Frequently Asked Questions from the November 18, 2009, Training Webinar

  • Questions 7 and Question 19 were revised January 10, 2011.
  • Questions 8 and Question 9 were removed January 10, 2011.
  • Question 2 was revised July 8, 2010.
  • Question 24 was revised February 25, 2010.

1. When should the National Institutes of Health Stroke Scale (NIHSS) be performed?

The initial NIHSS should be performed during initial evaluation, prior to tPA decision.

2. Who may perform the NIHSS? [Revised July 8, 2010]

The NIHSS must be performed by a certified clinician, including a Physician, Physician Assistant, Nurse Practitioner or Registered Nurse.

Note: Physical therapists may be certified to perform the NIHSS upon discharge. The facility is responsible for assuring continued competency.

3. When must the discharge NIHSS be performed?

Beginning in January 2010, the Department of Health (DOH) is requiring that the NIHSS be done at discharge in addition to the initial evaluation. Department of Health has discussed the timeframe with the Stroke Physician Advisory Workgroup and determined that the NIHSS at discharge should be within twenty four hours of discharge.

4. Why in 2009 did the DOH definition of acute stroke include the onset of symptoms up to 12 hours?

The decision to include symptoms from onset up to 12 hours was based on recommendations from the Stroke Physician Advisory Workgroup that the designation of a Primary Stroke Center conveyed to the public a special awareness of the signs and symptoms of stroke, as well as, a focused monitoring of patients not only to treat, but to monitor these patients at risk for stroke.

TIAs, even those which have resolved, present a specific risk and require early assessment and careful monitoring.

5. In 2010 is DOH going to change the definition of acute stroke for purposes of data collection and monitoring of the time targets?

The DOH has received several comments relative to the issue of timely CT scans in the Emergency Room for all acute strokes, including TIAs.

DOH remains committed to the principle that patients who have had a TIA are at risk for stroke and require rapid assessment upon arrival in the Emergency Department. This principle has been discussed with the Joint Commission and stroke physician experts and has been confirmed. Therefore, DOH will continue to require that TIAs, Ischemic and Hemorrhagic strokes be rapidly assessed in accordance with the five time targets.

However, beginning in January 2010, for purposes of data collection of the 12 performance measures and the five time targets, acute stroke will be defined as the onset of continuous symptoms up to 6 hours.

The data collection of the time targets may separate TIAs from the other two types of strokes. Therefore, what will be submitted in 2010 is the monthly average, by month, for each of the five time targets as follow:

EACH MONTH
Target Time Measures TIA Ishemic/
Hemorrhagic
10 minutes Door to MD Average time Average time
15 minutes Door to team Average time Average time
25 minutes Door to CT taken Average time Average time
45 minutes Door to CT read Average time Average time
60 minutes Door to treatment Average time Average time

6. Neurosurgery capability is required at every primary stroke designated center or the procedure must be performed within two hours of when it is deemed clinically necessary. When must the patient be transferred?

If neurosurgery capability is not available on site, the primary designated stroke center must have the ability to transfer the patient timely so that the two hour timeframe is met.

The evaluation and transfer must occur so that the procedure at the receiving hospital can be performed in the required two hour timeframe.

7.What is the difference between the educational requirements of the "stroke team" and other staff who care for stroke patients? [Revised January 10, 2011]

The stroke team, including all physicians, physician assistants and nurses in the ED, ICU and stroke unit must meet the following educational requirements Year 1 - 8 Category 1 CMEs Year 2 and thereafter 4 Category 1 CMEs each year.

For nurses in year one, the requirement is for eight (8) hours of continuing education specific to stroke. The education does not have to be CEUs, but may be the equivalent hours in all subsequent years. Four hours of specific stroke education is required in each subsequent year.

For all staff who care for stroke patients, but who are not members of the stroke team (PT, OT, Speech) the requirement is for bi-annual education specific to stroke. There is no specific hour requirement for the education.

The evidence needed to support that the appropriate number of hours has been met, is a spreadsheet listing the name of the stroke team members and the number of hours of education obtained for the appropriate year.

8. [Removed January 10, 2011]

9. [Removed January 10, 2011]

10. Who may provide the in service for the bi-annual education of stroke staff?

The bi-annual education may be provided by the Emergency Department physician or neurologist or the nurse educator knowledgeable about stroke.

11. Are patient care technicians in the category of other staff for purposes of the bi-annual education?

If the patient care technician cares for stroke patients, they would be responsible for complying with the bi-annual education requirement.

12. If the physician was previously at another designated stroke center and achieved the 8 hours of CMEs there, does that satisfy the requirement for initial year education at the current designated center?

Yes. The physician who achieved 8 CMEs at another designated center would only have to complete 4 hours of CMEs or be board certified to meet the subsequent year requirements at the current designated center.

