research funding from Chiesi. ### Funding Statement This data was obtained as part of the IMPROVE Stroke project which is partially funded by The Medtronic Foundation, and Daiichi Sankyo. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Duke University IRB waived approval for this study and associated data. All study procedures were deemed exempt from review by the Duke University Institutional Review Board. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors