Heterogeneity of State Stroke Center Certification and Designation Processes

Abstract

Background:

Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on a national certification.

Methods:

In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and/or communication with state officials in all 50 states to capture each state’s process for stroke center certification and/or designation. We categorized this information and outlined examples of processes in each category.

Results:

Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify three main categories of state processes: A. No State Certification or Designation Process (n=12); B. State Designation Reliant on National Certification Only (n=24); and C. State Has Option for Self-Certification or Independent Designation (n=14). Further, we describe three subcategories of self-certification or independent state designation processes: C1. State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital (ASRH) or Equivalent (n=3); C2. State Has Hybrid Model for ASRH or Equivalent (n=5); and C3. State Has Hybrid Model for Primary Stroke Center and Above (n=6).

Conclusions:

Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Graphical Abstract

Introduction

Stroke centers form a key part of the infrastructure for the diagnosis and treatment of patients with acute stroke. Previous studies have suggested that increased participation in stroke center certification or designation systems improves the quality of stroke care and patient outcomes; ^1–4 stroke patients admitted to certified facilities are more likely to receive IV thrombolysis^5–7 and have lower mortality and readmission rates^3,8 than those admitted to non-certified hospitals. The establishment of Primary Stroke Centers (PSC), which was first recommended by the Brain Attack Coalition (BAC) in 2000,⁹ helped to identify centers with certain specialized processes, capabilities, and infrastructure for stroke patients and encouraged that patients be treated at said centers. These standards formed the foundation for evaluating hospitals against consistent and objective criteria that have been associated with improved outcomes.

In 2003, The Joint Commission (TJC), in collaboration with the American Heart Association (AHA) and the American Stroke Association (ASA), became the first national certifying body to certify PSCs.¹⁰ TJC certifications have since expanded to include three additional levels of care: Comprehensive Stroke Centers (CSC), introduced in 2012; Acute Stroke Ready Hospitals (ASRH), introduced in 2015; and Thrombectomy Capable Stroke Centers (TSC), introduced in 2018. Stroke center certification is also offered by three other organizations nationally: Det Norske Veritas (DNV), Accreditation Commission for Health Care (ACHC), which includes the former Healthcare Facilities Accreditation Program (HFAP), and Center for Improvement in Healthcare Quality (CIHQ). Some states have also developed their own independent state-specific processes to certify or designate stroke centers.

Despite these positive developments, the past decade has seen both increased complexity in care paradigms for all types of stroke, as well as significant heterogeneity and variability in the definitions and processes used to certify or designate centers, raising concern about the consistency and rigor of certification and designation processes across the United States (US). Moreover, recent changes in processes, coupled with variability in regulations at the state-level, have further impacted the uniformity of how different levels of stroke centers actually deliver care throughout the nation.

Few previous studies offer details on independent state certification and designation processes,^11,12 which are especially impactful as states introduce stroke-related policies including prehospital triage and transport of suspected stroke patients to certified centers. Our study provides an overview of state-level stroke center certification and designation processes, categorizes said processes, and identifies processes that have undergone changes in recent years. We hypothesized that there would be significant heterogeneity in state processes which might lead to inconsistencies in stroke center capabilities across states.

Methods

Study Design

This study followed the CROSS reporting guideline. The data that support the findings of this study are available from the corresponding author upon reasonable request. We performed a cross-sectional study of state-level stroke center certification and designation processes across the US from September 2022 through April 2023.

National Stroke Center Certification Levels

For the purposes of this study, we chose to use the definitions of stroke centers proposed by the AHA/ASA/TJC, which are based largely on recommendations from the BAC, a group of non-profit professional, voluntary, and governmental agencies that meet and function under the auspices of the National Institute of Neurological Disorders and Stroke,¹³ and are dedicated to advancing knowledge and best practices for stroke prevention and treatment.¹⁴ From most to least advanced these levels include: CSC, TSC, PSC, and ASRH. Of the four organizations, TJC, ACHC, and DNV certify all four levels (with some variation in terminology and outcome measures),^15–17 while CIHQ certifies just two levels (PSC and ASRH).¹⁸ In addition to these national organizations, some states have developed their own processes for certifying or designating stroke centers.

