When someone suffers a stroke, the type of treatment they get in the first few hours can be absolutely crucial to their ability to survive or recover. But stroke treatment at a host of United States hospitals has lagged behind clearly outlined standards of excellence. Out of more than 4,000 hospitals in the country, only about 200 have a certified stroke center, says Dan Sullivan, a doctor and lawyer who runs the Sullivan Group, which specializes in consulting with providers on patient safety, error reduction and risk management. "That's not a lot," says Sullivan. "We need more, and we need to do a better job of taking care of stroke." The absence of JCAHO-certified primary stroke centers has helped foster confusion about therapies like thrombolytic agents that caused widespread complications a few years ago, says Sullivan. Researchers discovered that the complications were often caused by a failure to follow clearly established protocols. The agents needed to be given to patients within the first three hours of a stroke – not four – and providers were failing to check glucose levels as required. "It became clearer that if you do this right, according to protocol, that this treatment works," says Sullivan. And it can have a dramatic effect when done properly. "We're talking about a patient coming in paralyzed on one side. You give them this medicine and sometimes, in 10 to 15 minutes, they have their body back for the rest of their life." Hospitals, he says, just didn't know how to organize the best response. "They weren't coordinating their team," says Sullivan. "They weren't taking a team approach – involving doctors, administration officials, emergency room nurses and so on – getting everybody on board." To get more hospitals to adopt a team approach to treating strokes, the Sullivan Group assembled a turnkey program that would help hospitals meet the strict provisions required to receive a "primary stroke center" designation from JCAHO. "We say, you're the team, you're the leader, here are the protocols; but come to a team agreement, with 30, 60, and 90-day goals." Sullivan's program "includes the certification process, mandatory education, a Web-based curriculum, and they have to report each stroke case back to the certifying organization. If necessary, we'll do an on-site presentation on research protocols, with Web meetings. We also provide a Web-based, stroke-related library." How hospitals treat stroke is, of course, key for patients. But new research also underscores that the patient plays a critical role in the process as well. In one recent study, published in Stroke: Journal of the American Heart Association, patients with slow onset of symptoms often failed to get to a hospital in time to get the therapy they needed. "The time from symptom onset to seeking medical help is influenced by a patient's perception of the seriousness of symptoms, being advised by others to seek help, and calling 911 immediately," said Lori Mandelzweig, PhD, lead author of the study and a researcher at the Sheba Medical Center in Tel Hashomer in Israel. Key factors that influenced their ability to get to a hospital inside the three-hour target period: - Patients who called for an ambulance reduced their risk of delaying treatment by almost 75 percent. - Patients who perceived their symptoms as "severe" reduced their risk of delay by almost 60 percent compared to patients who failed to recognize the severity of symptoms. - Patients who had sudden onset of symptoms were highly unlikely to delay treatment. - While fatigue was associated with delay in both sexes, a patient's perception of control of symptoms was associated with a more than five-fold risk of delay in women. - When someone else recognized the seriousness of the symptoms and advised the patient to get help, patients reduced their risk of delaying treatment by more than 80 percent. - Overall, the risk of delay in hospital arrival among women was three times greater than among men. For hospitals, getting outside help for improving their level of stroke care can start small, but a comprehensive effort isn't cheap. "It depends on what they want," says Sullivan. "Education is $20 a credit hour. If they want all the support materials, it costs about $25,000." He adds that if a hospital wants them on site 90 to 120 days for certification, the cost can rise as high as $75,000. Sullivan is hopeful that with the current emphasis on quality and error reductions, hospitals will be quick to see the importance of improving stroke care. "By the end of '07," he says, "I would hope we are assisting, in some capacity, several hundred hospitals. We already are working with physicians and nurses from 500 hospitals on our risk and safety program. We think they should be moving into the stroke arena."