Southwest Texas Regional Advisory Council Regional Stroke Center

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1 Southwest Texas Regional Advisory Council Regional Stroke Center LETTER OF ATTESTATION DRAFT Document for Updates - Jan 2014 BACKGROUND The Southwest Texas Regional Advisory Council (STRAC) formed a Regional Stroke System Committee in September The Regional Stroke System Committee s creation followed the 80 th session of the Texas Legislature, where Stroke Systems were codified in statute based on HB 1 (General Appropriations Bill, Rider 80), which mandated the Texas Department of State Health Services (DSHS) develop and implement rules for designating stroke centers for Texas. During the initial rule-making sessions, Regional Advisory Councils (RACs) were tasked by DSHS to establish regional stroke systems, both to address EMS triage and transport guidelines, and assist with improving stroke centers in each region of Texas. The STRAC Regional Stroke System Committee has broad, inclusive membership from a wide group of stakeholders. This includes urban and rural hospitals, EMS leaders, neurologists, neurosurgeons, emergency physicians, stroke nurse champions, hospital administrators and interested citizens from the area. The vital components of creating a coordinated system of stroke care are outlined by the American Stroke Association's (ASA) Task Force on the Development of Stroke Systems in the document entitled Recommendations for the Establishment of Stroke Systems of Care. The Committee recognizes that coordinating stroke systems should help patients access a full range of services such as stroke prevention, acute pre-hospital and hospital treatment as well as rehabilitation. In the pre-hospital phase of care, the time-sensitive goals include quick identification of the stroke patient, initiation of appropriate care, and transportation to a Certified stroke center or support stroke center. The Committee has made great strides with the development and implementation of pre-hospital Stroke Alert triage criteria. The Stroke Alert is the emergent process for recognition and treatment for acute stroke patients which mirrors Trauma Alert or Heart Alert a similar notification process for patients who are critically ill. This method of communicating priority patients is a critical stroke system function, requiring EMS personnel to not only identify those patients with stroke symptoms but then to label them as patients requiring the highest priority of care. Protocols and care guidelines are developed in cooperation with hospitals that are participating in the regional stroke system of care. Transport protocols for EMS agencies have been established for the hospitals that are designated Stroke Centers per STRAC criteria

2 As the maturation of the regional stroke system continues, the next significant steps for the system include identifying the other tiers of hospitals in the continuum of care; Support (Level III) Stroke Centers and Comprehensive (Level I) Stroke Centers. The Letter of Attestation (LoA) process has served the region well during the initial development of the system. In the next phase of the system maturation, the Letter of Attestation will be critical as an interim process to identify hospitals meeting the criteria and performance guidelines of Level I and Level III Stroke Centers while the certification and designation processes from The Joint Commission and the Department of State Health Services are solidified. It is mutually understood by the Committee members and the participating hospitals and EMS agencies that formal certification and designation is the preferred process for Stroke Center designation. This Letter of Attestation will be replaced by DSHS Designation of Level I and Level III Stroke centers when established At present, there is no pre-hospital stroke designation process, but the Committee feels that performance criteria are equally important for EMS agencies to provide the best care of the stroke patient. The Letter of Attestation therefore has components that apply to hospitals, to EMS agencies and in some cases to both hospitals and EMS. The Committee sees this document as a work in progress. It is the intent of the Committee that the criteria in this document will be reviewed and adjusted to better meet the needs of our region based upon the relevant science at that time. Primary (Level II) Stroke Centers must be certified by an accredited body recongnized by DSHS and must present validating documents to the STRAC Regional Stroke Systems Committee. Until the Texas Department of State Health Sevices has a process to certify and designate the other levels of Stroke Centers., Facilities that intend to seek either Comprehensive (Level I) Stroke Center or Support (Level III) Stroke Center status shall utilize the LoA process, attesting that their facilities meet the criteria and they will maintain the capabilities listed in this document twenty-four hours a day, seven days a week. Regional EMS agencies will use this information and work with the Regional Stroke Systems Committee to determine destinations for Stroke Alert patients from the scene. Future work will be done to establish methods and procedures to rapidly move patients from outlying facilities in our Region to Regional Stroke Centers. ABBREVIATIONS/DEFINITIONS: 1. Stroke Patient any patient with a blood glucose levels as outlined in the stroke alert criteria showing signs and symptoms including but not limited to acute onset (less than 8 hours)of weakness in one or more extremities, facial droop, and slurred speech. 2. Stroke Alert This term will be used in telephone and radio communications between EMS agencies and hospitals and within hospitals to identify patients with signs and symptoms of stroke and in which rapid intervention is critical. Pre-hospital personnel who call a Stroke Alert must have a patient in their care who meets Stroke Alert Criteria 3. Stroke Alert Criteria A patient who has: 1. One or more findings on Cincinnati stroke scale:

3 A. Facial Droop Abnormal B. Arm Drift Abnormal C. Speech Abnormal --And-- 2. Less than 8 hours from onset of symptoms --And-- 3. Blood sugar between 60mg and 600mg (See Appendix A) 4. EMS Agency EMS providers, although in general, it refers to the EMS agencies throughout the STRAC region. 5. MEDCOM Medical Communication Center housed in San Antonio AirLife s Communications Center whose purpose is to facilitate inter-facility trauma transfers rapidly across STRAC. This center has also developed into a regional center for disaster response requests of regional rescue resources and regional EMS mutual aid. 6. Comprehensive (Level I) Stroke Center A hospital that has signed the Stroke Letter of Attestation and meets and maintains the Level I criteria as laid out in this document. 7. Primary (Level II) Stroke Center - A hospital that has signed the Stroke Letter of Attestation and meets and maintains the Level II criteria as laid out in this document. 8. Support (Level III) Stroke Center - A hospital that has signed the Stroke Letter of Attestation and meets and maintains the Level III criteria as laid out in this document.

