Research letter
The Accessibility of Stroke Units in Germany
The most recent revision of the German evidence-based guideline “Acute Treatment of Ischemic Stroke” recommends that all persons suspected of having a stroke should undergo diagnostic imaging—cranial computed tomography (CCT) or magnetic resonance imaging (MRI)—within 60 minutes of stroke onset. The guideline also recommends that all patients with acute stroke or acute transient ischemic attack should be treated at a stroke unit (1).
If all stroke patients are to benefit from prompt treatment at a stroke unit, such a facility must beeasily accessible geographically. However, the recommended maximum of 60 minutes to imaging includes all stages of the process: discovery of the suspected stroke victim, notification, deployment, and arrival of the emergency rescue service, initial on-site investigation, transport to hospital, handover, and finally the imaging itself. To meet the recommendation, the transport time has to be well below 60 minutes.
In 2020, around 9 million inhabitants of Germany lived more than 30 minutes away from a stroke unit, including 400 000 persons for whom the transport time would even have exceeded 60 minutes. About one quarter (23.2%) of stroke treatments are carried out at institutions with no stroke unit. If all stroke patients were to be taken to a stroke unit for treatment, the average transport time would increase from just under 22 minutes to over 23.5 minutes (3).
The aim of the study reported here was to provide an updated assessment of the accessibility of stroke units in Germany. Furthermore, incidence-adjusted average transport times were calculated on the basis of new data from the German Stroke Society, the German Federal Hospital Compendium (Bundes-Klinik-Atlas), and the 2022 German national census.
Methods
The addresses of certified stroke units were obtained from the German Stroke Society (as of 1 July 2024), those of non-certified stroke units from the German Federal Hospital Compendium (as of 2022). The continued existence of the latter in 2024 was verified and necessary corrections were made. A total of 351 certified and 111 non-certified stroke units were identified. Because “stroke unit” is not a protected designation, facilities where stroke is treated can apply for certification of the fact that their stroke therapy and the quality of their structures and processes conform with the guideline (4).
The map of Germany used for this study is in a raster format with each cell representing an area of 1 km × 1 km. The ambulance transport time from the center of a given cell to the nearest stroke unit was calculated using a locally hosted Open Source Routing Machine (5) based on OpenStreetMap (basically, a route planner).
For calculation of incidence-adjusted average transport times, age- and federal state-specific stroke incidences were generated from the German Federal Statistical Office data on inpatient treatments (ICD10: I60–I64, G45) in 2022 and population data from the 2022 census and were transferred to the raster cells of the 2022 census.
Results
German residents who suffered a stroke needed an average of 16.8 minutes to reach a certified stroke unit. Inclusion of non-certified stroke units in the calculation brought the average down to 14.9 minutes.
Figure 1 shows the transport times to the nearest stroke unit. In most regions, the time was less than 30 minutes. Transport times in excess of 50 minutes are found particularly in northern and southern Brandenburg, in the area along the border between Lower Saxony and Mecklenburg–West Pomerania, and in eastern North Rhine–Westphalia. Times of over 50 minutes also apply on the peninsulas of Fischland–Darß–Zingst and Usedom. If patients were to be taken only to certified stroke units, the transport times would be longer, especially in northern Thuringia and adjacent areas and in southeastern Thuringia.
The more rural the area, the longer the transport time (Figure 2). In 2022, a total of 383 029 patients with stroke were treated as inpatients in German hospitals. Of these, 352 849 (92.1%) reached a stroke unit in less than 30 minutes, 29 792 (7.8%) needed 30–60 minutes, and 388 (0.1%) took more than 60 minutes. Considering only certified stroke units, 333 743 patients (87.1%) reached such a facility in less than 30 minutes, 47 481 (12.4%) needed 30–60 minutes, and 1805 (0.5%) took more than 60 minutes.
Discussion
This study of the average time needed to transport stroke patients to the nearest specialized treatment facility shows that in most regions of Germany a stroke unit can be reached within 30 minutes. In some places, however, the transport time is in excess of 50 minutes. These areas include parts of the states of Brandenburg and Mecklenburg–West Pomerania and communities along the border between Lower Saxony and Mecklenburg–West Pomerania. If patients were to be taken exclusively to certified stroke units, transport times would be longer, especially in northern Thuringia and adjacent areas and in southeastern Thuringia. It is evident that living in an urban area means to have swifter access to a stroke unit.
The calculated transport times may diverge from reality, because the driving times were simulated with a normal automobile. In Germany, however, stroke patients are usually transported by ambulance, which is exempted (under § 35 paragraph 5a of the German road traffic regulations [Straßenverkehrsordnung, StVO]) from certain rules of the road, e,g., adherence to speed limits, staying in lane, and stopping at red lights. Emergency vehicles may therefore reach a hospital more quickly than conventional passenger vehicles. Moreover, other forms of emergency care were not taken into account. Furthermore, the time to arrival of the emergency medical personnel and the on-site investigation time were not considered. Attention has recently been drawn to the fact that the data in the German Federal Hospital Compendium, used in this study, may be incomplete or erroneous. It is thus possible that not all stroke units are listed in the compendium.
Niklas Ullrich-Kniffka, Institute of Sociology and Demography, University of Rostock, niklas.ullrich@uni-rostock.de
Conflict of interest statement
The author declares that no conflict of interest exists.
Received on 29 August 2024, revised version accepted on 2 January 2025
Translated from the original German by David Roseveare
Cite this as:
Ullrich-Kniffka N: The accessibility of stroke units in Germany. Dtsch Arztebl Int 2025; 122: 170–1. DOI: 10.3238/arztebl.m2025.0001
| 1. | https://register.awmf.org/assets/guidelines/030-046l_S2e_Akuttherapie-des-ischaemischen-Schlaganfalls_2022-11-verlaengert.pdf |
| 2. | Pütz T, et al.: Informationen Zur Raumentwickl 2020; 47: 30–53. |
| 3. | www.bundesgesundheitsministerium.de/fileadmin/ |
| 4. | www.schlaganfall-hilfe.de/de/fuer-betroffene/akutbehandlung/stroke-unit |
| 5. | Luxen D, Vetter C: ACM 2011; 513–6. |
