Stroke: Frequently Asked Questions
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?
A hospital must apply to become a designated stroke center. Applications may be found at:
http://www.nyhealth.gov/professionals/hospital_administrator/stroke_center_designation/stroke_center_designation_application.pdf (PDF, 127KB, 10pg.).
One original and two copies must be sent to the Medical Director of the Office of Health Systems Management, Department of Health, Empire State Plaza, Corning Tower, Room 1415, Albany, New York 12237
The completed written application is reviewed by Office of Health Systems Management Executive staff, the Major Medical Equipment and Appropriateness Review Committee, and the State Hospital Review and 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:
- Participation in at least two regional, national or international stroke conferences yearly;
- Complete a Stroke fellowship (a fellowship in Epilepsy will not suffice);
- Eight or more CMEs ( While the education requirement for physicians other than the Stroke Director may be met with Board Certification in Neurology/Neurosurgery, Emergency Medicine or Internal Medicine, board certification is not a substitute for this requirement for the Stroke Director.)
- 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?
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.
Physicians in the field of Emergency Medicine, Internal Medicine, Neurology, and Neurosurgery may meet this annual requirement by maintaining current board certification in their respective field. New physician team members (including those who are board certified) 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?
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?
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 improvement discussions.
The designated center must submit a summary of aggregate data. The designated center should indicate whether or not the time requirements were met for each of the process time frames. The designated center should provide the percentage of compliance data.
Here is an example of a log:
| Stroke Log Summary Process Time Frames | Ischemic | TIA | Hemorrhagic | Not Otherwise Specified |
|---|---|---|---|---|
| Door to MD Assessment Time (min) reported as % of patients assessed within 10 min | ||||
| Door to Stroke Team (min) reported as % of patients seen by stroke team within 15 min of arrival | ||||
| Door to CT Performed Time (min) reported as % of patients with CT completed within 25 min of arrival | ||||
| Door to CT Performed Time for potential t-PA Candidates reported as % of patients with CT completed within 25 min of arrival |
||||
| Door to CT Read Time (min) reported as % of patients with CT read within 45 min of arrival | ||||
| Door to CT Read Time (min) for potential t-PA Candidates reported as % of patient with CT read within 45 min of arrival |
||||
| ER to t-PA Administration Time (min) reported as % of Patients receiving t-PA in 60 min of arrival |
15. What stroke patients must be included in stroke log?
All patients with new stroke symptoms, including those found to be ischemic, hemorrhagic, or TIA in origin, must be included in the stroke log and reported to the DOH. Patients which experience a stroke as an inpatient must also be included in the log.
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 NIH scale be performed?
A NIH stroke scale should be performed by a physician member of the stroke team, concurrent with the initial patient evaluation within 15 minutes of presentation to the facility.
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?
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, 2009.
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 4 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. Where can questions related to Stroke Center designation be directed?
Questions should be sent to Stroke email box at telemed@health.state.ny.us.