The New York State Coverdell Stroke Quality Improvement and Registry Program (Coverdell)

EMS QI Initiative

The NYS Department of Health's Stroke Program and Bureau of EMS are partnering for a new Quality Improvement initiative that aims to increase pre-notification for suspected stroke patients. To this end, the Department will evaluate the existing pre-notification practices and work to strengthen relationships and communication between designated stroke centers and EMS. This will lead to decreased treatment times for stroke patients and improved stroke patient outcomes. For this initiative, hospitals will be reporting on five measures:

  1. Was the pre-hospital stroke screen performed?
  2. Was the time of patient last known well (Time of Symptom Onset) documented by EMS?
  3. Did EMS pre-notify the ED?
  4. Did pre-notification include: Cincinnati Stroke Scale findings and Time of Last Known Well (Time of Symptom Onset)?
  5. If the hospital received advanced notification by EMS, was the stroke team activated prior to the patient's arrival?

New EMS Measures FAQs and Presentations

Stroke Quality Initiative: EMS Webinar I - September 22, 2014

Stroke Quality Initiative: EMS Webinar II - October 9, 2014

Stroke Quality Initiative: Hospital Presentation - October 20, 2014

Frequently Asked Questions for Hospitals

1. Who will be responsible for sharing information with EMS and providing education related to this quality initiative?

Answer: Both the Department of Health and the hospitals have a role in sharing information with EMS. The DOH has conducted two informational webinars for EMS to introduce this hospital quality initiative related to pre-hospital care for the stroke patient. As part of stroke designation, hospitals are required to provide two trainings a year for the EMS. This may include strengthening communication with the Emergency Department, as well as information regarding this new initiative. It is understood that there are many voluntary agencies that don't transport stroke patients to the hospital on a regular basis. The Department's Bureau of EMS and Trauma Systems has sent a letter to all EMS agencies notifying them of this hospital initiative. The Department encourages hospitals to communicate with their State Regional EMS Councils.

2. Must hospitals retrospectively collect information from a paper PCR in order to be compliant with this stroke quality initiative?

Answer: Data collection for this initiative begins in January 2015. The PCR is not the only resource to collect information about the elements necessary for EMS reporting measures and there is no requirement to go back and locate a paper PCR. The hospital may keep a log of the call from EMS to the Emergency Department to capture the information. However, EMS is aware that PCRs are a valuable source of information for the Emergency Department and should be shared.

3. How do I add the paper EMS record to the Electronic Hospital Medical Record?

Answer: This is something you must determine within your hospital. It is dependent on the particular product capabilities as to how you add a paper document. Scanning might be an option, but it is specific to the particular vendor.

Please note: You do not need the paper PCR to be compliant with this initiative.

4. There are additional data elements included in the data collection tool in the Get with the Guidelines (GWTG) patient management tool, related to EMS. Are hospitals required to answer these additional questions?

Answer: No. There are five elements that are required – the others are optional.

The five required elements are:

  1. Advanced notification by EMS?
  2. Date/Time patient last known to be well as documented by EMS:
  3. Pre-hospital stroke screen performed?
  4. Did EMS pre-notification contain the following : (check all that apply)
    1. Pre-hospital stroke screen findings
    2. Last Known Well
  5. If advanced notification by EMS, was the stroke team activated prior to patient arrival?

5. How do hospitals determine the denominator for these elements?

Answer: The EMS data elements are required to be collected for all patients (including stroke mimics-those with presumptive stroke who turn out not to be stroke) who arrive to the hospital within 6 hours of last known well AND arrival to the hospital via EMS from home/scene (this does not include patients who are transferred from another Emergency Department or acute care hospital). Additionally the data elements of "Did EMS pre-notification contain the following:" and "If advanced notification by EMS, was the stroke team activated prior to patient arrival?" are only required for patients with advanced notification by EMS.

6. How are hospitals going to be evaluated, relative to compliance with these reporting measures? Will there be a determination that a hospital is an outlier?

Answer: This is a quality initiative to determine if the system is working the way it was designed. The focus on pre-notification is designed to strengthen communication between EMS and the ED and determine if information shared by EMS prior to arrival helps with decisions made in the ED and decreases door to treatment times. These are reporting measures and do not impact GWTG awards. The Department will be evaluating the variations across the state relative to pre-notification and identifying ways to improve communication. There will be no determination that a specific hospital is an outlier.

7. What are the sources of information that satisfy compliance with this reporting measure?

Answer: The coding instructions within GWTG will identify what sources of information satisfy the documentation requirement.

8. If we collect information on a call log, should we make it part of the patient record?

Answer: This is ideal, but is not required. However, you should maintain a copy of the call log that identifies the patient and can be connected to the medical record for verification if required.

9. Can EMS be requested to start IV lines before the patient's arrival?

Answer: EMS can be requested to start an IV line before patient arrival if the provider is a paramedic or Advanced Life Support provider. Starting IV lines is within their scope of practice. Basic Life Support providers are not certified to start IVs. Therefore, the answer to this question depends on the level of EMS provider who has responded.

10. If a patient's time last known well is within 6 hours but they have a negative pre-hospital stroke screen, should EMS still prenotify the receiving hospital for these patients?

Answer: Yes. While the final diagnosis should be determined by the physician, every suspected stroke patient should be reported to the hospital before arrival as the information is still vital to patient care.

11. What if prenotification contains the time last known well, but not the date?

Answer: If pre-notification indicates the patient was last known well "today at 10:00 am" it would be acceptable to use today's date and the reported time. However, if there is only reference to a time of last known well with no mention of date, then the date may not be presumed.

12. Can we coach the EMS providers while taking the pre-notification call? i.e. Can we say "What is the Cincinnati Stroke Scale?" "What is the last known well?"

Answer: Yes, you can. In fact, it is suggested that a checklist be used by the person answering the phone call from EMS.

13. Must all patients that arrive as presumed stroke be entered into the registry?

Answer: All patients with a presumptive diagnosis of stroke who arrive with 6 hours of last known well (even if they do not have a final diagnosis of stroke) must be included in the time target and EMS measures and entered into Get With The Guidelines.