Minnesota Stroke System. Hospital Designation. Toolkit

Transcription

1 Minnesota Stroke System Hospital Designation Toolkit

2 Table of Contents Background... 3 Definitions... 3 Designation Process... 4 Special Notes... 5 Criteria for Acute Stroke Ready Hospital Designation An acute stroke team available or on-call 24 hours a day, seven days a week Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures Emergency department personnel who are trained in diagnosing and treating acute stroke The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually A neurosurgery coverage plan, call schedule, and a triage and transportation plan Transfer protocols and agreements for stroke patients A designated medical director with experience and expertise in acute stroke care Checklist of Criteria and Documentation Required Minnesota Stroke System Contacts Appendices for Acute Stroke Ready Hospital Designation Criteria Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Criterion 1) Appendix B: Example Stroke Code Algorithm (Criterion 2) Appendix C: Example Stroke Code Protocol (Criterion 2) Appendix D: Example EMS Stroke Protocol (Criterion 3) Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement (Criterion 3) Appendix F: Example Letter Attesting Training of ED Personnel (Criterion 4) Appendix G: Stroke Education Documentation (Criterion 4) Appendix H: Training Resources for ED Personnel (Criterion 4) Appendix I: Example Diagnostic Capability Scope of Service (Criterion 5) Appendix J: Example Brain Imaging Interpretation Capability Scope of Service (Criterion 6) Appendix K: Example ED Order Set for Administering tpa (Criterion 7) Appendix L: Hospitals with Neurosurgery Services in Minnesota and Bordering States (Criterion 8) Appendix M: Example Neurosurgery Scope of Service (Criterion 8) Appendix N: Example MOA with a Hospital that has Neurosurgery Services (Criterion 8) Appendix O: Example Transfer Protocol (Criterion 9) Appendix P: Example Transfer Agreement with a Primary Stroke Center (Criterion 9) Appendix Q: Example Letter Attesting a Designated Stroke Medical Director (Criterion 10)

3 Background In 2013, the Minnesota Legislature authorized the Minnesota Department of Health (MDH) to designate hospitals in Minnesota as stroke hospitals. A hospital that meets the criteria for a Comprehensive Stroke Center (CSC), Primary Stroke Center (PSC), or Acute Stroke Ready Hospital (ASRH) may voluntarily apply to the commissioner for designation, and upon MDH s review and approval of the application, shall be designated as a CSC, PSC, or an ASRH for a three-year period. Hospitals not designated by MDH, The Joint Commission, or any other nationally recognized certification body may not use the term stroke center or stroke hospital in its name or advertising, or shall otherwise indicate that it has stroke treatment capabilities. The stroke hospital designation process is the principal component of the Minnesota Stroke System. This statewide stroke system and designation criteria were developed by the Minnesota Acute Stroke System Council, convened by MDH and the American Heart Association (AHA) between March 2011 and December This voluntary stakeholder group developed criteria and provided invaluable input into the development of a statewide system that would be specific to Minnesota and meet the unique needs of our state. The designation process and thus the launch of the statewide stroke system is scheduled to begin in This manual serves as a toolkit for hospitals who wish to be designated and recognized by the Minnesota Department of Health as Acute Stroke Ready Hospitals. Definitions Acute Stroke Ready Hospitals An Acute Stroke Ready Hospital has the infrastructure and capability to care for acute stroke, including administration of intravenous thrombolytic therapy (also known as tissue plasminogen activator tpa, or alteplase). An ASRH has fewer overall capabilities than a Primary Stroke Center, but has staff and resources able to diagnose, stabilize, treat, and transfer most patients with stroke. Most acute stroke patients may be transferred to a Comprehensive Stroke Center or Primary Stroke Center posttreatment. 3

4 Primary Stroke Centers A Primary Stroke Center has the necessary staffing, infrastructure, and programs to stabilize and treat most acute stroke patients. A PSC provides acute care to most patients with stroke, is able to provide some acute therapies, and admit the patient to a stroke unit. The criteria for a PSC are based on the 2011 revised and updated recommendations statement from the Brain Attack Coalition (Alberts, 2011). Additional functions of a PSC may be to act as a resource center for other facilities in their region. This might include providing expertise about managing particular cases, offering guidance for triage of patients, making diagnostic tests or treatments available to patients treated initially at an ASRH, and being an educational resource for other hospitals and health care professionals in a city or region. Comprehensive Stroke Centers A Comprehensive Stroke Center (CSC) has the personnel, infrastructure, and expertise to diagnose and treat stroke patients who require intensive medical and surgical care, specialized tests, or interventional therapies. The types of patients who might use and benefit from a CSC include, but are not limited to, patients with large ischemic strokes, hemorrhagic strokes (in particular patients with suspected aneurysmal subarachnoid hemorrhage), those with strokes from unusual etiologies or requiring specialized testing or therapies (e.g., endovascular, surgery), and/or those requiring multispecialty management. Additional functions of a CSC would be to act as a resource center for other facilities in their region. This might include providing expertise about managing particular cases, offering guidance for triage of patients, making diagnostic tests or treatments available to patients treated initially at a PSC or ASRH, and being an educational resource for other hospitals and health care professionals in a city or region. The criteria for a CSC are based on the 2005 Brain Attack Coalition paper on Comprehensive Stroke Centers (Alberts, 2005). Designation Process This application is filled out and submitted electronically through the Minnesota Stroke Registry Tool. Click here: Hospitals must assign a) a primary contact and b) a secondary contact for the designation application. The primary contact is responsible for completing the application. This person must establish a 4

5 username and password from the facility administrator for the Minnesota Stroke Registry Tool in order to complete the application. We require a secondary contact in case the primary contact is unavailable. MDH will review the submitted application and notify the primary contact within 10 business days of the application submission date if there are issues with completeness. The Minnesota Stroke System Designation Committee will evaluate the application and notify the primary contact within 60 days if the application is approved. Hospitals not meeting the designation criteria will receive notification and a detailed description of how to respond. Stroke hospital designation is valid for three years. Designation status must be renewed every three years through reapplication. Special Notes Primary Stroke Centers and Comprehensive Stroke Centers Hospitals which are certified by a nationally-recognized accreditation organization as a Primary Stroke Center or Comprehensive Stroke Center will be designated by the Minnesota Department of Health with these same titles. These hospitals must still complete and submit an application to the Minnesota Department of Health in order to receive their state designation. Hospitals which are not certified by a nationally-recognized accreditation organization as either a Primary Stroke Center or Comprehensive Stroke Center are only eligible to be designated by the Minnesota Department of Health as an Acute Stroke Ready Hospital. Site Surveys A sample of designated hospitals will be surveyed every year for the purpose of providing an in-depth assessment of the capacities and processes for designated Acute Stroke Ready Hospitals. These reviews are intended to be supportive opportunities for technical assistance, are not meant to be punitive or regulatory. Surveys will be scheduled well in advance to accommodate both the hospital s and reviewers schedules. Reviewers will be selected stroke experts based in Primary Stroke Centers or Comprehensive Stroke Centers who will be able to provide input and insight on issues for which an ASRH may need improvement. Site surveys will be completed in no more than one day. 5

