Stroke Center Demonstration: Frequently Asked Questions

Questions 3 and 4 were amended February 1, 2011.

Questions 7, 11 and 20 were amended and Question 30 was added January 31, 2011 due to changes in the 2011 reporting requirements.

Question 18 was revised July 8, 2010.

Questions 14 and 15 were revised March 19, 2009.

Questions 27, 28, and 29 added April 10, 2009.

Questions 3, 14, 15 and 28 revised January 12, 2010.

1. When did Stroke Designation begin in New York State?

In 2002-2003 there was a pilot demonstration utilizing "brain attack coalition" guidelines involving 19 hospitals in Brooklyn and Queens. The results were a decrease in time from door to assessment, from door to CT scan, and from door to the administration of t-PA. In 2004 all New York hospitals were invited to apply to become stroke designated hospitals.

2. Who were the original demo hospitals in Brooklyn and Queens?

The original demonstration hospitals in Brooklyn were Brookdale University Hospital Medical Center, Coney Island Hospital, Kings County Hospital Center, Lutheran Medical Center, New York Methodist Hospital, Victory Memorial Hospital, Wyckoff Heights Medical Center, University Hospital of Brooklyn, and Long Island College Hospital.

The original demonstration hospitals in Queens were Flushing Hospital Medical Center, Jamaica Hospital Medical Center, Parkway Hospital, Peninsula Hospital Center, City Hospital Center at Elmhurst, Forest Hills Hospital, New York Hospital Medical Center of Queens, North Shore University Hospital, and Long Island Jewish Medical Center.

3. How does a hospital become designated? [Revised January 12, 2010]

A hospital must apply to become a designated stroke center. Applications may be found at: Application for Designation of Stroke Center (PDF, 127KB, 10pg.).

One original and two copies must be sent to the attention of Anna Colello, Esq., Director of Regulatory Compliance, Department of Health, One University Place, Suite 218, Rensselaer, New York 12144.

The completed written application is reviewed by Office of Health Systems Management staff, the Public Health and Health Planning Council. An onsite survey is conducted by regional survey staff and if compliance is verified, a designation letter is issued by the Commissioner of Health.

4. What are the qualification requirements of the Stroke Medical Director?

The Stroke Medical Director has to meet two of the following four criteria:

  1. Participation in at least two regional, national or international stroke conferences yearly;
  2. Complete a Stroke fellowship (a fellowship in Epilepsy will not suffice);
  3. Eight or more CMEs;
  4. Five or more peer review publications relating to stroke.

This is the requirement in the first year. In subsequent years the Stroke Director need only complete one of the requirements. It should be noted that the Stroke Director need not be a neurologist. An Emergency Medicine physician may be the Stroke Director if the above requirements are met.

5. Can the Stroke Director serve in that position at more than one designated center?

Yes, providing all obligations to each of the stroke centers are met.

6. What are the qualification requirements for stroke team members?

Per the initial application requirements in Criterion No. 3, the qualification requirements for stroke team members are that the team must be staffed by qualified health care professionals including, at a minimum, board-certified or board-qualified physicians who possess special competence in caring for acute stroke patients and other health care providers who have experience caring for acute stroke patients, such as physician assistants (PAs), nurse practitioners (NPs) and registered nurses (RNs).

7. What are the education requirements for stroke team members? [Revised January 31, 2011]

The training requirements for all clinicians (MDs, PAs, RNs, NPs) who are stroke team members include eight or more (category 1 for physicians) CME/CEU credits in the first year, with four credits annually in subsequent years, specific to the area of cerebrovascular disease.

Stroke team members include all staff in the ED, ICU, and stroke/telemetry unit who provide care to patients experiencing an acute cerebrovascular event.

The training requirements for all clinicians (MDs, PAs, RNs, NPs) who are stroke team members include eight or more (category 1 for physicians) CME/CEU credits in the first year, with four credits annually in subsequent years, specific to the area of cerebrovascular disease.

Stroke team members include all staff in the ED, ICU, and stroke/telemetry unit who provide care to patients experiencing an acute cerebrovascular event.

New physician team members who are providing stroke care must meet the 8-hour CME requirement in their first year.