Terminology

There are inconsistencies in the terminology surrounding stroke center definitions and processes, specifically the meaning of stroke center “certification” and “designation”. In response to these inconsistencies and the widespread lack of transparency in state processes and guidelines, we standardized the terminology used in this study as follows: First, we use the term “national certification” to describe hospitals certified by one of the four Centers for Medicare & Medicaid Services (CMS) approved national certifying organizations. Certified hospitals have met the rigorous requirements put forth by these organizations, including passing site visits and submitting data on standardized performance measures. Second, we use the phrase “designation reliant on national certification” to describe hospitals that are designated as stroke centers by the state after obtaining a national certification from one of the four national certifying organizations, as described above. State designation may range from a formal application processes and inclusion in stroke system organization to simply publishing a list of hospitals and corresponding stroke certifications on a state webpage. Third, we use “self-certification or independent designation” to describe states with independent state processes through which a hospital and/or the state determine a hospital’s stroke center status without reliance on a national certification. The term “self-certification” is not commonly used by states; however, we use it synonymously and in conjunction with the more frequented term, “independent designation”, to differentiate between designation processes reliant on a national certification and those which are not. Fourth, we use the term “hybrid model” to refer to state processes with an option for “self-certification or independent designation” or “designation reliant on national certification”.

Data Collection

We undertook a multi-step process to ensure we accurately captured each state’s process for stroke center certification or designation, whether non-existent, conferred by a national certifying organization, state government entities, or both. The steps were as follows:

1. First, from September to October 2022, we conducted internet searches of public-facing webpages and administered a survey instrument to all PIs at the 25 National Institutes of Health StrokeNet Regional Coordinating Centers around the country to obtain preliminary information on state certification or designation processes. Although StrokeNet is primarily a research consortium, we sought to elicit initial information on stroke center certification and designation practices by state as well as contact information for individuals at state agencies who could confirm policies or provide additional information.

2. Next, we compared the preliminary results from Step 1 with a recently published inventory of stroke centers¹² and a historical list of state stroke policies¹¹ to identify recent changes in state processes and policies.

3. We proceeded to categorize states into two preliminary groups: states with a self-certification or independent designation process (12 states) and those without (38 states).

4. Next, from October 2022 through April 2023 we verified the preliminary categorizations of state processes from Step 3 using peer-reviewed literature, primary source documents from states (e.g., state policy documents or legislation), and/or direct contact with state officials.

   1. We identified state contacts in all 50 states using responses from the survey instrument in Step 1 and/or by searching state DOH websites using keywords/phrases such as “Heart Disease and Stroke Prevention,” “Cardiovascular Health,” “EMS and Trauma System,” “Chronic Disease Prevention,” and “Time Sensitive Emergency System.” Once state contacts were identified, we reached out to each state program by email to elicit additional information (survey questions included in Supplemental Methods). We made two or three separate attempts to reach each contact (by email, phone, or a combination) before reaching out to a new contact.
   2. For the 12 states preliminarily determined to have a self-certification or independent designation process, we confirmed whether there was an independent state process and requested to schedule a call to learn more.
   3. For the states preliminarily determined not to have a self-certification or independent designation process, we confirmed that there was, in fact, no self-certification or independent designation process, and subsequently determined whether there was any state designation process.

5. Email responses and call notes were recorded in a data file. If a state contact could not be reached during the study period, peer-reviewed literature and/or primary source documents describing the state process were required for final categorization. For many states, multiple source types was used to verify the state process.

Results

From September 2022 to April 2023, we successfully elicited information and categorized state stroke center certification and designation processes in all 50 states.

State Stroke Center Designation Processes

Using the terminology previously described, we identified three main categories and three subcategories of state-level stroke center certification and designation processes among the 50 states: A. No State Certification or Designation Process; B. State Designation Reliant on National Certification Only; and C. State Has Option for Self-Certification or Independent Designation (includes subcategories C1–3) (Figure 1).

Figure 1.