6 Updates to Agreements, Protocols, and Personnel Midway through your designation period, a call for updates will be sent to all designated hospitals. This will be your opportunity to update your hospital designation portfolio. The most current protocols, written agreements, letters and other documentation which identify staffing requirements should be submitted to the Minnesota Department of Health at this time. Data Reporting Tracking success of the Minnesota Stroke System is essential. Hospitals are currently required to report data to the Minnesota Department of Health on two stroke patient care indicators, Door-to-imaging initiated <25 minutes and Time to intravenous thrombolytic therapy. These indicators are reported under the auspices of the Minnesota Statewide Quality Reporting and Measurement System (SQRMS), as part of Minnesota s 2008 Health Care Reform Act. These two measures will be used to track the impact of the Minnesota Stroke System. Hospitals are strongly encouraged to join the Minnesota Stroke Registry Program, a voluntary quality improvement program of the Minnesota Department of Health. Minnesota participates in the national CDC Paul Coverdell National Acute Stroke Program, in which additional stroke patient care data are collected, reported, and used for addressing stroke performance improvement. In 2013, 47 acute care hospitals in Minnesota were voluntarily participating in this important program. For information on how to join this program, please contact health.stroke@state.mn.us. At this time, no additional data will be required of hospitals or Emergency Medical Service (EMS) agencies for participation in the Minnesota Stroke System. 6

7 Performance Improvement The criteria for Acute Stroke Ready Hospitals are not performance-based. Hospitals are not required, in order to be designated as an ASRH, to meet time standards for procedures or treatments. The designation criteria describe merely the capacities and formal processes that a hospital has established to be able to diagnose and treat acute stroke patients. Best practices in stroke care, however, are driven by meeting time standards. By meeting the criteria for acute stroke readiness, your hospital will be in a strong position to meet these time-to-action goals. These time goals have been published by the American Heart Association/American Stroke Association: Acute Stroke Care Time Goals Action Door to acute stroke team Door to imaging (initiated) Door to imaging (interpretation) Laboratory test results available Door to tpa administered* Door to admission or transfer Telemedicine*** link established Availability of neurologist or other physician experienced in acute stroke diagnosis and treatment Availability of vascular neurosurgeon Goal 15 minutes 25 minutes 45 minutes (CT), 60 minutes (MRI) 45 minutes (of when ordered) 60 minutes 3 hours** Within 20 minutes (of when deemed necessary) Within 20 minutes (either on-site or via telemedicine***) 30 minutes (CSC); 2 hours (PSC); 3 hours (ASRH) *NQF-Endorsed Measure #1952 **This time goal (door to admission or transfer)is for patients treated with IV tpa. More rapid transfer is indicated for patients not eligible for IV therapy, but may be eligible for intra-arterial therapy. In general, delays in transfer should be avoided. ***Telemedicine may include either telephonic, video linkage, or both. Source: (Jauch et al., 2013). See Table 5 in this guideline. Please note: designation as an Acute Stroke Ready Hospital by the State of Minnesota is NOT contingent on meeting these time standards. These goals are provided here only as a reference for hospitals in their performance improvement efforts. 7

8 Governance Advisory Committee The Minnesota Department of Health will appoint an advisory committee whose role will be to advise the State on matters relating to the Minnesota Stroke System. This committee will monitor progress, provide recommendations for implementation processes, and advise as needed. Members will be asked to volunteer their time and expertise for two-year terms, which will be renewable. Every effort will be made to convene a committee which will appropriately represent both rural and metropolitan areas, multiple professional specialties, and health systems and organizations. This committee shall have no greater than 20 members and will meet at least semi-annually. Designation Review Committee A smaller group of experts chosen by the Minnesota Department of Health will review and recommend approval of hospitals for stroke hospital designation by the State. This group will comprise no more than seven individuals and their role will be to review applications, provide feedback for areas of improvement, and make recommendations to MDH for approval. Working Groups Small working groups will be convened by the Minnesota Department of Health and the American Heart Association to address and work to implement specific components of the system. These working groups (committees or task groups) will be time-bound and limited in scope. Their role will depend on the subject at hand. We anticipate working groups to be formed around these topic areas: - EMS training and protocol adoption - Hospital Performance Improvement - Provider Education - Data Reporting and Evaluation 8

9 Criteria for Acute Stroke Ready Hospital Designation 9

10 1. An acute stroke team available or on-call 24 hours a day, seven days a week. Rationale: An acute stroke team (AST) is a key component of an Acute Stroke Ready Hospital. Studies have shown the importance of such a response team to provide organized care in a safe and efficient manner. The presence of an AST is an independent predictor of the ability to administer intravenous thrombolytic therapy and improve the outcomes of stroke patients. References: (Jauch et al., 2013), (Alberts et al., 2011), (Alberts et al., 2013). Requirements: 1. The AST may be staffed by a variety of healthcare personnel depending on the resources available at a particular facility, but should include a minimum of one nurse and one physician. Hospitals not staffed with an emergency department physician may assign a licensed independent practitioner (LIP) instead of a physician. 2. Members of the AST should be available and/or on-call 24 hours a day, seven days a week. 3. The existence and operations of the AST should be supported by a written document that provides information about administrative support, staffing, notification plans, and care protocols. Recommendations, Allowances, and Notes: 1. Each member of the AST should have some training and expertise in acute stroke care. Examples might range from a nurse (or advanced practice nurse) with prior experience in a neuroscience ICU, an emergency department nurse who has completed continuing education units (CEU)/CME in areas of acute stroke care, and physicians who have attended regional or national courses in areas of acute stroke care. 2. The AST is primarily responsible for responding in the emergent setting to patients with an acute stroke, and initiating diagnostic testing and immediate care, not ongoing in-hospital care. 3. Different members may rotate on the team depending on staffing levels and patient needs. 4. Physician expertise in stroke can be provided via a telemedicine link with another facility, but if this is done, there should be at least one physician on site to supervise patient care, order medications, and manage other emergent issues. 5. Although the AST does not have to be led by or include a neurologist or neurosurgeon, it is recommended that the AST include personnel with experience and expertise in areas of cerebrovascular disease. 6. The AST should respond to suspected acute stroke patients who are in the emergency department OR in-hospital. 7. While their presence in the hospital is preferred, critical members of the AST may reside outside of the hospital as long as they can be at the bedside within 15 minutes of being called. 8. If locum tenens are used as emergency department providers, the names of these providers are not required in your documentation. 9. In all cases, the hospital s disciplines and departments, which will be available 24/7 to respond to an AST activation, should be listed. 10. The hospital should support the development of a call-log for the AST that captures key data points such as the number of AST activations, response times, and patient diagnosis, treatments and/or disposition. A worksheet for real time collection of response times may be helpful in collecting these data. Documentation Requirements: A letter on hospital letterhead signed by the CEO or chief medical officer listing the position titles of the members on the acute stroke team. Appendices: Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Pg. 24) 10