13. Are all time targets, including those for lab results, measured from arrival time in the Emergency Department?

Yes. All times are calculated from arrival or door time in the Emergency Department. However, when calculating "door to MD" for an in-patient stroke, the "door" time is when the symptoms were recognized as stroke and the difference in time to when the physician arrived.

14. For purposes of submission of policies and procedures, may they be submitted on-line?

For any subsequent document submission, on-line is preferred. For those wishing to become designated, two paper copies are required.

Once designation is achieved, the annual audit requires on line submission. The yearly audit does not require submission of the policies unless they have changed. The annual audit requires the designated center to attest that policies and procedures are reviewed annually.

15. In the November 18, 2009 webinar, reference was made to high-grade stenosis putting patients at risk for stroke. Are designated centers required to track all high-grade stenosis patients?

No. The reference to high-grade stenosis patients was to demonstrate patients at risk and the need for rapid assessment. However, those patients do not need to be tracked for purposes of DOH data submission.

16. May a RN hang and administer tPA?

The decision as to who may administer tPA is a matter of expertise and hospital policy. The DOH does not have a requirement for who may administer tPA. In some designated centers, Emergency Room physicians administer tPA. In other hospitals, according to their own policies, tPA may only be administered by a neurologist. For community hospitals where the Emergency Room may be staffed by Physician Assistants or Nurse Practitioners, tPA may be administered under the supervision of a physician who does not have to be on site, if it is in accordance with the expertise and scope of practice of the physician extender and hospital policy.

17. What does it mean to have door to stroke team within 15 minutes?

The requirement for stroke team means that the team member, who will assess the patient for treatment, must arrive within 15 minutes of the patient arriving in the Emergency Department. If the Emergency Department physician is the one to make the decision about tPA, then the time is met when the Emergency Department physician arrives. If at the particular center, the neurologist must make that decision, then door to team is recorded when the neurologist on the team makes that decision. The neurologist may be on the phone. A nurse member of the stroke team does not satisfy this requirement.

18. Where are the communications from the DOH posted?

All the letters from Dr. Morley regarding stroke have been posted to the Health Provider Network (HPN).

All hospitals are required to have an HPN Coordinator who has access. The letters are found in the Hospital "Dear CEO" section and are listed by year.

19. If the Nurse Practitioner or Physician Assistant is the first to see the patient at a designated center, which does not have an Emergency Department staffed by a physician, does this satisfy the Door to MD requirement off hours? [Revised January 10, 2011]

In order to meet the "Door to MD" and "Door to Team" requirements at a facility at which the Emergency Department is not staffed by a Physician in the off hours, the Physician extender must call the physician who will make the decision about the administration of tPA. The time of the conversation with the physician should be recorded.

Pursuant to the Department of Health Regulations ( 10 NYCRR 405.19) hospitals with unscheduled emergency visits of less than 15,000 the supervising or attending physician need not be present but must be available within 30 minutes (effective December 22, 2010)

20. When will the instructions for 2009 data submission be posted on HERDS?

It is expected that instructions for the 2009 electronic data submission and audit tool will be posted to HERDS mid January for the March 1, 2010 due date.

The document is being revised so that the instructions included in the November 18, 2009 webinar will be reflected in the audit document.

21. What is the time frame for the "rollout" of Comprehensive Stroke Centers?

No specific time frame has been set for comprehensive stroke centers.

The process of evaluation continues with the Stroke Physician Advisory Workgroup.

Criteria from the Brain Attack Coalition for comprehensive stroke centers is being reviewed to determine which criteria will be mandated.

Additional discussions must take place relative to how the Emergency Medical Services system will be trained and included. The process also must include procedures for how the system will be evaluated by the Regional Offices

22. Must a designated stroke center use the GWTG data reporting system?

For purposes of NYS Stroke Center designation, there is no requirement for the specific data collection system used. However, in the fall of 2010 the Centers for Medicaid and Medicaid Services (CMS) will be instituting stroke core measures. These core measures require that there be a stroke registry and the GWTG system is qualified as a stroke registry for CMS purposes.

23. What is the stroke team education requirement in year three (3)?

The requirement for education of the stroke team is the same in all subsequent years.

24. Does the requirement for all acute stroke patients (i.e. those whose symptoms onset was within 12 hours) apply to time targets as well as the 12 performance measures?

No. In year 2009, the 12 hour requirement applies only to the collection of time targets. The 12 performance measures should be collected on all Ischemic and Hemorrhagic Stroke and TIA patients regardless of symptom onset.

Please note that in 2010 time targets need only be collected for patients whose symptom onset occurred within six (6) hours rather than the 12 hours required in 2009. Please note for the 12 measures plus the addition of NIHSS on discharge, it is still expected that data collection be performed for all Ischemic and Hemorrhagic Stroke and TIA patients regardless of symptom onset.