8. What are the educational requirements for other stroke staff?

For stroke staff other than those defined in Question 7 (occupational therapy (OT), Physical Therapy (PT) and Speech Therapy), the requirement is for in-service training related to the care of patients with cerebrovascular disease. Bi-annual in-service training is sufficient and need not be CMEs / CEUs.

9. What is meant by the term "bi-annual"?

Twice a year.

10. What verification is needed to establish that team members have completed education requirements?

It is sufficient verification to list the hours of "stroke related" CMEs obtained during the past year for each of the facility's stroke team staff in the ED, ICU, and stroke/telemetry unit. There is no need to send course material.

11. When may a designated stroke center transfer a stroke patient to another hospital? [Revised January 31, 2011]

Designated stroke centers are required to provide a basic level of acute stroke care. Designation requires that the facility has a system in place to provide such care. Transfer should be made to optimize the care of the stroke patient. All designated centers are required to have transfer agreements in place for neurosurgical assessments, and/or interventions if these services are not available at their facility 24/7. Transfers are appropriate if patients require services not available at the facility.

"Beginning in 2011, designated stroke centers must document why the patient was transferred to another stroke center."

Examples of some reasons are:

  1. Ischemic stroke with ED arrival within 2 hours of onset but another stroke center can offer additional interventional procedure not available here.
  2. Ischemic stroke with ED arrival beyond 3 hours of onset and another stroke center can offer interventional procedure not available here.
  3. Ischemic stroke and another stroke center can offer neurocritical care and/or neurosurgical care not available here.
  4. Intracerebral hemorrhage and another stroke center can offer interventional procedure, neurocritical care, and/or neurosurgical care not available here.
  5. Subarachnoid hemorrhage and another stroke center can offer interventional procedure, neurocritical care, and/or neurosurgical care not available here.
  6. Other - please specify diagnosis and reason for transfer.

Designated stroke centers are required to provide a basic level of acute stroke care. Designation requires that the facility has a system in place to provide such care. Transfer should be made to optimize the care of the stroke patient. All designated centers are required to have transfer agreements in place for neurosurgical assessments, and/or interventions if these services are not available at their facility 24/7. Transfers are appropriate if patients require services not available at the facility.

12. What is the timeframe for the provision of neurosurgery service?

Per the initial application requirements in Criterion No. 23, neurosurgical services must be performed within two hours from time deemed clinically necessary. If the facility's plan specifies that patients needing such care are to be transferred to another facility, the neurosurgical services must still occur within that two hours timeframe.

13. Must Curricula Vitae (CV) be sent for all stroke team members with the yearly self audit tool?

Curriculum Vitae are required with the original application. For the yearly audit tool, CVs are required only for new members of the stroke team.

14. Must the facility submit the complete stroke log? [Revised January 12, 2010]

Designated Stroke Centers are required to meet certain time frames which, when met, have been found to result in better outcomes for all stroke patients. These time frames should be tracked and, when not met, should be included in quality assurance meetings at the hospital.

Designated centers are required to submit a summary, by month, of the average times for each of five process times and not the entire log.

Here is an example of a log:

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

15. What stroke patients must be included in stroke log? [Revised January 12, 2010]

All patients with acute stroke symptoms, including those whose strokes are ischemic, hemorrhagic, or TIA in origin, must be included in the stroke log. Patients who experience a stroke as an inpatient must also be included in the log.

The time requirements for all acute stroke patients are the same. There is no distinction with regard to the time requirements for patients who are eligible for tPA and those who are not.

Beginning on January 1, 2010, acute strokes are defined as those for which there are continuous symptoms of six (6) hours or less.

16. Must designated centers submit program agendas for public education programs?

Evidence of programs must be kept on-site for future substantiation. Program agendas do not need to be submitted.

17. What are the performance measures for the NYS Designated Centers?

The performance measures for stroke patients treated at the NYS Designated Centers are:

  • Thrombolytic Therapy Administered
  • Antithrombotic Therapy by End of Hospital Day Two
  • Antithrombotic at Discharge
  • Deep Vein Thrombosis (DVT) Prophylaxis
  • Dysphagia Screening
  • Discharged on Cholesterol Reducing Therapy
  • Patients with Atrial Fibrillation Receiving Anticoagulation Therapy
  • Smoking Cessation / Advice / Counseling (documented)
  • Assessed for Rehabilitation
  • Stroke Education (documented)
  • NIH Stroke Scale (upon admission and discharge)
  • Discharge Destination

There are some measures which are only applicable to certain types of strokes. This chart indicates which measures are indicated for which types of stroke.