11 2. Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications. Rationale: A written stroke protocol is essential to ensure that all stroke patients receive organized care in a safe and efficient manner. A written protocol also ensures that important care elements are not omitted, and that prohibited medications or treatments are not administered. References: (Jauch et al., 2013), (Alberts et al., 2011), (Alberts et al., 2013). Requirements: 1. This protocol should encompass care in the ED. A separate protocol for inpatient care may also be submitted. Protocols should be developed by a multidisciplinary team and reviewed, and if necessary revised at least once a year to reflect changes in medical knowledge, care standards, and guidelines. 2. A written protocol should include standardized order sets that deal with aspects of acute diagnosis, such as checks of vital signs and neurologic function, blood work, and brain imaging studies. 3. At a minimum, the submitted written protocol must address the triage and treatment decisions for ischemic stroke patients. Recommendations, Allowances, and Notes: 1. The protocols can be paper-based or computer-based, depending on the standard practice at a specific facility. If computer-based, a paper-version must be submitted to the Minnesota Department of Health. 2. Written protocols should ideally address all types of strokes (i.e., ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage). However, the minimum requirement for Acute Stroke Ready Hospital designation is a written protocol for ischemic stroke only. 3. We are looking for an actual stroke code protocol or algorithm - not simply an order set. This is a document that outlines and/or informs the flow of activity, procedures, treatment options, and actions to take when a patient with signs and symptoms of a stroke presents to the ED. For an example, please see Appendix B, page 25. Documentation Requirements: A stroke protocol or algorithm that is used for triage and treatment of acute stroke patients in the emergency department. Appendices: Appendix B: Example Stroke Code Algorithm (Pg. 25) Appendix C: Example Stroke Code Protocol (Pg ) 11

12 3. A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures. Rationale: In most settings, a patient with a stroke is taken to the hospital by EMS personnel. The ability of EMS personnel to recognize patients with a possible stroke, communicate their findings to the receiving hospital, and stabilize and transport such patients is a key element of an Acute Stroke Ready Hospital. Data from recent studies have shown that EMS communication and notification to the ED that a potential stroke patient is en-route can shorten door-to-imaging and doorto-needle times, both of which are key parameters in receiving IV TPA therapy. References: (Jauch et al., 2013), (Acker et al., 2007), (Alberts et al., 2013). Requirements: 1. The written plan or EMS stroke protocol should detail how patients with a suspected stroke will be triaged and routed to the most appropriate hospital. 2. The written plan should include a plan for notification to the hospital emergency department when a suspected stroke patient is being transported. 3. The written plan should detail assessments and interventions to be performed. Recommendations, Allowances, and Notes: 1. EMS personnel should have specific training in the recognition of possible stroke patients, including the use of an accepted field assessment tool (e.g., Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen (LAPSS)). Training in such stroke protocols should ideally occur at least annually with a minimum educational exposure of two hours per year if possible, or as often as indicated by protocol updates. We recommend that the Acute Stroke Ready Hospital provide or facilitate access to this type of training to their local EMS agencies. 2. Key elements of a written plan include documenting assessment of stroke symptoms (e.g., Cincinnati Prehospital Stroke Scale findings), the time of symptom onset (the clock-time of the time last known to be well), the use of concomitant medications, and other major medical conditions. 3. Identifying timing goals for on-scene time and transport, as well as identifying interventions that can aid in timely thrombolytic therapy is recommended. Documentation Requirements: 1. A written plan or protocol for the primary EMS agency that transports to your facility. 2. A letter on hospital letterhead co-signed by the hospital s primary EMS agency and the hospital CEO or chief medical officer acknowledging a triage and transportation agreement for potential stroke patients. Appendices: Appendix D: Example EMS Stroke Protocol (Pg. 30) Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement (Pg. 31) 12

13 4. Emergency department personnel who are trained in diagnosing and treating acute stroke. Rationale: Most patients with acute stroke will enter the ASRH through the emergency department. It is essential for emergency department providers have protocols for the acute diagnosis, stabilization, monitoring and treatment of stroke patients. Staying up to date on current guidelines of care is vitally important in order to ensure proper care for all patients can be given. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. Emergency department personnel should have education annually and as needed to ensure staff are aware of protocol updates related to the care of patients with cerebrovascular disease. Recommendations, Allowances, and Notes: 1. We have purposely omitted a specific number of hours required because we understand that this is a very difficult criterion to meet. In addition, we acknowledge that ensuring locums meet this requirement is nearly impossible. Therefore, the key part of this requirement is that the hospital should ensure key staff is knowledgeable of current acute stroke treatment protocols. 2. This requirement might be met in a variety of ways, including on-line continuing education units (CEU)/CME, attendance at grand rounds, lunch-time lectures, regional and national meetings, and various educational courses. Please see Appendix G for education opportunities. 3. For hospitals with a very low volume of stroke patients, consideration should be given to running mock stroke codes with various clinical scenarios. This might serve to keep personnel and protocols up-to-date with current stroke care guidelines, refresh their memory, and address logistical issues that could affect stroke care. Documentation Requirements: A letter on hospital letterhead signed by the CEO or chief medical officer attesting that at least one staff provider per shift has received training in current stroke diagnosis and treatment guidelines. Appendices: Appendix F: Example Letter Attesting Training of ED Personnel (Pg. 32) Appendix G: Stroke Education Documentation (Pg. 33) Appendix H: Training Resources for ED Personnel (Pg. 34) 13

14 5. The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week. Rationale: The ability to perform and complete basic laboratory testing on patients with a stroke is essential for diagnosing metabolic and infectious disorders that can masquerade as a stroke syndrome, to ensure stroke patients can be treated with the proper acute medications, and to determine the possible etiology of some types of stroke. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. Ability to complete basic lab tests, electrocardiogram, and a chest x-ray at all times (24 hours a day, seven days a week). Recommendations, Allowances, and Notes: 1. Basic tests such as a complete blood count, chemistries, coagulation studies, pregnancy test, EKG, and a chest x-ray must be available 24/7. 2. These basic tests are not mandatory to be conducted on all patients, and only need to be performed under specific circumstances. Please consult the 2013 American Heart Association guidelines for details. 3. More advanced testing in the ED such as a toxicology screen might be helpful in some cases. 4. An ASRH should be able to complete basic laboratory tests, an EKG, and chest x-ray (if needed) within 45 minutes of them being ordered. Documentation Requirements: A Scope of Service OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. Appendices: Appendix I: Example Diagnostic Capability Scope of Service (Pg. 35) 14

15 6. The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week. Rationale: Brain imaging confirms the absence of contraindications to thrombolytic therapy and may help diagnose hemorrhagic stroke. This is an essential function of an Acute Stroke Ready Hospital. In most cases, the first (and perhaps only) imaging study readily available will be a non-contrast head CT scan. This type of scan is usually sufficient to rule-out other conditions that could present with stroke-like symptoms such as a hemorrhagic stroke, large abscess, or tumor. When performed acutely, a head CT will often be either negative or show only subtle changes in cases of ischemic stroke, especially if the stroke is small or very acute. A head CT is very sensitive and accurate for the diagnosis of most types of hemorrhagic stroke (i.e., intracerebral hemorrhage or subarachnoid hemorrhage). References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. Acute brain imaging capabilities and interpretation services must be available on a 24/7 basis. 2. Personnel interpreting such scans should be board-certified radiologists with experience and expertise in reading head CTs and brain MRIs. Recommendations, Allowances, and Notes: 1. Reading may be performed by on-site personnel or via a tele-radiology process. 2. It is recommended that brain imaging with a non-contrast head CT or MRI be performed and read within 45 and 60 minutes (respectively) of it being ordered. Documentation Requirements: A Scope of Service OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. Appendices: Appendix J: Example Brain Imaging Interpretation Capability Scope of Service (Pg. 36) 15

