Should we close the local infirmaries and refer all patients directly to tertiary hospitals?

No, Local Infirmaries Should Not Be Dismantled

Local hospitals in rural and underserved areas should be strengthened and integrated into regional stroke systems of care rather than closed, as they serve critical roles in timely stroke evaluation, thrombolysis administration, and community-based care. 1

The Evidence Against Closure

Stroke Care Requires Local Access Points

The 2025 American Heart Association scientific statement explicitly recommends direct local interventions to strengthen rural hospitals rather than bypass them entirely 1:

• Establish teleneurology systems that include local telestroke support at spoke hospitals 1
• Subsidize stroke certification and coordinator positions at local facilities 1
• Organize transition of care back to communities for secondary prevention 1
• Engage spoke hospitals as active participants in system-of-care decisions 1

Geographic Realities Make Complete Bypass Impractical

Only 20% of the population has access to a thrombectomy-capable center within 15 minutes, and access challenges are even more pronounced in rural areas 1. The 2021 consensus statement from multiple societies (AAN, AHA/ASA, NAEMSP, NASEMSO) provides clear transport algorithms 1:

• Patients should go to the nearest stroke-ready hospital or primary stroke center if no comprehensive stroke center exists within 45 minutes total transport time 1
• All suburban and rural hospitals should have protocols for rapid thrombolysis administration when indicated 1
• Bypass strategies are only appropriate when additional transport time to a comprehensive center doesn't exceed 30 minutes past the nearest capable facility 1

Patient and System-Level Consequences of Closure

Research demonstrates significant harms from eliminating local access 2, 3, 4:

• Rural hospital closures create knowledge gaps related to community health impacts, with alarming closure rates threatening local health service delivery 2
• Many patients prefer local care even when regional centers offer lower mortality risk—45% of patients would choose local surgery even if operative mortality were twice as high (6% vs 3%) 3
• Transfer delays increase nosocomial infections—patients requiring transfer from peripheral to tertiary hospitals experience 20.7% infection rates versus 5-6% for direct admissions 4
• Prolonged pre-operative waiting times occur with transfers, with 52.8% of total admission time spent awaiting surgery versus 26-38% for direct tertiary admissions 4

The Hub-and-Spoke Model Is the Solution

Strengthen Rather Than Eliminate

The evidence consistently supports a coordinated regional system where local hospitals serve as initial access points 1:

• Local hospitals should administer IV thrombolysis when indicated and rapidly assess for endovascular therapy needs 1
• Predetermined transfer protocols with regional partners enable rapid escalation when advanced care is needed 1
• Simultaneous notification systems allow parallel activation of receiving centers and interfacility transport 1

Quality Improvement Over Closure

Rather than dismantling local facilities, the guidelines emphasize 1:

• Participation in national stroke quality improvement programs 1
• Recurring stroke education for local staff 1
• Minimizing door-in-door-out times for patients requiring transfer 1
• Feedback loops between all providers in the system of care 1

Critical Caveats

When Bypass May Be Appropriate

The guidelines do support selective bypass in specific circumstances 1:

• Suspected large vessel occlusion patients in suburban areas where a comprehensive stroke center is within 45 minutes total transport time and no more than 30 minutes past the nearest primary stroke center 1
• Medically unstable patients should follow local protocols for the most appropriate destination 1

Transfer Challenges Must Be Addressed

The system requires attention to 1:

• Standardized supportive care protocols during transfer, particularly for post-thrombolysis patients 1
• Ambulance availability in rural areas where third-party transport may be limited 1
• Capacity and bed availability at receiving hospitals 1
• Data and image sharing between facilities 1

Social and Economic Factors

Patient preferences matter 3, 5:

• Family support networks are disrupted by distant transfers 1
• Cost concerns affect transfer acceptance 1
• Racial and insurance disparities exist in transfer patterns 1
• Patient dissatisfaction with communication and perceived errors drives transfer requests more than specialized care availability 5

The evidence unequivocally supports maintaining and strengthening local hospitals within integrated regional systems rather than dismantling them for direct tertiary referral. 1