key: cord-0895369-kvpity00 authors: Boggs, Krislyn M.; Vogel, Brian T.; Zachrison, Kori S.; Espinola, Janice A.; Faridi, Mohammad K.; Cash, Rebecca E.; Sullivan, Ashley F.; Camargo, Carlos A. title: An inventory of stroke centers in the United States date: 2022-02-28 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12673 sha: 01efb637b6afec90888c97aba934216f8b488e8b doc_id: 895369 cord_uid: kvpity00 OBJECTIVES: Stroke centers are essential for the optimal care of patients with acute stroke. However, there is no universally applied standard for stroke center certification/designation and no unified list of confirmed US stroke centers. Multiple national organizations, and some state governments, certify/designate hospitals as stroke centers of various levels, but discrepancies exist between these systems. We aimed to create a unified, easily accessible, national stroke center database. METHODS: Lists of confirmed stroke centers were obtained from national certifying bodies (The Joint Commission [TJC], Det Norske Veritas, and Healthcare Facilities Accreditation Program) and each state government. Lists were reconciled to a common standard based on TJC requirements and incorporated into the 2018 National Emergency Department Inventory–USA database, which includes all emergency departments (EDs). RESULTS: Among 5533 US EDs, we confirmed 2446 (44%) as stroke centers, including 297 Comprehensive Stroke Centers, 14 Thrombectomy‐capable Stroke Centers, 1459 Primary Stroke Centers, and 678 Acute Stroke Ready Hospitals. Compared with EDs without stroke centers, EDs with stroke centers had higher annual visit volumes, were more often academic, and were more often located in hospitals that had trauma or burn centers. CONCLUSION: We report the consolidation of multiple stroke center designation groups with varying criteria into a unified list of all confirmed US stroke centers linked to a comprehensive, national ED database. This data set will be valuable for future stroke systems research and improving access to emergency stroke care for patients. These data have the potential to further optimize the emergency care of patients with stroke. Stroke is the fifth leading cause of death in the United States, accounting for ≈140,000 American deaths annually. 1 Strokes not only cost the nation $34 billion annually through healthcare costs, medications, and lost productivity, but also they are a significant cause of disability. Stroke reduces mobility in more than half of stroke survivors aged older than 65 years. [1] [2] [3] In the late 1990s and early 2000s, the medical establishment at large recognized the need for improvement in both acute stroke care as well as preventive care for recurrent strokes in response to sev- Certification is associated with higher stroke quality of care and lower mortality after ischemic strokes. 4, [7] [8] [9] [10] [11] [12] However, to our knowledge, there has never been a unified list of all confirmed US stroke centers, and there is no unified stroke center certification system in the United States. 8 (CMS) to certify stroke centers nationally. In addition to these national agencies, individual states also certify stroke centers. With a focus on acute stroke care, the aim of the current study was to develop a unified database of confirmed stroke centers colocated with emergency departments (EDs). We then aimed to make this information easily accessible to the public to optimize access to emergency care for patients with stroke. This is a cross-sectional study of all stroke centers colocated with EDs during the year 2018. The Mass General Brigham Human Research Committee reviewed this project and classified it as exempt. We developed a unified list of confirmed stroke centers by collecting and integrating data from a number of different national-level (ie, across multiple states) and state-level sources. We only included stroke centers formally recognized by 1 of these external sources to reflect confirmation of their stroke center capabilities. Regarding national stroke lists, TJC list was downloaded (December 18, 2018) from the "TJC Quality Check" website, which publishes an up-to-date list of all TJC-certified stroke centers. 13 The DNV 14 and HFAP 15 lists were compiled into a spreadsheet from lists found on their respective websites. Regarding state lists, we conducted online Google searches using combinations of terms, including "[state name]," department of health," "stroke center," and "emergency medical services" (EMS). To supplement online data, representatives from each state's department of health and Washington, DC, were contacted through email, online form, or phone. We did this to either obtain a list (or updated list) of stroke centers for the year 2018 if data posted online were missing or not up to date or to confirm that data posted online were comprehensive. We compiled information from the state's sources, including source organization type and details, source download link, source of last list update when applicable, contact information for source information when applicable, and PDFs of all relevant correspondence. We incorporated these methods into a manual of procedures to facilitate the abstraction of stroke center data in future years. Once the stroke lists were finalized and confirmed as up to date, we matched all stroke centers by name and address to hospitals/EDs from the 2018 National Emergency Department Inventory (NEDI)-USA database from the Emergency Medicine Network at Massachusetts General Hospital. 