16 7. Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually. Rationale: An ASRH should be able to deliver several acute therapies that can improve outcomes for patients with a variety of strokes. In addition, the stroke-ready hospital should have an organized set of protocols to address various clinical presentations and complications which may arise in acute stroke patients. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. Protocol for the diagnostic work-up, intervention (including alteplase dosing and administration guidelines), and patient monitoring required for IV thrombolytic therapy. 2. Guidelines for identification of contraindications to thrombolytic therapy and blood pressure management prior to and during IV thrombolytic therapy. This may be a part of OR adjunct to the protocol. Recommendations, Allowances, and Notes: 1. Protocols should be reviewed and updated at least annually using current published care guidelines from organizations such as the American Heart Association, the American Academy of Neurology, the Congress of Neurosurgeons, as well as other organizations. 2. In some cases, the use of telemedicine/telestroke and related technologies will aid the treating clinicians and help guide therapy. 3. The hospital should consider developing performance indicators for therapies and protocols. 4. The protocol should specific performance measures. To that end, it is strongly recommended that timing goals be identified for key elements of assessment, work-up, and treatment. Examples: 1. Intravenous tpa protocol for acute ischemic stroke 2. Ischemic to hemorrhagic stroke conversion, post-tpa infusion 3. Measures to reverse coagulopathies in patients with hemorrhagic strokes 4. Development of symptomatic systemic bleeding 5. Development of allergic reaction to tpa (angioedema) 6. Assessment of initial neurological function and stroke severity 7. Control or reduction of elevated intracranial pressures in appropriate patients 8. Control of seizures 9. Treatment of blood pressures (too high or too low) 10. Stabilization of other vital functions or metabolic derangements Documentation Requirements: A protocol or order set for the administration of IV tpa for acute ischemic stroke. Appendices: Appendix K: Example ED Order Set for Administering tpa (Pg ) 16

17 8. A neurosurgery coverage plan, call schedule, and a triage and transportation plan. Rationale: Some patients who present to an Acute Stroke Ready Hospital will need acute or eventual neurosurgical evaluation and treatment, particularly those with large ischemic strokes, cerebellar strokes, intracerebral hemorrhages, or subarachnoid hemorrhages. A neurosurgeon may not be readily available in many cases. A plan for addressing potential neurosurgery cases will ensure an organized and timely transfer of care for this type of stroke patient. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. Written agreement between the ASRH and at least one hospital that has neurosurgery coverage consistent with the Primary Stroke Center or Comprehensive Stroke Center recommendations. 2. Written neurosurgery triage and transportation plan for those patients in need of acute neurosurgical services. Recommendations, Allowances, and Notes: 1. This is an area where tele-radiology and urgent transfer of patients after they are stabilized would be most appropriate and effective. 2. Considering the remote locations of some ASRHs, and other logistical challenges with emergent transfer, we recommend that neurosurgical services be available to such patients within three hours (by ground transport) of when it is deemed necessary. 3. A coverage plan may involve either transporting the patient to a facility with a neurosurgeon readily available, or having a neurosurgeon go to the Acute Stroke Ready Hospital. 4. A Scope of Service or other documentation is to specify 24/7 availability of OR room(s), OR staffing and neurosurgeon(s). 5. We do NOT need a call schedule. Documentation Requirements: 1. A Scope of Service or other documentation from a hospital with neurosurgery services that demonstrates 24/7 availability of neurosurgery. The Operating Room Scope of Service often provides this documentation. 2. A letter of understanding/agreement from at least one hospital or neurosurgery group with whom you have an agreement for transfer. Appendices: Appendix L: Hospitals with Neurosurgery Services in Minnesota and Bordering States (Pg ) Appendix M: Example Neurosurgery Scope of Service (Pg ) Appendix N: Example MOA with a Hospital that has Neurosurgery Services (Pg. 49) 17

18 9. Transfer protocols and agreements for stroke patients. Rationale: Many stroke patients at an Acute Stroke Ready Hospital will require emergent transportation to a Primary Stroke Center or Comprehensive Stroke Center. In some cases, the transfer will occur as soon as possible after acute therapy is initiated; in other cases the patient might require a longer stay at the ASRH if s/he is medically unstable. Even in such cases, transfer to a Primary Stroke Center or Comprehensive Stroke Center with more resources should occur as soon as possible, since a higher level of care is likely to ultimately benefit even the unstable patient. Written transfer protocols and agreements ensure that ground or air transportation arrangements are unambiguous, expectations for en-route care are clear, and appropriate documentation on the patient is provided to the receiving hospital. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements: 1. At least one written transfer agreement or protocol exists between the Acute Stroke Ready Hospital and a Primary Stroke Center or Comprehensive Stroke Center that contains key information such as contact personnel, phone numbers, hours of operation, and transportation options. Recommendations, Allowances, and Notes: 1. It is recommended that such transfers occur within three hours of the patient presenting to the Acute Stroke Ready Hospital, to allow time for the initial diagnosis, stabilization, discussions with family and outside facilities, and the arrangement of transportation. Patients who may be candidates for intraarterial therapy should be transferred as quickly as possible after IV thrombolytic therapy has been initiated, or it has been determined that the patient is not a candidate for IV therapy. 2. Some patients will be transferred while they are receiving various acute medications or shortly after such medications are administered (i.e., drip and ship ). This treatment paradigm has been used in many cases of IV tpa therapy, and may be applicable to other therapies such as neuroprotective agents and perhaps coagulopathy reversal treatments. In such cases, close attention and documentation should be provided about the type of therapy, dosing, time of initiation and completion. 3. During the transfer, the patient must be accompanied by qualified personnel who have training directly related to any therapy being administered. 4. There are some patients and circumstances in which the transfer of a patient might be superfluous. This might include patients who are obviously moribund, those who decline further treatments, end-of-life situations (e.g., severe dementia, diffuse cancer), and patient or family refusal, among others. The option of transfer should be offered to all patients in whom further medical therapy can reasonably be expected to lead to improved outcomes and reduced complications. 5. Specific transfer criteria and expectations for care en-route should also be part of the transfer agreement or protocol. 6. If past experience shows that the receiving hospital(s) is often on diversion due to lack of bed space, then additional receiving hospitals should be part of the transfer agreement. 7. General transfer agreements are acceptable so long as they are applicable to stroke patients. 8. We recommend that a checklist and/or protocol that can be used prior to departure be developed (and submitted for this application). This document should also include phone numbers for contacts at both the transferring and receiving hospitals. A copy of this document may also be included as part of the documentation to accompany the patient to provide the receiving hospital staff with information that will be useful in making treatment decisions. Documentation Requirements: A transfer protocol or agreement applicable to stroke patients. Appendices: Appendix O: Example Transfer Protocol (Pg. 50) Appendix P: Example Transfer Agreement with a Primary Stroke Center (Pg. 51) 18