4 (need name for this) SUPPORT CRITERIA: (insert protocol/process/packet telemedicine support) (no designation) SUPPORT STROKE CENTER (LEVEL III) CRITERIA: HEALTHCARE FACILITIES AGREE TO ACHIEVE THESE CRITERIA IN TREATING STROKE PATIENTS IF THEY DESIRE TO BE RECOGNIZED AS SUPPORT (LEVEL III) STROKE CENTERS : 1. Level III 1 : Support Stroke Center ( SSCs ) provide timely access to stroke care but may not be able to meet all the criteria specified in the Level I(CSCs) and Level II (PSCs) guidelines. They are required to: a. Develop a plan specifying the elements of operation they do meet. b. Have a Level I or Level II center that agrees to collaborate with their facility and to accept their stroke patients where they lack the capacity to provide stroke treatment. 2. Transport or communication criteria with the collaborating/accepting Level I or Level II center. 3. Protocols for administering thrombolytics and other approved acute stroke treatment therapies. 4. Obtain an EMS/RAC agreement that: a. clearly specifies transport protocols to the SSC, including a protocol for identifying and specifying any times or circumstances in which the center cannot provide stroke treatment; and, b. specifies alternate transport agreements that comply with GETAC EMS Transport protocols. 5. Document ED personnel training in stroke. 23. Designate a stroke medical director (this may be an ED physician or non-neurologist physician) 24. Employ the NIHSS for the evaluation of acute stroke patients administered by personnel holding current certification 25. Document access and transport plan for any unavailable neurosurgical services within 90 minutes of identified need with collaborating Level I or II Stroke Center. 28. ED physician/ed nursing staff activates the stroke team: 29. Utilize Stroke Alert Criteria for Field activation of Stroke Team: a. Whenever a hospital is notified by any participating EMS transport agency that they are enroute with a patient that meets the STRAC regional criteria for a Stroke Alert, the ED shall immediately activate Emergency Department Stroke Alert for an incoming stroke patient who meets the Stroke Alert Criteria. 30. One call activates the Stroke Team: a. As a Support Stroke Center, a facility will employ methods as needed to insure that their stroke team and physicians are notified via a one call activation system. The methods each facility utilizes to accomplish this are their own, however compliance is achieved by methods involving as few steps as possible to notify the entire team needed for successful care of the stroke patient in accordance with all Stroke Center criteria. 31. Stroke team (including a physician with appropriate neurologic expertise) be (available) within 15 minutes of activation: a. As a Support Stroke Center, facilities should employ methods appropriate to have a Stroke Team (available) within 15 minutes. The American Heart Association/American Stroke Association states that a physician with expertise in the management of stroke should be available or notified within 15 minutes of

5 patient arrival. Activating a stroke team is dependent on protocols established by each facility. (Jauch et al., 2013). 32. PI process will include Stroke Performance Measures and Stroke Target Times as core component: a. All Support Stroke Centers shall have an in-house PI Process specific to their Stroke Program processes. A main component of these processes shall be to achieve treatment times that meet or exceed current goals: Door to ED MD < 10 minutes Door to Stroke Team (including an MD with appropriate neurologic expertise) < 15 minutes Door to CT < 25 minutes CT results < 45 minutes Lab results <45 minutes 80% of the time The time targets for stroke are defined, measured and captured in the American Heart Association s Get With The Guidelines database. As with other criteria, best practices learned in achieving this criteria should be shared in the Regional Stroke System PI discussions. Time targets captured: Date/Time Stroke Team Activated and Arrived Date/Time Neurosurgical Services Consulted Date/Time Brain Imaging Ordered and Reported Date/Time Lab tests Ordered and Completed Date/Time ECG Ordered and Completed Date/Time Chest x-ray Ordered and Chest x-ray Completed The 8 stroke performance measures are defined and captured in the Get With The Guidelines database: 1. Deep Vein Thrombosis (DVT)Prophylaxis by End of Hospital Day Two 2. Discharged on Antithrombotics 3. Patients with Atrial Fibrillation Receiving Anticoagulation Therapy 4. Thrombolytic Therapy Administered 5. Antithrombotic Medication by End of Hospital Day Two 6. Discharged on Statin Medication 7. Stroke Education 8. A Plan for Rehabilitation was Considered 33. Participation in Regional Stroke System PI Committee: a. All Support Stroke Centers shall have a physician representative who is regularly involved in stroke care and a designated representative who regularly attends and participates in the Regional Stroke System PI Committee. 34. Participation / Compliance with Regional Stroke System Registry: a. All Regional Stroke Centers shall submit data on all patients meeting the criteria as established by the Regional Stroke System Committee to the Regional Stroke System Registry. This data shall be in a format and contain all data elements as defined by the Committee. At a minimum this shall include all Stroke patients, but further cases may be included as the system matures.

