Nirali Vora, MD

Schuberg S, Song S, Saver JL, Mack WJ, Cen SY, and Sanossian N. Impact of Emergency Medical Services Stroke Routing Protocols onPrimary Stroke Center Certification in California. Stroke. 2013

Pre-hospital delays in stroke care are an ongoing target in the battle of time vs. brain. One way to save time is to have paramedics divert patients directly to stroke centers capable of acute treatment rather going to the nearest hospital until transfer to a stroke center is arranged.

The body that governs the process of routing patients is not uniform. In California, it is governed at a county level, with progressive adoption in the last 10 years of paramedics routing stroke patients only to hospitals designated as “Primary Stroke Center” (PSC). Schuberg and colleagues found the rate of hospitals seeking PSC certification increased dramatically around the time the routing policy was adopted in that county. Makes sense. If I was a hospital administrator, I would not want to lose all the stroke business because I wasn’t certified. There are added variables like increased Medicare reimbursement for tPa in 2005 that may also have contributed to PSC growth.

The authors go on to suggest that adopting a national policy to route patients to stroke centers would continue to increase rates of PSCs, and therefore lead to better stroke care. While I certainly expect the economic motivation to drive more PSCs, the last part about improved care is a bit of an assumption. I live in one of the top 4 counties with greatest number of PSCs in California and recognize that there are variable services and care offered at each hospital, despite the label of “PSC.” With the advent of Comprehensive Stroke Center (CSC) designation by the Joint Commission, an even higher complexity certification is available. Should EMS be routing patients only to CSCs? Do labels really guarantee quality? Maybe we should study disability (mRS) at 7, 30, or 90 days in stroke patients treated at centers before and after certification, or compared to non-certified centers. What do you think?