19 10. A designated medical director with experience and expertise in acute stroke care. Rationale: Medical leadership for the stroke program at an Acute Stroke Ready Hospital is essential. Although leadership by a neurologist or neurosurgeon might be beneficial in many cases, the distribution of these specialists is likely to limit their availability at many ASRH facilities. Others who might lead such a program include emergency medicine physicians, internists, pharmacists, and radiologists. In some settings, advance practice nurses have been very successful in leading a stroke center. Whoever the leader is, they should have demonstrated experience and expertise in the care of patients with cerebrovascular disease. References: (Jauch et al., 2013), (Albert et al., 2011), (Alberts et al., 2013). Requirements: 1. A designated medical director with experience and expertise in acute stroke care for the hospital. Recommendations, Allowances, and Notes: 1. An Acute Stroke Ready Hospital may consider a medical advisor to serve in this role who may or may not be primarily located at the facility itself. This may be a mid-level provider or nurse. However, this person should be regularly engaged with the staff and administration at the ASRH. Regular engagement is defined by consistent review of data (quarterly) with key staff; involvement in protocol adoption; consistent communication. 2. A telestroke coverage relationship with the medical director is acceptable. 3. The medical director should ideally have at least six hours per year of educational time in the area of cerebrovascular disease. Specialized training might include completion of a fellowship or other specialized training in the area of cerebrovascular disease, attendance at national courses, prior experience in a neuroscience ICU, etc. 4. Specific areas in need of change that a medical director for stroke might address include enhanced staffing of the emergency department, improvement of infrastructure, investment in tele-technologies, partnering with other facilities to enhance transfer of patients, and educational programs. Documentation Requirements: A letter on hospital letterhead co-signed by the designated medical director and CEO or chief medical officer attesting that s/he will serve in this capacity for the hospital. Appendices: Appendix Q: Example Letter Attesting a Designated Stroke Medical Director (Pg. 52) 19

20 Checklist of Criteria and Documentation Required Criterion Documentation Required Completed? 1. An acute stroke team available or on-call 24 hours a day, seven days a week. A letter on hospital letterhead signed by the CEO or chief medical officer listing the position titles of the members on the acute stroke team. 2. Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications. 3. A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures. 4. Emergency department personnel who are trained in diagnosing and treating acute stroke. 5. The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week. 6. The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week. 7. Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually. 8. A neurosurgery coverage plan, call schedule, and a triage and transportation plan. A stroke protocol or algorithm that is used for triage and treatment of acute stroke patients in the emergency department. 1. A written plan or protocol for the primary EMS agency that transports to your facility. 2. A letter on hospital letterhead co-signed by the hospital s primary EMS agency and the hospital CEO or chief medical officer acknowledging a triage and transportation agreement for potential stroke patients. A letter on hospital letterhead signed by the CEO or chief medical officer attesting that at least one staff provider per shift has received training in current stroke diagnosis and treatment guidelines. A Scope of Service OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. A Scope of Service OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. A protocol or order set for the administration of IV tpa for acute ischemic stroke. 1. A Scope of Service or other documentation from a hospital with neurosurgery services that demonstrates 24/7 availability of neurosurgery. 2. A letter of understanding/agreement from at least one hospital or neurosurgery group with whom you have an agreement for transfer. 9. Transfer protocols and agreements for stroke patients. 10. A designated medical director with experience and expertise in acute stroke care. A transfer protocol or agreement applicable to stroke patients. A letter on hospital letterhead co-signed by the designated medical director and CEO or chief medical officer attesting that s/he will serve in this capacity for the hospital. 20

21 References Stroke Systems of Care Alberts, M., Wechsler, L., Lee Jensen, M., Latchaw, R., Crocco, T., George, M., & Walker, M. (2013, November). Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the Brain Attack Coalition. Stroke ( ). doi: /STROKEAHA Alberts, M., Latchaw, R., Jagoda, A., Wechsler, L., Crocco, T., George, M., & Walker, M. (2011, September). Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the Brain Attack Coalition. Stroke ( ), 42(9), Alberts, M., Latchaw, R., Selman, W., Shephard, T., Hadley, M., Brass, L., & Walker, M. (2005, July). Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke ( ), 36(7), Schwamm, L., Pancioli, A., Acjer, J., Goldstein, L., Zorowitz, R., Shephard, T., & Adams, R. (2005, March). Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association s Task Force on the Development of Stroke Systems. Stroke ( ), 36(3), Emergency Medical Services Acker, J., Pancioli, A., Crocco, T., Eckstein, M., Jaunch, E., Larrabee, H., & Stranne, S. (2007, November). Implementation strategies for emergency medical services within stroke systems of care: a policy statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke ( ), 38(11), Lin, C., Peterson, E., Smith, E., Saver, J., Liang, L., Xian, Y., & Fonarow, G. (2012, August). Patterns, predictors, variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke. Journal of the American Heart Association, 1(4):e doi: /jaha Clinical Management Guidelines Adams, H., Del Zoppo, G., Alberts, M., Brass, L., Furlan, A., & Wijdicks, E. (2007, May). Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke ( ), 38(5), Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J. Demaerschalk, B., & Yonas H. (2013, March). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke ( ), 44(3), Summers, D., Leonard, A., Wentworth, D., Saver, J., Simpson, J., Spilker, J., & Mitchell, P. (2009, August). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke ( ), 40(8),

22 Minnesota Stroke System Contacts Minnesota Stroke System Coordinator: Megan Hicks Data Collection and Reporting: Jim Peacock Performance Improvement Support: - Megan Hicks, Minnesota Department of Health (megan.hicks@state.mn.us) - Shaina Witt, American Heart Association (shaina.witt@heart.org) Minnesota Stroke Registry Program: Albert Tsai (albert.tsai@state.mn.us) 22

23 Appendices for Acute Stroke Ready Hospital Designation Criteria 23

24 Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Criterion 1) Sample ONLY Hospitals must make revisions consistent with their care environment. 10,000 Lakes Hospital 555 Lady Slipper Drive Loon, MN January 20, 2014 Minnesota Department of Health: This letter is attesting that 10,000 Lakes Hospital has an acute stroke team available or on-call 24 hours a day, seven days a week. The role of the acute stroke team is to respond to patients in the emergency department, or in-hospital presenting with stroke symptoms. The team s role is to initiate diagnostic testing and provide the appropriate action of care in a well-timed and coordinated manner in accordance with hospital protocols for the treatment of stroke patients. Additionally, the ED physician and critical care nurse of the acute stroke team complete four hours of stroke education annually. The members on the acute stroke team include: Neurologist, available via telemedicine within 15 minutes Emergency Department Physician Stroke Trained Nurse Laboratory Technician Radiology Technician Radiologist (images read off site) Pharmacist If you have any questions regarding 10,000 Lakes Hospital s acute stroke team, please don t hesitate to contact me. Sincerely, John Smith, CEO 10,000 Lakes Hospital 24

