Frequently Asked Questions from the June 16, 2011 Training Webinar
1. For 2011, what information must be recorded for every stroke patient, with symptom onset of 6 hours or less, seen in the emergency room?
Stroke designation requires that a stroke log is kept in the emergency room for all stroke patients. The information that must be recorded in this log includes the five (5) time targets and the thirteen (13) performance measures. We would like to clarify the 5th time target is Door to tPA administration. In addition to these time targets, there is an additional requirement that all stroke patients are tracked for disposition from the emergency department (admitted to the same hospital, transferred to a different hospital or discharged from the emergency department to home).
2. What TIAs must be included in the measures for time targets and performance?
A patient with symptoms of a TIA within the last six hours must have a rapid assessment by the Emergency Department physician.
a) If the NIHSS assessment is zero, a rapid CT does not have to be done nor the stroke team activated. The patient does have to be continued to be monitored as being at risk for stroke.
b) If the NIHSS is anything other than zero (there are any neurological signs identified even if resolving), the patient is a stroke until proven otherwise and must have rapid CT scan and all performance measures are tracked.
If the stroke center is using Get With The Guidelines, DOH is aware that a NIHSS of zero does not automatically track all measures for the purpose of the pre-configured reports. Therefore, measures may be tracked independently.
If time targets and measures were not met and TIA was the discharge diagnosis, the stroke center will be required to justify what was done as is required for all outliers.
For 2009 reporting purposes, stroke centers were required to explain outliers by stating what the common reason was for the failure to meet the time.
For 2011 reporting purposes, stroke centers will be required to give additional information. The purpose for collecting this information is to provide evidence that the issue has been identified, it has been reviewed by the Quality Assurance Committee and a plan of correction has been designed and implemented. Therefore, the following will be required:
- the specific reason why the target was not met;
- what corrective action has been employed to assure this does not happen again;
- who is responsible for assuring that this does not happen again;
- how will problems be identified; and
- what measurement will be used to sustain the corrective action.
3. What is "Door Time"?
Door time is calculated from the arrival of EMS in the emergency room or from triage if the patient arrived other than by ambulance.
4. How is Door time calculated for purposes of the five time targets?
Door time is the time recorded in the pre hospital report. In 2011, the Department adopted the NEMSIS compliant data fields for the Emergency Medical Service reporting. The DOH will be able to track this information through our records to assure consistency in reporting. If hospital has documentation to prove that a time other than the pre-hospital recorded time, they must provide that information to DOH.
5. Why is it important to record all time targets?
The stroke system of care is believed to improve patient outcomes. Designation by NYS DOH as a stroke center represents compliance with specific criteria including time targets and performance measures. The DOH hospital complaint program has received patient complaints for failure of the hospital to meet the time targets and provide the appropriate treatment. Administration of tPA within 3 hours of the onset of stroke symptoms is a standard of care for a stroke designated hospital and failure to meet that standard may result in a statement of deficiencies. Please record all timeframes.
6. Can a resident physician serve as a stroke team member for purposes of tracking the target time "Door to Stroke Team"?
No. Some hospitals have residents that are allowed to act as the initial physician assessor for the presumptive stroke patient. A resident, acting under the direct supervision of an attending physician may assess the patient for purposes of door to MD. However, residents who can only function under direct supervision of the attending may not serve as the door to Stroke Team assessor as they are not a decision maker. Therefore, only the physician who is a decision maker may satisfy the door to Stroke Team time. The phone contact with the decision maker (not when call placed but when neurologist responds even if by phone) satisfies the time for stroke team.
Since in this case the resident is not a member of the stroke team, they do not need to meet the eight (8) CME education requirements that stroke teams must meet. However, if a resident is working at another hospital, serving as a house physician, or in the emergency department, he/she may be a decision maker at that other hospital and therefore does need to meet the requirements of eight (8) CMEs as are all other members of the stroke team.