Categorization of States with State-Level Stroke Center Certification or Designation Processes

States are categorized by the presence of a state-level certification or designation process for hospitals. Many hospitals choose to pursue certification through certifying organizations outside of the state-level process; this is not represented in this figure. Categories include A. No State Certification or Designation Process; B. State Designation Reliant on National Certification Only; or C. State Has Option for Self-Certification or Independent Designation. *In addition to the four national certifying organizations, Texas also accepts certifications from Texas EMS Trauma & Acute Care Foundation for Level IV (Acute Stroke Ready) hospitals. **The Michigan Department of Health and Human Services publishes a list of hospitals participating in the Paul Coverdell National Acute Stroke Program (PCNASP) and corresponding stroke certification levels. While PCNASP is not a state designation program, state recognition of hospital stroke certification categorizes Michigan’s process as category B. Washington DC was not included in this study. Figure created with mapchart.net

A. No State Certification or Designation Process

Some states (n=12) reported having no state-level certification or designation process. For example, Alaska does not have a state-level designation process, and only one hospital in the state has a national stroke certification. There is also no state stroke center designation process in Wisconsin. The state has received funding from the Centers for Disease Control and Prevention to participate in the Paul Coverdell National Acute Stroke Program (PCNASP), which provides funding for the state to collect, measure, and track stroke patient data and improve quality of care, but this is not a designation program. While stroke-certified hospitals in PCNASP-funded states often participate in the PCNASP program, eligibility is not limited to certified centers.

B. State Designation Reliant on National Certification Only

Most states (n=24) require stroke centers to have acquired a national certification to be designated by the state, and these processes varied across states. For example, in Nevada, the state publishes a list of all PSCs in the state based upon certification data from TJC and this list is updated annually. In Ohio and New Jersey, hospitals are designated as stroke centers upon submitting an application to the state with proof of certification from a national certifying organization with no additional requirements. Further, in Texas, state designation is reliant on a national certification from TJC, DNV, or CIHQ, but Level IV hospitals (equivalent to ASRH) can also be certified by the non-profit organization, Texas EMS Trauma & Acute Care Foundation (TETAF), to be eligible for designation.

C. State Has Option for Self-Certification or Independent Designation (subcategories C1–3)

A total of 14 states (28% of respondents) offered self-certification or independent designation processes based on state-specific criteria that did not require a national certification. Due to the significant heterogeneity in these independent processes, the states in category C were further classified into three subcategories: C1. State Relies on Self-Certification or Independent Designation for ASRH or Equivalent; C2. State Has Hybrid Model for ASRH or Equivalent; and C3. State Has Hybrid Model for PSC and Above. A list of states with processes in each of these three subcategories and examples of state processes are included in Table 1.

Table 1.

Categorization of Self-Certification or Independent Designation Processes with Examples

Independent Designation Process	State	Description
C1. State Relies on Self-Certification or Independent Designation for ASRH or Equivalent	Massachusetts	Primary Stroke Service Centers (similar to ASRH) are self-certified/independently designated by the Commonwealth through an alternate licensure process, without a national certification. This is the only level designated by the state.
	Utah	Stroke Receiving Facilities (similar to ASRH) are self-certified/independently designated by the state. A letter of intent and site visit are required for designation, but this process is not as rigorous as would be required by TJC. All other levels (PSC, TSC, and CSC) must be certified by a national accrediting body.
	North Dakota	ASRHs are self-certified/independently designated by the state using department approved, nationally recognized guidelines-based criteria and a site visit is required. All other levels (PSC, PSC+, and CSC) must be certified by a national accrediting body.
C2. State Has Hybrid Model for ASRH or Equivalent	Minnesota	ASRHs can be self-certified/independently designated by the state or designated with proof of a national certification. Designation for all other levels (PSC and CSC) requires a national certification.
	Illinois	ASRHs can be self-certified/independently designated by the state or designated with proof of a national certification. All other levels (PSC, CSC and soon, TSC) require a national certification.
	Louisiana	ASRHs can be self-certified/interpedently designated by the state though self-attestation or by submitting a national certification. National certifications are required for PSC, TSC, and CSC designation.
	Georgia	RTSCs (similar to ASRH) can be self-certified/independently designated by the state or designated with proof of a national certification. All other levels (PSC, TSC, and CSC) require a national certification for state designation.
	Arkansas	Arkansas Stroke Ready Hospitals (similar to ASRH) are self-certified/independently designated by the state, while PSC, TSC, and CSC and are certified by national accreditors.
C3. State Has Hybrid Model for Primary Stroke Center and Above	Alabama	Levels IIa, II, and III (TSC, PSC, and ASRH) can be self-certified/independently designated by the state or designated with proof of a national certification. Level I (CSC) requires a national certification for designation.
	Idaho	Levels I, II, and III (CSC, PSC, and ASRH) can be self-certified/ independently designated by the state or designated with proof of a national certification.
	Maryland	ASRH, PSC, TSC, and CSC can be self-certified/independently designated by the state or designated with proof of a national certification.
	Mississippi	Levels 1, 2, and 3 (similar to CSC, PSC, and ASRH) can be self-certified/independently designated by the state or designated with proof of a national certification.
	Missouri	Levels I, II, III, and IV (CSC, TSC, PSC, and ASRH) can be self-certified/independently designated by the state or designated with proof of a national certification.
	Washington	Levels I, II, and III (CSC, PSC, and ASRH) can be self-certified/independently designated (the state uses the term “categorized”) by the state or designated (“categorized”) with proof of a national certification.