25 Appendix B: Example Stroke Code Algorithm (Criterion 2) ED ADULT SUSPECTED ACUTE STROKE PROTOCOL Evidence of Acute Stroke Symptoms or Positive FAST Exam 1. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body 2. Sudden confusion, trouble speaking or understanding 1. Sudden trouble seeing in one or both eyes (visual field changes) CLOCK TIME LAST KNOWN WELL hours tpa tpa Candidate Candidate hours IR Treatment Candidate Candidate hours Consider neuro ACTIVATE STROKE TEAM Goal: 5 min ASSESSMENT Assess ABCs and keep 02 SATs >94% Start 2 large bore IVs Labs: Glucose, INR, Creatinine, CBC, Troponin, BMP, PTT, pregnancy test 12 Lead EKG (do not delay CT for EKG) Goal: 10 min CONTINUED ASSESSMENT Perform NIHSS Swallow Screen / NPO H&P (obtain pt weight) Goal: min Non contrast CT Goal: 25 min 1. Initiate arrangements for rapid transfer 2. Telestroke, Blue Phone, One Call or for Neuro Consult Goal: min Negative CT Interpretation Goal: 45 mins Yes <4.5 hours of LKW Yes IV tpa Candidate Inclusion / Exclusion Screen & Checklist Yes Manage Blood Pressure: BPs<185 BPd<110 No No Consult with neurologist/surgeon; consider rapid transfer or admission as inpatient. No Discussion with pt/family on risks/benefit/ alternatives Interventional Radiology (IR) Candidates Ischemic stroke pts out of IV tpa window Ischemic stroke pts with IV tpa contraindications Patients s/p IV tpa with NIHSS >10 25 Transfer Patient Goal: 90 min Alteplase: Start tpa STAT. Bolus 10% of the total (0.9 mg/kg dose) over 1 min. Infuser remainder dose over 60 minus. Max dose is 90mg. Goal: 60 min

26 Appendix C: Example Stroke Code Protocol (Criterion 2) PROTOCOL: STROKE CODE Essentia Health- ST. JOSEPH S MEDICAL CENTER BRAINERD, MINNESOTA PURPOSE To establish a standard, well-coordinated and integrated approach to the recognition and treatment any patient exhibiting signs and symptoms of acute stroke < 7 hour duration without associated hypoglycemia. INDICATIONS Sudden onset of any one of the following; 1. Numbness or weakness in the face, arms or legs, particularly on one side of the body 2. Confusion with aphasia (expressive and / or receptive) 3. Difficulty speaking or understanding what others are saying 4. Difficulty walking, loss of balance or coordination 5. Severe headache that does not have obvious or known cause 6. Nonspecific visual complaints with Partial, Complete or Bilateral visual field loss or double vision 7. Sudden onset of continuous vertigo and ANY of the following 65 years of age or older Younger than 65 with risk factors (i.e. Smoking, diabetes, HTN, etc.) Posterior neck pain in setting of recent manipulation or injury (suggesting dissection). DEFINITIONS Stroke Code Consistent phrase used to identify all patients meeting inclusion criteria, regardless of the transportation destination. Team members: Responsible Licensed Practitioner (RLP) or ED physician, ED RN, ED Technician, ED Ward Clerk, ICU RN, Lab Phlebotomist, CT Tech, Pharmacist. PROCEDURE 1. Activation of Stroke Code A. Ambulance Service may activate Stroke Code protocol prior to arrival 1. Notifies the ED that the patient en route meets inclusion criteria 2. Nurse receiving report will notify Ward Clerk to activate Stroke Code team and provide ETA 3. Nurse will inform ED Provider and obtain direction re: timing of initial CT 4. The ED will notify CT when the CT will be performed prior to going to ED exam room B. Emergency Department activation: 1. Activated upon direction of the ED Provider C. Inpatient activation: 1. Activated at the direction of the Rapid Response Team a. May be activated by ICU nurse in absence of MD 2. Obtain a stat blood sugar 3. Initiate O2 per nasal cannula at 4 liters 4. Obtain vital signs 26

27 5. Notify the Emergency Department to activate the Stroke Code 6. Obtain ED room assignment 7. Patient will be transported immediately to assigned ED exam room via hospital bed accompanied by primary nurse, RRT nurse and the RLP activating the Stroke Code Physician TIME GOAL: Stroke Code initiated prior to arrival for patients that are identified in the field and meet inclusion criteria. Stroke code initiated < 5 minutes after arrival and patient headed to CT < 15 minutes Initial patient contact will occur in CT when EMS has been directed there Obtain history and review criteria for treatment Review initial info re: case with Neuro by phone if they are calling in and using video connection Order antihypertensive treatment if BP > 180 / 105 Oversee least 1 IV is started and blood drawn before patient leaves for CT and ensure 15 minute door to CT goal is achieved Perform NIH stroke scale in ER with Neuro via video or alone and finish it en route to CT TIME GOAL: Drug ordered < 20 minutes ER HUC TIME GOAL: Door / notification to page out < 5 minutes Overhead page the Stroke Code Alpha Page Stroke Code group with location of stroke code patient TIME GOAL: Telestroke unit connected < 10 minutes Call United Hospital Telestroke # , specify request for Dr. Hanson s and Dr. Porth s service to initiate telestroke. (Document time of calls). Provide information including patient name, hospital location, physician name(requesting provider), and ED call back number Initiate stroke code orders (labs, CT, CTA, EKG, NIH neuro checks / VS) Find family for consent and bring to patient room for history especially if using telestroke Provide MRI Questionnaire to family to complete Fax the following to Neuro fax cover sheet 2. Demographics sheet 3. Request for neuro consult Notify CT to make copy of scans if pt is being transferred Notify United Patient Placement center of patient transfer to obtain disposition RADIOLOGIST Radiologist reading CT will call CT reading to the on-call Stroke Neurologist ER Nurse TIME GOAL: VS, abbreviated NIHSS, monitor, O2 < 5 minutes & door to drug < 45 minutes Transport and set up Telestroke Unit - Camera should be at foot of stretcher on side opposite nurse working on VS/starting IVs. Connect the unit Turn on the unit Activate connection to Omnijoin Telestroke site Take stretcher from planned exam room and move it to CT and wait for patient arrival Cardiac monitor, O2, check vital signs, abbreviated NIHSS Finger stick glucose (if not done by EMS) Obtain or determine patient weight for tpa dosing 27