Measure Name Ischemic TIA Hemorrhagic Not Otherwise Specified
DVT Prophylaxis X   X X
Early Antithrombotics X X    
Anticoagulation for AF X X    
IV t-PA 2 Hour X      
Antithrombotics at Discharge X X    
LDL 100 or ND X X    
Dysphagia screening X   X X
Stroke Education X X X X
Smoking Cessation X X X X
Rehabilitation Considered X   X X
NIHSS X X X X
Discharge Destination X X X X

18. When should the initial NIHSS be performed? [Revised July 8, 2010]

A NIHSS should be performed by a medical professional certified to perform the NIHSS including a Physician, Physician Assistant, Nurse Practitioner or Registered Nurse, concurrent with the initial patient evaluation within 15 minutes of presentation to the facility.

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

19. Must outcome data be submitted through Get With The Guidelines (GWTG)?

No. GWTG provides an electronic means for submission of data but it is not a requirement.

20. How are designated stroke centers monitored? [Revised January 31, 2011]

All designated stroke centers must submit a self-audit review tool on a yearly basis. It is anticipated that this tool will be able to be submitted electronically before the next due date, March 1, 2011.

21. What must be provided in the review tool for the organization chart?

The organizational chart of the stroke center should include, at a minimum, the stroke medical director, the stroke program coordinator, the Emergency Department (ED) medical director, the ED nurse manager, the stroke unit medical director, the stroke unit nurse manager, the Intensive Care Unit (ICU) medical director, and the ICU nurse manager. Once designated, CVs are needed only for new stroke team members.

22. Does the audit tool require submission of all documentation required in the original application?

No. The original application contains 31 criteria that must be met. The annual review tool for designated stroke centers contains 15 criteria that must be submitted.

23. What is the status of the department's rural health initiative?

There are four Hubs and 22 Spokes operational. Since 2007, 160 neurology consults have been obtained using the telestroke system. Hospitals interested in becoming a spoke should contact their DOH regional office for more information.

24. If I have telemedicine, may an ambulance be diverted to my hospital?

An ambulance must drive the presumptive stroke patient to an approved designated stroke center unless the patient chooses otherwise. Refer to February 20, 2005 EMS Protocol.

The ability to receive neurology consults through Telemedicine, does not, in and of itself, allow for the diversion to a non-designated stroke center.

25. Is a separate consent needed for telemedicine?

No.

26. What is the period for designation?

Once a facility is designated, it remains designated as long as the facility is in compliance with the initial application criteria, and completes and submits a yearly audit tool that is received and approved by the Department.

27. The original application criterion #19 requires a specific designated area to be identified as a stroke unit for all stroke patients except those requiring intensive services. May stroke patients be cared for on other units?

The designation program requires that stroke patients receive priority treatment. The facility must state the number of beds designated as the stroke unit. The beds should be in close proximity. Telemetry units may be identified as the stroke units.

TIAs are to receive the same care as all other strokes with regard to meeting the time frames and services for stroke care.

28. What is the time frame for new stroke team members to meet the educational requirements? [Revised January 12, 2010]

New hires have up to 60 days to meet CME requirements.

If a new stroke team member was previously at another designated center and met the requirement in the last year at the other facility, this will meet the requirement for the new facility. The yearly requirement must be met by 12/31 of the previous year. For example, for the 2008 audit tool submission due March 1, 2010, the CME requirement had to have been met on 12/31/09.

29. Where can questions related to Stroke Center designation be directed?

Questions should be sent to Stroke email box at telemed@health.state.ny.us.

30. Why is the Department collecting the NIHSS both on Admission and Discharge? [Added January 31, 2011]

The NIHSS is collected on Admission as it is a measurement used to determine the appropriateness for tPA administration as well as document the condition of the patient on arrival.

The NIHSS on discharge is used to determine what is any improvement the patient has made between arrival and discharge. It is acknowledged that it is not the best assessment tool for every type of a stroke but it is required because it is an assessment which can be done to show change. The Stroke Physician Advisory Workgroup has recommended to the Commissioner that the measure be kept as we collect and analyze data after two years of use.

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