Webinar: NYS Data Collection Tool for Stroke Designation Centers

Frequently Asked Questions - Wednesday, March 6, 2013

1. Does stroke log also refer to inpatients who present with acute stroke symptoms?

Yes.

2. Where is the template for team CMEs and CEUs located?

A link to the template can be found under Question 3 in the portal.

3. Where do we find the instructions and templates/ attachments for submission?

Instructions for submission are imbedded into the portal. Templates/attachments can be found in the portal and links are included to download them.

4. Are education hours for RNs required to be accredited, ie, CMEs or CEUs?

No – see Slide #10, it can be CEUs (or equivalent) for nurses. Category 1 CMEs are required for physicians

5. Are we required to use the enclosed template to submit outliers?

Using the enclosed template is preferred in order to ensure all components are met. If the template is not used, you must clarify and identify each element.

6. Can you clarify the statement "CMEs cannot be counted if obtained at the same conference used to satisfy the second criteria" under Stroke Director?

You must meet two criteria in the first year, e.g. stroke fellowship and 2 conferences; stroke fellowship and 8 CMEs. Two conferences and 8 CMEs does not satisfy if all the CMEs are from the conference.

7. Are CAT Scan techs also required for biannual education?

Yes.

8. Please confirm that either the CEO or the COO may sign the CEO attestation. Can it be an electronic signature?

Yes, CEO or COOs may sign the attestation. Electronic signatures are acceptable.

9. An individual was the COO in 2012 is now a senior VP in 2013. Can he sign the attestation

Yes.

10. Regarding education for PT/OT/EMS, is semi-annual the same as biannual?

The education for PT/OT/EMS is twice a year, and not every two years.

11. For the outlier table, how do we identify the patient?

The patient is identified using your internal identifier, and you need to report what quarter this occurred. We are looking for input over the course of a year. If the interval covers several patients, you may include several patients. If one patient had multiple problems, you only need one report with a specific intervention for each of the problems leading to missing the target.

12. What about those patients that have deficit at baseline, but no new deficit?

More information may be needed to answer this question. The deficit to be addressed is that which is related to stroke since that relates to the immediacy of the CT scan. A patient who has an unrelated deficit still may require an immediate CT scan due to their stroke.

13. For the attachment under Question 16: Is a 1 page grid that addresses all questions acceptable?

Yes, if it includes all elements for all patients.

14. What if NIHSS was not done but they say symptoms resolved?

In regard to the exclusion of patients from the Door to Stroke Team, CT Complete and CT Read/reported measures, NIHSS of 0 must be documented in addition to a note that symptoms were resolved upon arrival in order for the patient to be excluded from the measure. If NIHSS is not done/documented, these patients should be included in the above mentioned measures.

15. If the time delay was due to patient condition, i.e. the patient needed to be intubated prior to CT scan. Do we need to include this patient on outlier template?

Yes, this patient needs to be included with an explanation.

16. The HERDS tool states door to IV tPA > 60 minutes only ED patients. However, reason for delay report includes inpatient strokes. Can you clarify which patients should be included?

A separate report needs to be included for inpatients.

17. Is it acceptable to include all patients that miss the time target for the same reason on the same "outlier template" rather than using a template for individual patient?

It is acceptable only if the same intervention was used, tracked and successful.

18. The instructions for time targets ask to list the time from triage (ED arrival) for each time measurement. We captured all patients within 6 hours on our log (ED, transfers, in-house, etc). Do we report time targets and identify outliers for all patients within 6 hours (ED, in-house, transfers)?

Yes

19. Where then should be put the discharges to hospice? We should not leave them out of the stats, correct? What category do we put the patients that were discharged to a hospice house, not discharged to home with hospice?

Yes, discharges to hospice should be left out and not included. Patients discharged to a hospice house should also not be included.

20. Do patients who left against medical advice (AMA) go under discharges home or do they get left out?

These patients get left out.

21. For cases where ED doctors fail to document the exact time seen, but who write orders and assume responsibility for the patient at a clear time in the EMR (early in the course), it seems right to use the EMR Orders as the time seen. Can we agree this is acceptable?

It is what is documented but it might not meet the target.

22. Upon reviewing previous years, supporting documentation dashboards were submitted showing current submission year compared to prior year (exp 2011 and 2012). Is this necessary or can just the 2012 data be submitted?

Just the 2012 data needs to be submitted, we are not comparing to the previous year.

23. What is your recommendation for the patients with presentation of a single symptom, not clearly a stroke symptom and are triaged to the ED Midlevel. The patient then relates other symptoms to the admitting Hospitalist and admitted as a TIA/CVA.

Midlevel does not meet door to the MD requirement. If a patient was missed, we would like to know your plan for improvement.

24. "Home with Home Care" remains a required field in the review tool. How do we get past it? Enter zero?

For this field, enter zero.

25. Are AMAs discharge to home?

No, GWTG has a separate category.

26. Is there an extension to the March 15th deadline for submission?

You can apply for an extension. When applying for extensions please submit supporting documentation to the Stroke Center Document Submission Mailbox (strokedocs@health.state.ny.us) and let us know whether data can be entered in a timely manner into the HERDS system.

27. How do we know if we are admitted into the Coverdell project?

We will be sending out notifications shortly.

28. Some of our hospitalists became board certified during 2012. Does this meet the CME requirement for physicians?

Board certified is not a substitute for CME

29. Is it too late to submit application for Coverdell?

No, it is not too late to submit an application, however you must submit data going back to July 1, 2012.

30. In the past we did not list each individual outlier by patient but rather in the aggregate as the issues associated with the delays were found to be due to the same 2 or 3 causes. All of the issues identified were addressed in our outlier action plan. It seems that this requirement has changed?

Two years ago, a summary was permitted. Last year, the 5 elements existed, but were not enforced. This year, it is required.

31. Is there a requirement to submit a separate report on the 10 Stroke Center PI measures, other than the already discussed Time Targets and 12 performance measures.

No.

32. How will we know when the new tool is there?

We will submit a notification to all stroke coordinators, and also work with Greater New York Hospital Association (GNYHA) and the Healthcare Association of New York State (HANYS) to communicate this.

33. Is sub-acute rehabilitation considered inpatient rehabilitation or skilled nursing facility?

Skilled Nursing Facility

34. The last question for outliers related to improvement and identifying why not improved, how is the question answered, yes/no?

If the answer is no, you need to provide an explanation.

35. For patients who are outliers, if their symptoms had resolved, therefore diagnosed with a TIA, should they be included in the outlier list?

For the time target measures, TIA's are not automatically excluded. You must have documentation of an NIHSS=0 and no symptoms present on arrival in order to be excluded from the Door to Stroke Team, CT Complete and CT Read/Reported measures. Therefore if a TIA patient is an outlier and there is only documentation that symptoms resolved and no NIHSS, they must be included in outlier list.

36. In the presentation you said that door to MD, and door to stroke team should include the same population. However, in the measure descriptions, it says that you can exclude door to stroke team if symptoms resolved or NIHSS=0. Please clarify.

You may exclude patient for Door to Stroke Team, if NIHSS is documented as zero AND there is documentation that the patients symptoms resolved prior to arrival or they have no deficit. Both must be true in order for the patient to be excluded.

37. Is the Rankin scale is required for ALL strokes, hemorrhagic and ischemic (before NIHSS was only for ischemics)?

Yes.