28 Notify physician if BP > 180 / 105 Obtain medication list and allergies Verify 2 nd IV is started, if not completed prior to CT. Must have 2 IV sites prior to tpa administration. Administer antihypertensive treatment if needed (before or after CT) Remains available to provide status updates and lab results to stroke team. Ensure IV tpa is started and infusing in a timely matter when instructed to do so. o Verify order to administer o Verify drug mixing 1 mg/ml o Verify drug dosage is weight appropriate (0.9 mg/kg) and total dose not > 90 mg o 10% of total dosage given as bolus and remainder infused over next 60 minutes and then flush line with 50 ml NS Perform NIH abbreviated neuro check every 15 minutes after IV tpa is started If not a candidate for IV tpa o Keep NPO until swallow evaluation has been completed o Perform bedside swallow evaluation and document results ER / ICU Assisting Nurse TIME GOAL: 2 IVs < 15 minutes Start IVs and ensure blood is drawn and sent for stroke code labs (if not done by EMS) o 2 functional IVs needed with at least one gauge least one IV site prior to CT. o Verify 2 nd IV is started upon return from CT (if not done prior) Accompany patient to CT Administer anti-hypertensives as ordered Monitor vital signs / NIH abbreviated neuro checks during imaging Upon returning from CT, provide to the Stroke Team with an update of the patient s vital signs / status Insert foley catheter if needed (either prior to tpa or no sooner than 30 min post infusion) Administer IV tpa when instructed to do so. o Verify order to administer o Verify drug mixing 1 mg/ml o Verify drug dosage is weight appropriate (0.9 mg/kg) and total dose not > 90 mg o 10% of total dosage given as bolus and remainder infused over next 60 minutes and then flush line with 50 ml NS Perform abbreviated NIHSS every 15 minutes after tpa given Keep NPO if given IV tpa If transfer planned, assist as needed. Phlebotomist TIME GOAL: Creatinine resulted < 45 minutes Draw 2 green top tubes, 1 blue top, 1 purple top and 1 red top tubes Notify the lab and immediately send tubes of blood to the lab EKG personnel Complete EKG once patient has returned from CT CT Tech TIME GOAL: CT without contrast completed < 20 minutes Clear table for stroke alert patient Perform CT Load results to PACS and send for stat read Enter Name and telephone number of Neurologist into system for Radiologist to call result Perform CTA (if ordered, must have one 18-20G IV, no dye allergy, renal status cleared) 28

29 Rad Tech Obtain Portable chest xray immediately after Head CT, while patient is still in CT. Minnesota Stroke System Toolkit (9/20/2014) Pharmacist TIME GOAL: Drug calculation done ready to mix tpa < 10 minutes Deliver Stroke Code Kit to code site Ensure the patients weight, real or estimated, has been entered in the EMR Complete calculation for mixing drug. Reminder: 1 mg/ml Await order from MD tpa will be mixed in the Emergency Department. o Hand off tpa to nurse caring for patient when order to administer is verified Neurologist TIME GOAL: To ER via video < 10 minutes & door to drug 30 minutes Call ER to confirm page received and get initial info (patient name and record number if known). o Let staff know connecting via Telestroke. o For stroke codes, ask staff to set up connection. Connect to Omnijoin Perform NIHSS while patient is getting IV started if they are still in ER or when back from CT Take history from family and ER physician if patient is in CT Look at CT remotely with PACS Receive Radiologist CT reading Communicate CT results to ED MD Discuss case with physician and order the tpa Look at CTA when able Start or finish NIHSS when patient returns to ED or ICU (if in-house stroke alert) Pull together all data for final review history, exam, labs, BP If treatment appropriate tell nurse to initiate bolus and infusion as soon as you can and/or start discussion with interventional neuroradiology if needed DOCUMENTATION REMINDERS The Stroke Code Treatment Record provides dual purpose and is essential to the review process Audit tool Worksheet / transfer record PHONE LIST - commonly used phone numbers during Stroke Alert Admitting: CT Scan: EMS Dispatch: ER: 7555 Lab: Pharmacy: X-ray Main: Telemedicine Allina Network: United Patient Placement Center Fax United ER:

30 Appendix D: Example EMS Stroke Protocol (Criterion 3) Minnesota Stroke System Toolkit (9/20/2014) 30

31 Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement (Criterion 3) Sample ONLY Hospitals must make revisions consistent with their care environment. 10,000 Lakes Hospital 555 Lady Slipper Drive Loon, MN February 12, 2014 Minnesota Department of Health: This letter is acknowledging that 10,000 Lakes Hospital and Regional Emergency Medical Services has established a triage and transportation agreement for potential stroke patients. Our organizations have developed an EMS Stroke Protocol that supports the transition of care from pre hospital to the emergency department handoff. Key components of the protocol include: EMS personnel neurologic assessment using the Cincinnati Pre-hospital Stroke Scale. Notification using the term code stroke and providing estimated time of arrival to receiving hospital. Documentation of medical history including time last known well/normal, use of concomitant medications, other major medical conditions. Stabilization of patient and use of interventions including blood glucose monitoring and obtaining IV access when appropriate. Patient information communication hand-off process upon arrival at receiving hospital. Feedback mechanism to advise EMS on accuracy of stroke identification and patient outcomes. If you have any questions regarding the agreement between 10,000 Lakes Hospital and Regional Emergency Medical Services, please don t hesitate to contact me. Sincerely, Signature Signature Signature John Smith, CEO Mary Young, EMS Medical Director Steve Allen, Director of Transportation 10,000 Lakes Hospital Regional Emergency Medical Services Regional Emergency Medical Services 31

32 App Minnesota Stroke System Toolkit (9/20/2014) Appendix F: Example Letter Attesting Training of ED Personnel (Criterion 4) Sample ONLY Hospitals must make revisions consistent with their care environment. 10,000 Lakes Hospital 555 Lady Slipper Drive Loon, MN February 23, 2014 Minnesota Department of Health: This letter is attesting that 10,000 Lakes Hospital has established a stroke education protocol in the Emergency Department to ensure that at least one staff provider per shift is knowledgeable of current stroke diagnosis treatment guidelines. Clinicians will receive initial and ongoing education requirements to maintain competency in the area of cerebrovascular disease. The scheduling department ensures that at least one qualified clinician per shift is available for the acute diagnosis, stabilization, monitoring and treatment of stroke patients. Additionally, 10,000 Lakes Hospital will perform at least one mock code stroke per year to aid in hands-on training and identify opportunities for improvement. Our ongoing education activities include: Stroke protocol training for physicians, locums and nursing upon hire NIHSS Certification for nursing Stoke education as offered through tele-stroke / Primary Stroke Center affiliations Webinars offered by the AHA, MDH and Genentech Minnesota Stroke Conference & Regional Workshops (MDH) Please see the attached documentation regarding the education that our staff receives. If you have any questions regarding 10,000 Lakes Hospital stroke education protocol, please don t hesitate to contact me. Sincerely, John Smith, CEO 10,000 Lakes Hospital 32