16 We assume that all-or nearly all-stroke centers are colocated in EDs given the criteria for stroke center certification NEDI-USA includes annual total ED visits volumes, which were categorized into the following 4 groups: <10,000, 10,000 to 19,999, 20,000 to 39,999, and ≥40,000. US Census Bureau regions were used to classify ED locations: Northeast, Midwest, South, and West. ED locations were also classified as location within or outside of a core-based statistical area. 18 Other ED characteristics incorporated into NEDI-USA and examined were academic ED status, 19 freestanding EDs 20 (broken down into subgroups of autonomous and satellite EDs), Critical Access Hospitals (CAH), 21 trauma centers, 22 Each ED in NEDI-USA was classified according to (1) whether a stroke center confirmed by 1 of the 3 national organizations or by its respective state was colocated with the ED and (2) To address discrepancies in nomenclature, we assumed that a center "confirmed" to be a certain stroke level was the equivalent of a center "designated" or "recognized" at that level. The term certification is used by each of the 3 national agencies. However, state governments use a combination of "certification," "designation," and "recognition." For instance, stroke centers were often considered to be state certified if they attested to the national standards and had a site visit, and stroke centers were considered to be state designated if they attested to the national standards but did not require a site visit. From this framework, we were able to develop a nationwide count of each type of confirmed stroke center by certifying organization and state government designation. Data analysis was performed using Going forward, the updated lists will be made available in findERnow as soon as they are collected and will be later incorporated into the corresponding NEDI-USA database for that year. If EDs gain or lose stroke center certification before the annual update, they may request that we immediately update their information in findERnow by writing to us at emnet@partners.org. Overall, there were 1371 confirmed stroke centers certified by TJC, 191 by DNV, 60 by HFAP, and 1427 by state governments (Table 1) . When excluding overlap (eg, those certified by multiple organizations TA B L E 1 Nationwide counts of each type of stroke center by certifying organization and state government designation, n = 2446 Our study had several potential limitations. First, we primarily relied on data published online. However, the variation in availability of informa- Given that access to timely and specialized care are 2 areas of the utmost importance when providing emergency care for a patient with Although the current study does not explore patient outcomes, we indeed found that EDs that were part of confirmed stroke centers were larger and tended to be located in urban areas. Conversely, our results suggest that locations outside of core-based statistical areas (ie, more rural areas) may lack access to confirmed stroke centers. We encourage future research and policy work to investigate barriers to stroke center certification in those areas as well as exploring alternative methods for the improvement of the care of patients with stroke (eg, telehealth use). 26 There have been recent attempts to create a unified list of confirmed stroke centers, most notably by Shen et al. 27 8, 25, 29 To facilitate greater transparency in the stroke capabilities of hospitals/EDs, we encourage states with stroke center certification, designation, and recognition systems to make their stroke center requirements and updated lists of stroke centers publicly available online. This new unified, confirmed stroke list, linked with the NEDI-USA database, allows for the analysis of stroke center data and provides a more complete picture of the capabilities of US EDs in a way that was previously impossible. As described previously, we are incorporating the unified stroke center list into findERnow. 25 EMS personnel and emergency physicians might use this app to help patients identify nearby stroke centers if they are planning to travel. In addition, EMS can use the app to identify nearby stroke centers if they are on a long transport in an unfamiliar area. As described previously, Comprehensive Stroke Centers, Ready Hospital) stroke centers. In conclusion, creating an up-to-date list of confirmed stroke centers by combining all certified by national agencies as well as state agencies into 1 unified list will serve several purposes. By incorporating the data into a free smartphone app (findERnow), it will allow EMS as well as the general public to quickly and easily find a stroke center. In addition, linking these data with other databases will allow future researchers a more complete and accurate way of studying the outcomes at stroke centers in a way that has not been possible before. 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Madison, WI: Emergency Department Performance Measures Mapping primary and comprehensive stroke centers by certification organization The authors declare no conflict of interest.