7. Are there any circumstances in which a physician assistant may satisfy the Door to Stroke Team time target?
Yes. In a limited circumstance where the hospital has less than 15,000 Emergency Department visits, the physician assistant may be utilized to meet the door to team time, if he/she is appropriately trained to administer tPA and consults with physician capable of making the decision to administer thrombolytics within the fifteen minute target.
8. What is the appropriate time frame for lab results?
All relevant time frames including lab results for stroke are calculated from the arrival time (door to lab results is 45 minutes).
9. If a stroke patient is transferred from another hospital, must the receiving hospital record the time targets for that stroke patient?
Yes. If the stroke patient is still within 6 hours of symptom onset, the transferring hospital will have taken the NIHSS on admission and that same number could be entered upon discharge because the definition is "within 24 hours of discharge." Therefore, the admission and discharge NIHSS will be the same for the transferring hospital. The receiving hospital will do an admission NIHSS as part of the assessment of their patient for treatment. Clinically, the patient was transferred for a reason and so an assessment is appropriate.
If the patient, who has been transferred from another hospital, is outside the 6 hour window, the time targets would not be required for that patient.
10. If a patient is brought in by ambulance, diagnosed as a stroke patient, but was later determined that s/he was not a stroke patient, must the hospital record the time targets for this patient in the stroke log?
Yes. The stroke log is used to catch any potential stroke patients (stroke-like symptoms) who come in <6 hours to track them, to make sure they're being assessed promptly, and to ensure that you're meeting the time targets. While, SOME of the info in the stroke log will end up in GWTG (only those patients that turn out to be true strokes), there may be other patients in the stroke log who don't get entered because they turned out NOT to be a stroke. You still will need to demonstrate that ALL of those patients met time targets in that they were assessed promptly (the Door to Md, Door to CT, etc).
11. Does the DOH want to continue to collect NIHSS on Discharge?
Yes. While Get With The Guidelines (GWTG) does not require this data for hemorrhagic strokes as part of pre-configured reports, NIHSS must be captured on discharge for all ischemic strokes.
12. What is the discharge date for purposes of the NIHSS on discharge?
For purposes of NIHSS on discharge, the assessment must be done within 24 hours of discharge. However if the stroke patient remains in the hospital for another diagnosis, the date of discharge may be the date released from acute stroke service or discharge from the hospital. It should be noted that for those stroke centers using GWTG, the automatic date of discharge is going to be the discharge from the hospital and not stroke care. If the stroke center would like to capture the discharge from stroke care it must be done manually.
Please note: If the stroke center has certified inpatient rehab beds, the discharge from the stroke service should be when NIHSS is recorded. Admission to inpatient rehab is a separate admission and DOH is not tracking NIHSS in the rehab admission.
13. Why is the Department collecting the NIHSS on discharge?
DOH is interested in having a measure of improvement from admission to discharge. As has been previously discussed, this recommendation to use the NIHSS is based on discussions with the Stroke Physician Advisory Workgroup. It is recognized that there are other measures. NIHSS was chosen because it is simple to use and physicians, physician assistants and nurses can be certified to use it. (In one instance a hospital has requested that physical therapists be allowed to perform the NIHSS on discharge. That is permitted if the physical therapist is properly certified and there is a mechanism in place to assure competency.)
14. Should the physical therapist getting certified to perform the NIHSS be included as a member of the stroke team for purposes of the CEU requirements?
No. Since the physical therapist would not be part of the initial assessment, they would not need to meet CEU requirements. Their educational requirement is bi-annual (twice a year). They independently must complete NIHSS certification if their assessment at discharge is to be valid.
15. Will the DOH consider another measure of functional status?
DOH considered the use of the alpha FIM (Functional Independence Measure) to be used as a more accurate representation of what the patient can do rather than the neurological deficit. After discussion with the Stroke Physician Advisory Workgroup, the alpha FIM was rejected.