Stroke Survival Greater When Hospitals Treat High Volume

Is that stroke victim going to survive? It may depend on where you take him.

A recent study in the Journal of Neurosurgery indicates a strong correlation between in-hospital mortality following subarachnoid hemorrhage (SAH)-the most deadly form of stroke-and the hospital's overall SAH caseload.1 SAH victims seen at hospitals that treat a high volume of SAHs have a 40% better chance of leaving the hospital alive than similar patients seen at low-volume hospitals. Specifically, in low-volume hospitals (those treating fewer than 10 cases of SAH a year), the mortality rate for SAH victims was 38.7%. In high-volume hospitals (those treating more than 35 a year), it was 27%.

The difference, the study's authors suggest, is attributable to factors including the availability of specialized personnel, equipment and protocols. The high-volume hospitals tended to have more stroke specialists on staff, have more sophisticated and less invasive imaging equipment, and use a defined "team" approach to treatment. They additionally had experienced neuro-intensive care units and offered both surgical and endovascular treatment.

With this in mind, it seems logical, from an EMS perspective, to take SAH patients to these high-volume hospitals. But that leads to two problems: One, EMS providers are often required to take patients to the nearest hospital, not necessarily the best hospital. Two, how do such providers even know what the best hospitals are?

The second issue is a bit more easily resolved. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has launched a Primary Stroke Center certification program to help EMS providers, among others, identify the best hospitals for treating stroke victims. Take them there, the reasoning goes, and more will be saved.

"Stroke is the third-leading cause of death and a major cause of disability in our country," says Maureen Connors Potter, executive director of JCAHO's Disease-Specific Care Certification program. "Around 700,000 people suffer a stroke every year. We think that through this certification program, we can reduce some of that death and disability."

To be certified, hospitals have to comply with evidence-based clinical practice guidelines and recommendations from the Brain Attack Coalition. They also must submit performance measurement data and analysis on four of 10 defined draft outcome measures (listed at www.jcaho.org/dscc/performance+measures/stroke+measure+set.htm).

As of late February, nine hospitals had been accredited, and other applications were pending. But even as these numbers grow, EMS faces the question of getting patients to them. If that hospital across town is a better bet for your patient than the one down the street, can you take him there?

"That's emerging as an area of focus," says Potter. "There are several states that have expressed interest in working with us to look at their regulations and begin to identify and take patients to certified programs. We want to encourage as many hospitals as possible to pursue certification, so they can be identified for stroke care, and EMS can know its patients will benefit from best practices at those locations."

Reference

• Cross DT III, Tirschwell DL, Clark MA, Tuden D, Derdeyn CP, Moran CJ, Dacey RG Jr. Mortality rates after subarachnoid hemorrhage: Variations according to hospital case volume in 18 states. J Neurosurg 99(5):805–6, Nov. 2003.

-JE