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Transitions of Care for Stroke Patients: Opportunities to Improve Outcomes.

The last 30 years have seen tremendous progress in primary and secondary stroke prevention in the United States with better control of hypertension, decreasing smoking rates, antithrombotic treatment for atrial fibrillation, use of statins, and blood transfusions for children with sickle cell disease.1 In 1996, intravenous tissue-type plasminogen activator was approved for treatment of acute ischemic stroke,2 and in 2014 to 2015, endovascular treatment of major arterial occlusion, primarily by stent retrievers, was demonstrated to result in better outcomes for patients with ischemic stroke when compared with patients treated with intravenous tissue-type plasminogen activator alone.3 During this same time period, the field of neurocritical care grew tremendously in terms of physician and nurse training, standardization of care, and technology. Finally, standardization and certification of primary and comprehensive stroke centers have improved the quality of acute stroke care and the use of secondary prevention medications when patients are hospitalized for acute stroke.4,5 These cumulative advances have resulted in the decline in stroke mortality rates from the third to the fifth cause of death in the United States.6

The bulk of these advances have occurred in 2 settings—the office of primary care physicians who manages stroke risk factors in persons with and without a prior stroke; and the acute care hospital. Yet, the stroke patient follows a complex path from first onset of symptoms to the years after the onset of stroke, and the transitions between the respective places of care along the path represent major challenges and opportunities.

### Transition From Place of Stroke Onset to Acute Hospital

One of the first major transitions of care is when emergency medical services (EMS) respond to a 911 call for a potential stroke. EMS personnel assess …