Early transfer of patients with stroke to comprehensive stroke centers is not necessary.

Ah, I see you have the machine that goes " ping! ". This is my favorite. W hen the Monty Python comedy film parodied the use of medical technology they raised an important point; doctors are easily seduced by new technology and need to look critically at what is in the best interests of their patients. Therefore, our key question here, what is the best pathway of care for this man at this time?, should be informed using the best available clinical evidence. There is no evidence that an ambulance journey improves stroke recovery, and there are good grounds to think that it may be harmful, so we should try to meet this man's immediate care needs in the admitting hospital. However " the devil is in the detail " about exactly what kind of stroke unit care is available in the community hospital. By examining this man's pathway of care and considering his care objectives we can see that he is unlikely to benefit from immediate transfer to a comprehensive stroke center: Recanalization: This man has presented too late for intravenous thrombolysis and there is currently no randomized evidence to indicate that he would benefit from mechanical clot retrieval. 1 Decompressive surgery: He is at some risk from malignant middle cerebral artery syndrome but his National Institutes of Health Stroke Scale is at the lower end of the range considered eligible for decompressive surgery 2 and supportive care is likely to be his best option. However, it is important to be able to monitor his progress appropriately and respond if his condition changes (see below). Stroke unit care: This is likely to be the key intervention for promoting this man's early recovery. An individual with this level of stroke severity will have a greatly increased chance of survival (≈10% absolute improvement) and a more modest increase in the chance of regaining some independence if he is managed in a properly run stroke unit. 3 Does he require transfer to a comprehensive center to receive this care? The answer is no—providing that the community hospital has certain key components in place 3 : • adequate levels of nursing, medical, and therapy staff who have a knowledge and interest in the essential components of stroke management, • multidisciplinary model of working involving regular team meetings to plan his care, • standard protocols to monitor and manage common complications (including raised intracranial …