Note: Hybrid Model denotes option for “self-certification or independent designation” or “state designation reliant on national certification” at the specified certification levels. ASRH = Acute Stroke Ready Hospital. PSC = Primary Stroke Center. TSC = Thrombectomy Capable Stroke Center. CSC = Comprehensive Stroke Center. TJC = The Joint Commission

C1. State Relies on Self-Certification or Independent Designation for ASRH or Equivalent

Three of the 14 states in category C offer a self-certification or independent designation option for ASRH or the state-equivalent level only (Utah, Massachusetts, and North Dakota). Utah and Massachusetts have an independent state designation process for the most basic certification level (similar to ASRH, Table S1 provides further information on certification levels). The Utah Department of Health independently designates Stroke Receiving Facilities (SRFs), which follow many of TJC ASRH guidelines,¹⁹ but the state does not require SRFs to go through the more detailed survey or review process required by TJC. In Massachusetts, the state independently designates one type of stroke center: Primary Stroke Service Centers (PSSCs) which is most similar to ASRH, but the state does not designate any of the four levels recognized by TJC (ASRH, PSC, TSC, and CSC). State-specific criteria for these acute stroke levels are typically less stringent than TJC requirements, have lower or no fees associated with designation, and account for the specific needs of the state.

Finally, hospitals seeking ASRH designation in North Dakota are required to meet nationally recognized, guidelines-based criteria outlined by the DOH and must pass a site visit to be designated by the state; however, as with Utah and Massachusetts, this process is not reliant on a national certification (i.e., having national certification is insufficient for designation) and is instead conducted independently by the state. All other North Dakota stroke center levels (PSC, PSC+ [equivalent to TSC, see Table S1], and CSC) require a national certification for state designation.

C2. State Has Hybrid Model for ASRH or Equivalent

Five other states offer a hybrid model for ASRH or equivalent certification or designation. Hospitals in this category can be self-certified or independently designated through the state process or can apply for state designation, reliant on a national certification (Minnesota, Illinois, Louisiana, Georgia, and Arkansas). State processes in Minnesota and Illinois require hospitals applying for ASRH designation through the self-certification/independent designation pathway to submit an application, attest that they meet state-specific requirements, and pass a site visit in order to be designated by the state. In Louisiana, hospitals can self-attest to meeting ASRH state requirements without a national certification or a site visit, and the independent state designation state criteria are less extensive than ASRH requirements from TJC. Finally, hospitals in Georgia and Arkansas can be self-certified or independently designated by the state as Remote Treatment Stroke Centers (RTSCs) and Arkansas Stroke Ready Hospitals (ArSRHs), respectively, which have less stringent requirements than ASRH certification by TJC. Alternatively, these hospitals can be designated as ASRHs by the state after obtaining a national certification. Though these five states all have hybrid models for ASRH designation, most hospitals are designated through the self-certification/independent designation pathway given fewer barriers to entry.

C3. State Has Hybrid Model for PSC and Above

The six remaining states have a hybrid model for PSC, TSC, and/or CSC certification or designation (Alabama, Idaho, Maryland, Mississippi, Missouri, and Washington). Typically, the self-certification or independent designation pathway involves a more extensive application, review of available resources and personnel, and sometimes a site visit, while designation reliant on a national certification is less involved. For example, hospitals in Idaho can be designated as stroke centers at three different levels: I, II, or III, which correspond to CSC, PSC, and ASRH, respectively. Hospitals can be designated independently by the state or with a national certification at any of the three levels, but those with a national certification complete an abbreviated state process (shorter questionnaire and no on-site survey) compared with hospitals applying through the independent state pathway.

