Frequently Asked Questions - September 2012

1. What were the reporting requirements for 2011?

The reporting requirements in 2011 included time targets, performance measures, outlier reports for the times beyond 30 minutes over the target, and the report of disposition from the Emergency Department.

The time targets were:

  • Door to MD (10 minutes)
  • Door to Team (15 minutes)
  • Door to CT taken (25 minutes)
  • Door to CT read (45 minutes)
  • Door to tPA administration (60 minutes)

The performance measures for 2011 were:

  • IV rt-PA Arrive by 2 Hour, Treat by 3 Hour
  • Early Antithrombotics
  • DVT Prophylaxis
  • Antithrombotics at Discharge
  • Anticoagulation for Afib
  • LDL 100 or ND Statin
  • Smoking Cessation
  • Dysphasia Screening
  • Stroke Education
  • Rehabilitation Considered
  • NIHSS on Admission
  • NIHSS on Discharge
  • Discharge Destination

The outlier reports for those times over 30 minutes must include 5 elements:

  • The specific reason why the target was not met;
  • What corrective action has been employed to ensure that this does not happen again;
  • Who is responsible for ensuring that this does not happen again;
  • How will problems be identified in the future; and
  • What measurement will be used to sustain the corrective action

The required information relative to the report of disposition from the Emergency Department is:

  • Admitted to the same hospital;
  • Transferred to a different hospital; or
  • Discharged from the Emergency Department to home

2. What are the reporting requirements for 2012?

The reporting requirements in 2012 are the same as those in 2011 with the addition of the following:

  • Report of Reasons for Delay in administering tPA within 60 minutes; and
  • DVT Measure has changed to VTE measure to align with Get With The Guidelines and The Joint Commission

The reasons why acute ischemic stroke patients who received IV rt-PA were not treated within 60 minutes of arrival are:

  • Delay in Stroke Diagnosis
  • Delay in Door to MD
  • Delay in Door to Stroke Team
  • Delay in Door to Brain Imaging Read
  • Delay in Door to Lab Results
  • Delay in IV tPA order to initiated
  • Difficult IV access
  • Patient/Family Consent
  • Equipment-related delay
  • Management of Concomitant Emergent/Acute Condition
  • Change in Patient Clinical Status/Condition
  • Other

3. What are the reporting requirements for 2013?

The reporting requirements in 2013 will be the same as those in 2012 except for the following:

  • NIHSS on Discharge will no longer be required, but stroke designated hospitals may continue to include this information as an optional field if they are utilizing Get With The Guidelines (GWTG).
  • Modified Rankin Scale at Discharge will be required and is not optional.

4. Why is the NIHSS on Discharge being replaced by the modified Rankin Scale?

The modified Rankin Scale is a better assessment of functional ability than the NIHSS on Discharge. It has been studied and validated as a reporting measure by the National GWTG Clinical Standards Committee.

5. Upon which stroke patients must the modified Rankin Scale be performed?

The modified Rankin Scale must be performed on all ischemic and hemorrhagic patients (except TIAs).

6. When must the modified Rankin Scale be done?

The modified Rankin Scale must be done within 24 hours of discharge.

7. Who may perform the modified Rankin Scale at Discharge?

The modified Rankin may be performed by the following clinicians: physicians, physician assistants, nurse practitioners, registered nurses, occupational therapists, physical therapists, and speech therapists that have been trained in performing the assessment.

8. Is there specific training required in order to perform the modified Rankin Scale?

There is no specific training required in order to perform the modified Rankin Scale. Designated stroke centers must assure that those clinicians performing modified Rankin are competent and that competency is kept up to date. For those clinicians who receive training, records must be available on site and provided should the Department of Health request such proof.

9. Is certification required to perform the modified Rankin Scale?

Certification is strongly encouraged, but is not required. Designated stroke centers must assure that those clinicians performing modified Rankin are competent and that competency is kept up to date. For those clinicians who receive certification, records must be available on site and provided should the Department of Health request such proof.

10. When does the requirement to perform modified Rankin begin?

The requirement to perform modified Rankin begins January 1, 2013.

11. Why is modified Rankin Scale not required at 90 days after discharge?

While it is best obtained 90 days after discharge, the Department of Health recognizes the burden of requiring hospitals having to collect this information post hospitalization; therefore will require it within 24 hours of discharge and not require it at 90 days.

12. Is modified Rankin required in the Get With The Guidelines data collection for Stroke?

Yes, beginning October, 2012.

13. What is the Coverdell Stroke Quality Improvement and Registry Program?

The Department of Health's Division of Chronic Disease Prevention, partnering with the Stroke Designation Program within the Office of Health Systems Management, will be participating in the Center for Disease Control and Prevention's Coverdell Stroke Quality Improvement and Registry Program. This work will focus on data collection, submission and analysis, of Coverdell data. NYSDOH will report back to hospitals utilizing this data. An assessment of Quality Assurance programs and technical assistance of targeted designated centers for performance measure improvement will also be performed. All designated centers will be invited to participate. An informational webinar about the Initiative will be hosted by HANYS and GNYHA on December 3, 2012.

14. Is modified Rankin a Coverdell requirement?

Yes, modified Rankin is a Coverdell requirement.

15. Is there an additional cost to hospitals using Get With The Guidelines – Stroke for adding the Coverdell elements?

With the inclusion of New York as a Coverdell State for the Center for Disease Control, hospitals participating in Get with the Guidelines – Stroke may elect to add the Coverdell layer at no additional cost. For further information, speak to your Outcome Sciences/Get With The Guidelines representative in your region.