Organized Stroke Care

T he firm scientific basis for organized stroke care is relatively short, little more than 10 years.During the past year, existing knowledge has not only been consolidated but also extended in several areas with important implications on clinical practice.Three areas can be identified: (1) organization of prehospital services, (2) hospital treatment, and (3) follow-up care.Progress has been highly variable among the 3 areas and around the world based on local practices and differences in health care systems and resources.Overall, more progress is evident in hospital care, primarily creation and promotion of "stroke units".Recent studies have supported the effectiveness of inhospital organized (stroke unit) care, 1 and that management in a stroke rehabilitation unit confers survival benefits 10 years after stroke, probably because long-term survival is related to early reduction in disability. 2 An estimate based on data from the North East Melbourne Stroke Incidence Study showed that although tPA was the most potent intervention, management in stroke units had the greatest population benefit.3 Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland was associated with reduced case fatality by Ϸ25%, 4 which is in line with previously reported data from the Swedish national registry of stroke care (Riks-Stroke), 5,6 and with the figure obtained from systematic analysis of stroke unit trial data.In a Japanese observational study, admission to an acute stroke unit during weekends and holidays, when level of multidisciplinary care and rehabilitation efforts was reduced, was associated with more unfavourable outcomes.7 Organization of prehospital care has received less attention but is recognized as an important component.Included in this domain would be protocols and methods for action by "first responders" and ultimately field triage of suspected stroke to determine the optimal hospital destination.Both Canada 8 and the US 9 have articulated concepts of integrated "Stroke Systems of Care" that include all 3 components listed above, but these have not been fully implemented.Testing the effectiveness and cost/benefit of such systems will also be a challenge.In the US particularly, the ASA Systems Plan points out that " . . . the current fragmented approach to stroke care in most regions of the United States provides inadequate linkages and coordination among the fundamental components of