Other Non-State Certifying or Designating Organizations

Many states have additional certification or designation bodies beyond the four national certifying organizations and state departments of health, but these external organizations have little to no impact on state certification or designation. The Kansas Initiative for Stroke Survival (KISS) is a nonprofit organization that allows hospitals to self-attest their capabilities and publicizes which hospitals can emergently treat stroke patients. KISS also educates emergency medical services (EMS) agencies to improve resource awareness and help transport patients to the most appropriate facilities, but these self-attested stroke centers are not recognized by the state. Similarly, the University of Arkansas for Medical Sciences (UAMS) independently certifies telestroke facilities within the UAMS system, but this is not synonymous with state ArSRH designation by the state. Finally, Veterans Affairs (VA) hospitals have an independent stroke center designation system nationally, outside of the four national accrediting bodies or state DOH. This system was established in 2011 through the Acute Ischemic Stroke Directive and mandated the reorganization of acute stroke care.²⁰ VA stroke centers are currently designated at four different levels: Comprehensive Stroke Center, Limited Hours Stroke Facility, Primary Stroke Center, or Supporting Stroke Facility,²¹ but these levels differ from those of certifying organizations or state DOH.

Recent Changes to State Processes

Previous research on state certification and designation processes from 2018 found that 23 states had various ways of confirming their own stroke centers.¹² Since then, at least 12 states have changed or adjusted their processes, and we provide examples of these changes. Many states now include TSCs and designate four levels of certification (CSC, TSC, PSC, and ASRH) rather than the previous three (CSC, PSC, and ASRH). Some states have expanded their designation processes to a hybrid model: offering self-certification through a self-certification/independent state process or designation reliant on national certification. For example, Idaho and Washington previously did not have a hybrid model for ASRH designation (Washington uses the term “categorization” instead) but both states now offer two distinct options—self-certification or designation through the independent state process or designation reliant on a national certification. Both pathways are available for ASRHs, PSCs and CSCs.

Designation processes in New Jersey and New York have also changed in recent years, as both states previously offered a self-certification pathway but now require hospitals to hold a national certification to be designated by the state. A 2004 New Jersey bill permitted the state to independently designate CSCs and PSCs, but this bill was repealed and replaced in 2020, and a national certification is now required for state designation at all levels. In 2019, New York also adopted a regulation that transitioned the state process from a single level, self-certified by the New York State Department of Health, to a three-tiered designation process that requires a national certification from an approved national certifying organization.

Discussion

Our characterization of state processes for stroke center certification and designation in all 50 US states reveals significant heterogeneity across states. Most state processes require proof of certification by a national certifying organization for state designation, though 14 states offer a self-certification or independent designation process, and many of these states offer hybrid models. Further, many states have modified stroke center levels or pathways in recent years and the language around certification and designation remains inconsistent. These findings underscore the important role that state governments play in stroke center certification and designation, which may be a critical component of stroke system organization.

The observed heterogeneity in state processes has numerous implications for patients and hospitals. First, stroke center certification or designation determines whether a hospital can hold itself out as a stroke center to the public, which may influence where patients choose to seek care. Several state processes assert that a hospital cannot hold itself out as a stroke center, regardless of whether it has obtained a national certification, if the facility is not also designated by the state.

Furthermore, in many states, stroke center certification or designation impacts pre-hospital EMS triage and transport protocols. Protocols may recommend taking suspected stroke patients to certified or designated centers while bypassing non-designated centers. Additionally, variations in stroke screening scales and differences in EMS prehospital transport protocols for patients with suspected large vessel occlusion (LVO) may prioritize TSCs and CSCs over PSCs and ASRHs, though the impact of this transport strategy on patient outcomes is still elusive.²² Nonetheless, since hospital revenue and patient volumes are dependent on critical care patients, many of whom arrive via ambulance transport,^23,24 ensuring inclusion in pre-hospital destination protocols provides a strong incentive for hospitals to become certified or designated.

