ASRHs are envisioned to be smaller facilities typically located in a rural or small city area with limited resources and capabilities. The concept is that in large states or relatively unpopulated areas of the country, where there might be a number of these small facilities, one or more will seek recognition and certification as an ASRH. This would then inform patients and assist EMS in terms of which hospital to go to should someone have a stroke. By virtue of having stroke protocols, training, expertise, and links via telestroke to another facility, patients would be more rapidly diagnosed, treated, and then transferred to a PSC or CSC. Before transfer, patients would be stabilized and receive emergency therapies such as IV TPA (for ischemic stroke) or perhaps reversal of anticoagulation (for a hemorrhagic stroke). It is unlikely that most patients would be admitted to an ASRH, since such facilities would not have on-site advanced imaging, personnel, stroke units, and other techniques important for a complete stroke work-up and ongoing care.

As noted above, an important aspect of an ASRH is a relationship with a nearby CSC and PSC. Although a formal or contractual agreement might be prohibited in some circumstances by antitrust issues, an informal agreement is needed to ensure that consultations and transfers can occur in a smooth and efficient manner at all times of the day. In addition to acute care issues, such a relationship should include educational efforts and perhaps research protocols in some cases [5].

Do ASRHs improve outcomes? This is hard to know at present, since this designation is relatively new and currently there are very few facilities certified as ASRHs (see below for details). While we know that some of the care elements and protocols that are required at an ASRH do improve outcomes (IV TPA for ischemic stroke), it remains to be seen if this translates to facility-level improvements in overall outcomes. It might be that the main benefits of an ASRH are to rapidly transport the patient to a PSC or CSC. But by virtue of the fact that an ASRH should lead to more rapid diagnosis and treatment, favorable outcomes might be anticipated.

PSCs were the first formally designated type of stroke center. This was done because it was believed (by the BAC) that this level of care could be achieved in a relatively short period of time by a large number of hospitals, and therefore this level of care would impact the largest number of patients in the shortest period of time. At present there are approximately 1100 PSCs in the USA. PSCs can provide standard levels of care for most types of stroke patients, and can also serve as resource hospitals for some ASRHs. Most PSCs have an average daily census of 100–500 patients with average annual stroke admissions of 300 or more in 48 % of cases [7]. A key required element of a PSC is a stroke unit. There is robust literature and abundant data showing the positive impact that stroke units have on outcomes for many stroke patients [8–10]. The benefits of a stroke unit are apparent for patients with ischemic strokes as well as those with cerebral hemorrhages.

There continues to be a misperception that the designation of PSCs was largely driven by the need to safely administer IV TPA to more patients. Certainly the safe and effective use of IV TPA can be increased at a PSC, as well as at an ASRH or a CSC. However, when the PSC guidelines were published in 2000, it was clear that <5 % of stroke patients in the USA were being treated with IV TPA. It was equally clear that many in-hospital care elements, which could reduce peri-stroke complications and secondary stroke risk (see Table 28.3), were not being done routinely at most hospitals or for most patients. These “routine” care elements would potentially impact 100 % of the admitted patients, which the BAC believed would have a greater impact than increasing TPA utilization from 3–4 % to 5–10 % or more. But these treatment goals are certainly not mutually exclusive; both should and are being accomplished simultaneously.

We analyzed data from PSCs certified by the JC to see how such certification affected the use of IV TPA. Overall, the rate of use of IV TPA steadily increased as a facility achieved and maintained PSC certification status by 6–20 % depending on the year studied [11]. The steepest part of the increase was in the first 1–3 cycles of PSC recertification. Another trend was that, in general, academic facilities had higher overall rates of TPA utilization in eligible patients compared to nonacademic facilities (see Fig. 28.2) [11]. Other studies have also shown that admission of patients with acute ischemic stroke to a PSC was correlated with 2.5 % reduction in mortality and a 3 % increase in the use of IV TPA [12].

In a related study, we examined the rate of compliance with various quality metrics at PSCs certified by the JC compared to non-certified facilities [13]. For all of the selected measures (such as VTE prophylaxis, discharge on statins, anticoagulation for Afib), the overall compliance rates were 74 % for non-PSCs compared to 91 % for certified PSCs. Stroke education for patients and family members had one of the greatest differences (70 % vs. 89 %, non-PSC vs. PSC) [13].

PSCs implemented the collection of data using tools such as Get With The Guidelines-Stroke (GWTG-Stroke). Data on meeting the various stroke measures have been collected on close to a million patients, many of whom were at PSCs. During the initial years of GWTG-Stroke, the percentage of patients and facilities meeting various guideline elements was in the 40–80 % range, depending on which care element was examined. Over the past 5–7 years these numbers have steadily increased, so that compliance rates for most elements are now routinely in the 80–90 % range (see Table 28.4) [14]. Furthermore, hospitals that are certified as PSCs had higher compliance rates with these quality measures compared to non-certified facilities [15]. Hospitals that were JC certified or preparing for JC certification had twice the rate of error-free compliance with JC performance measures compared to other facilities [15]. Whether one analyzes PSC certification through the JC, or uses GWTG-Stroke measures, it is clear that PSCs achieve high levels of compliance with a variety of performance measures, which serve as a surrogate for quality of care [16].

Another study examined the effects of a policy change that mandated pre-hospital EMS triage to a PSC for patients with suspected acute ischemic strokes. Analysis of over 1000 patients pre- and post-intervention showed that the percentage treated with IV TPA rose from 3.8 to 10.1 %, while onset-to-needle times fell by almost 30 min (both changes were statistically significant) [17]. This study, combined with other studies showing overall higher rates of TPA use at PSCs compared to non-PSC facilities, clearly supports the utility of such facilities as well as the preferential triage of patients with acute strokes to these hospitals. A separate but related study showed that once EMS began a program to preferentially route acute stroke patients to a PSC, the number of certified PSCs increased [18].