33 Appendix G: Stroke Education Documentation (Criterion 4) MEEKER MEMORIAL HOSPITAL STROKE EDUCATION Date Education Topic Participants 8/20/2010 NIHSS Certification and Training Course All ED and Critical Care RNs 12/6/2010 Stroke Program and Protocol Presentation Medical Staff 1/19/2010 New Stroke Management Guidelines Medical Staff presented by Dr. Tarrel, Stroke Neurologist 5/11/2011 Evolution of In-House Stroke Code presented RNs by Joshua Gramling, Clinical Care Supervisor, Hennepin County Medical Center 6/13/ Minnesota Stroke conference Program Coordinator 12/5/2011 Allina Telestroke Program presented by Medical Staff Karen Gozel, Clinical Practice Coordinator 3/20/2012 Allina Telestroke System Training presented by Karen Gozel and Dr. Tarrel Medical Staff; ED and Critical Care RNs 6/4/2012 NSA NIH Stroke Scale Exam Program Coordinator 6/3/ Minnesota Stroke Conference Program Coordinator 4/25/2014 Review of Stroke Reporting Criteria ED Staff RNs 6/2/ Minnesota Stroke Conference Program Coordinator 6/13/2014 Overview of MN Stroke Conference ED Staff RNs Highlights 8/11/2014 Genentech Stroke Management Learning System: Module 2, Inhospital Diagnosis of Acute Ischemic Stroke Program Coordinator RNs Planned Stroke Education Date Education Topic Intended Participants Annual Web-based Stroke Care Ed and Critical Care Staff RNs Upon hire Stroke Protocol Training Locum ED Providers Annual Stroke Protocol Review and Updates Current Locum ED Providers Annual Stroke Protocol Review and Updates Medical Staff 2014 MN ENA online lecture: Assessment and Care of the Stroke Patient Ed and Critical Care Staff RNs 2014/2015 Mock Stroke Code ED Providers; ED and Critical Care RNs Ongoing Dutie Cards Med/Surg and Critical Care Staff responding to Stroke Team Activation 33

34 Appendix H: Training Resources for ED Personnel (Criterion 4) American Heart Association My American Heart for Professionals offers online activities; most are free. They offer NIHSS certification. There is a $10 fee per test for non AHA members and free for AHA members. The OnlineAHA.org site offers two courses related to stroke: Acute Stroke Online ($25) and Stroke Pre-hospital Care Online ($20) Minnesota Department of Health The Minnesota Department of Health offers free or low-cost stroke education at the annual statewide stroke conference and the Minnesota Stroke Registry Program s regional workshop series. The Internet Stroke Center The Internet Stroke Center provides health professionals with multiple tools and educational presentations about stroke assessment, stroke treatment and management. Website supported by NINDS, Washington University in St. Louis School of Medicine and UT Southwestern Medical Center. The NIHSS training DVD can be ordered through this site. The cost is $50. They also offer a Know Stroke Community Education kit ($10), Spanish Stroke Toolkit for lay health educators ($35), and NIHSS pocket guide for health professionals ($1.75). National Stroke Association The National Stroke Association offers programs that will meet The Joint Commission and other certifying organization requirements for stroke education. The cost varies by the program. For example there are 10 nurse modules that cost $20 per module (AANN members pay $15). They also offer programs for physicians, EMS, and rehabilitation. Medscape Medscape is a reliable source for CME and continuing education for physicians and other health professionals. AIS Virtual Patient Builder & Health Stream Stroke Modules Genentech s AIS Virtual Patient experience is a free tool that supports professionals in boosting their diagnostic skills through practice in building virtual patient charts, calculating NIHSS scores, interpreting CT Scans, and determining potential treatment options and managing patient discussions. The Health Stream Stroke Modules prove free access to education materials and training on acute ischemic stroke and Activase. (Click on Resource Center Interactive Tools). Minnesota Emergency Nurses Association The Minnesota ENA has developed and published a stroke education course that is available for free CEUs. It is a two hour 15 minute presentation. A quiz and an evaluation are required to get the education credits. This program will be available through June 1,

35 Appendix I: Example Diagnostic Capability Scope of Service (Criterion 5) 10,000 Lakes Hospital Policy #4563 Effective Date: 04/12/2004 Reviewed/Revised: 06/24/2014 POLICY: LABORATORY SCOPE OF SERVICE Services: The Laboratory is dedicated to providing high quality services to help inform diagnosis, determine treatment modalities and improve public and personal health. Our testing services include routine chemistry, phlebotomy, toxicology, hematology, coagulation, electrophoresis, transfusion, pregnancy, urinalysis, electrocardiograms (EKG) and portable event monitors. Populations Served: The Laboratory provides services for patients of all ages in inpatient, emergent, outpatient and clinic specialties. Hours of Operation: Laboratory services are available in-house or on-call 24 hours a day 7 days a week. Staffing: The Laboratory is staffed in-house Monday-Saturday from 7:30 a.m. to 7:30 p.m. On-call coverage includes Sundays, holidays and Monday-Saturday from 7:30 p.m. to 7:30 a.m. On-call personnel must arrive at the hospital no later than 30 minutes from the initial phone call. Electrocardiograms are performed by medical technologists during in-house hours. Nursing staff is responsible for performing EKGs during on-call hours. Competency All staff providing patient care and testing are required to document training and competency in all specialty areas, safety, and compliance annually. All new hires are required to complete hospital orientation and lab orientation. 35

36 Appendix J: Example Brain Imaging Interpretation Capability Scope of Service (Criterion 6) 10,000 Lakes Hospital Policy #4861 Effective Date: 06/18/2002 Reviewed/Revised: 06/24/2014 POLICY: RADIOLOGY DEPARTMENT SCOPE OF SERVICE Services: The Radiology Department is dedicated to providing high quality services to help inform diagnosis, determine treatment modalities and improve public and personal health. Our services include computed tomography (CT), magnetic resonance imaging (MRI), mammography, ultrasound, echocardiography, nuclear medicine and x-ray. Populations Served: The Radiology Department provides services for patients of all ages in inpatient, emergent, outpatient and clinic specialties. Hours of Operation: Radiology services are available in-house or on-call 24 hours a day 7 days a week. Staffing: The Radiology Department is staffed in-house with technicians Monday-Friday from 7:30 a.m. to 5:30 p.m. On-call coverage for technicians includes weekends, holidays and Monday-Friday from 5:30 p.m. to 7:30 a.m. On-call technicians must arrive at the hospital no later than 20 minutes from the initial phone call. Call consists of coverage for x-ray and CT only. Competency The radiology department is staffed by registered technologists. All staff providing patient care and testing are required to document training and competency in all specialty areas, safety, and compliance annually. All new hires are required to complete hospital orientation and Radiology Department orientation. Contracted Services: Contracted Radiology Services remotely interpret all radiographic examinations 24 hours a day 7 days a week. This service is staffed by board certified Radiologists. STAT radiographic examinations are interpreted within 20 minutes. URGENT radiographic examinations are interpreted within 60 minutes. ROUTINE radiographic examinations are interpreted within 24 hours. 36

37 Appendix K: Example ED Order Set for Administering tpa (Criterion 7) 37

38 38 Minnesota Stroke System Toolkit (9/20/2014)

39 39 Minnesota Stroke System Toolkit (9/20/2014)

40 40 Minnesota Stroke System Toolkit (9/20/2014)

41 41 Minnesota Stroke System Toolkit (9/20/2014)

42 42 Minnesota Stroke System Toolkit (9/20/2014)

43 43 Minnesota Stroke System Toolkit (9/20/2014)

44 44 Minnesota Stroke System Toolkit (9/20/2014)