Incentives for certification or designation may also vary between state processes that require a national certification and those with options for self-certification or independent designation. The lower barriers of entry characteristic of many independent designation processes, specifically for ASRH, may encourage hospitals to pursue independent state designation rather than designation reliant on a national certification. For example, in 2021, the initial site visit fee for ASRH certification was $2,375 through TJC and $3,900 through Det Norske Veritas,²⁵ while there is no such fee for ASRH self-certification or independent designation through several of the state programs (e.g., Georgia and Minnesota). Moreover, a previous study on PSC and CSC designation found that states in the NorthEast Cerebrovascular Consortium, where there are a large number of Department of Health (DOH) operated state designation programs, had greater rates of PSC and CSC designation than areas with a smaller number of DOH designation programs.²⁶ Hospitals in states without low- or no-cost self-certification or independent designation pathways may be less likely to pursue a national certification or designation due to financial constraints, lack of resources, or limited perceived benefits associated with a higher level of designation.

On the contrary, lower barriers to entry and variability in self-certification/independent state designation processes may impact delivery of care. Previous research provides some evidence that certification by a national organization is associated with more favorable outcomes than designation through independent state-level processes.^4,7 For example, in Massachusetts, all state designated stroke centers are designated as PSSCs. This means large well-resourced hospitals, that may also be certified as PSC or above by a national certifying organization, are designated by the state in the same category as less resourced, rural hospitals with capabilities closer to that of an ASRH. While recent Massachusetts state legislation is anticipated to transition the state’s EMS triage framework to a tiered system, in an attempt to improve patient care and outcomes,²⁷ state processes with similar inconsistencies may potentially obscure available resources and hospital capabilities.

As states continue to develop and improve their certification or designation processes, many are modeling off existing state emergency systems and protocols, such as those for trauma or ST-elevation myocardial infarction (STEMI). In 2017, Alabama extended the capacities of its state trauma system to include one central hub where all EMS stroke and trauma patients could be directed to the most appropriate available hospital. Similarly, the Idaho Time Sensitive Emergency System (TSE) for trauma was introduced in 2016, just a year before including stroke and STEMI in 2017. These existing systems for trauma, stroke, STEMI, and other time-sensitive emergencies, may provide guidance as processes continue to adapt and evolve.

Limitations

This study has several limitations. First, state processes were identified using a variety of sources (website information, legislation, policy language, and personal communications) and there may be inconsistencies between sources. Second, as with other state-level processes (e.g., trauma or STEMI designation), stroke center designation processes are constantly changing. This is a cross sectional study with all data collected between September 2022 and April 2023. Any changes in state processes that have occurred since the study period may not be reflected in our findings. Third, we recognize that not all stroke center designation processes occur at the state level. For example, the state of California also does not designate stroke centers at the state-level, though many hospitals have been certified by a national certifying organization, and some are also designated by their local emergency medical service agency. While regional and local protocols may play a role in stroke center recognition, these processes lack uniform recognition at the state level. Fourth, even in states with established state-level designation processes, not all hospitals participate in said process. However, the purpose of this study was not to quantify hospital participation, nor to examine the distribution of stroke centers across the US (which has been done in other studies^12,28). Next, designation processes in category B include states that simply publish a list of hospitals with stroke center certifications on their public-facing webpage. This list may not affect pre-hospital EMS transport or inclusion in state stroke system organization; however, our study did not go so far as to evaluate the specific implications of designation in each state. Finally, we did not study certification or designation motivations, incentives, regionalization, or health care markets, nor did we systematically capture any of these potential factors (e.g., we did not systematically capture heterogeneity in the implications of ambulance routing). Future studies may look to systematically address some or all these factors to better inform established and developing stroke systems of care.

Conclusion

Overall, despite national standards and certification processes for US stroke centers, there remains significant heterogeneity in current state-level certification and designation processes. Further research on whether or how this heterogeneity impacts patient care and clinical outcomes is a valuable consideration that warrants further study. Our findings may help inform and guide state departments of health, EMS agencies, and policymakers as they design and update their own processes aimed at establishing or improving stroke care and outcomes.

Non-standard Abbreviations and Acronyms

ASRH

Acute Stroke Ready Hospitals

CSC

Comprehensive Stroke Center

DOH

Department of Health

EMS

Emergency Medical Services

PSC

Primary Stroke Center

TJC

The Joint Commission

TSC

Thrombectomy Capable Stroke Center