6 35. Senior Administration, Medical Staff Commitment: a. Facilities that desire to be recognized by the Committee as a Support Stroke Center shall have commitment from their senior administration as well as their physician leadership. This senior commitment is confirmed by signature on this Letter of Attestation as a Support Stroke Center. PRIMARY (LEVEL II) STROKE CENTER CRITERIA: HEALTHCARE FACILITIES AGREE TO ACHIEVE THESE CRITERIA IN TREATING STROKE PATIENTS IF THEY DESIRE TO BE RECOGNIZED AS PRIMARY (LEVEL II) STROKE CENTERS : 1. Meets requirements specified for Support Stroke Center 2. Level II: Primary Stroke Centers ( PSCs ) will meet the requirements specified in the advanced disease-specific care certification requirements for primary stroke center from the Disease-Specific Care Certification Manual. (2013 ed., text rev.; D-SCCM; Joint Commission, 2013). They will be able to deliver stroke treatment 24/7. These include, but are not limited by, the following specifications: a. 24 hour stroke team b. Written care protocols c. EMS agreements and services d. Trained ED personnel e. Dedicated stroke unit f. Neurosurgical, Neurological, and Medical Support Services g. Stroke Center Director that is a physician h. Neuroimaging services available 24 hours a day i. Lab services available 24 hours a day j. Outcomes and quality improvement plan k. Annual stroke CE requirement l. Public education program (ct missing) COMPREHENSIVE (LEVEL I) STROKE CENTER CRITERIA: HEALTHCARE FACILITIES AGREE TO ACHIEVE THESE CRITERIA IN TREATING STROKE PATIENTS IF THEY DESIRE TO BE RECOGNIZED AS COMPREHENSIVE (LEVEL I) STROKE CENTERS : 2. Meets requirements specified in Primary Stroke Center 3. Level I: Comprehensive Stroke Centers ( CSCs ) will meet the requirements specified in the advanced disease-specific care certification requirements for comprehensive stroke center from the Disease-Specific Care Certification Manual. (2013 ed., text rev.; D- SCCM; Joint Commission, 2013). These include, but are not limited by, the following specifications: a. A 24/7 stroke team capability as defined herein plus all of the requirements specified for a Primary Stroke Center b. Personnel with expertise to include vascular neurology, neurosurgery,

7 neuroradiology, interventional neuroradiology/endovascular physicians, critical care specialists, advanced practice nurses, rehabilitation specialists with staff to include physical, occupational, speech, and swallowing therapists, and social workers. c. Advanced diagnostic imaging techniques such as magnetic resonance imaging (MRI), computerized tomography angiography (CTA), digital cerebral angiography and transesophageal echocardiography 24/7. d. Capability to perform surgical and interventional therapies such as stenting and angioplasty of intracranial vessels, carotid endarterectomy, aneurysm clipping and coiling, endovascular ablation of AVM s and intra-arterial reperfusion 24/7. e. Supporting infrastructure such as 24/7 operating room support, specialized critical care support, 24/7 interventional neuroradiology/endovascular support, and stroke registry f. Educational and research programs Comment [ee1]: This is DSHS Level I requirements, Stroke Coordinators should edit these as applicable. EE

8 EMS AGENCIES AGREE TO ACHIEVE THESE CRITERIA IN TREATING STROKE PATIENTS TO BE RECOGNIZED AS REGIONAL EMS STROKE ALERT AGENCIES : 1. Utilize Stroke Alert Criteria: EMS Agencies agree to develop protocols and transport plans to deliver patients who meet Regional Stroke Alert Criteria to the appropriate Regional Stroke Centers (needs to be edited to include telemedicine/non designated support). Outlying Agencies shall work with their local facilities to integrate their plans with those of the non-regional Stroke Centers to facilitate rapid treatment and transfer to a Regional Stroke Center. EMS Agencies agree to utilize Cincinnati Stroke Assessment. 2. On Scene Times: EMS Agencies should employ methods appropriate to minimize On Scene Times with Stroke Alert patients. This includes developing procedures for: Rapid recognition of Stroke Alert candidates Determination of Stroke Alert criteria as soon as possible Departing the scene with a Stroke Alert patient with a target time under 20 minutes. Best practices learned in achieving this criterion should be shared in the Regional Stroke System PI discussions. 3. Timely notification: EMS will notify the stroke center as soon as possible with the Stroke Alert declaration while enroute to the hospital. 4. Participation in Regional Stroke PI Committee: All participating EMS Agencies shall participate with the Regional Stroke System PI Committee and work to implement its recommendations. 5. Participation / Compliance with Regional Stroke System Registry: All participating EMS Agencies shall submit data on all patients meeting the criteria as established by the Regional Stroke System Committee to the Regional Stroke System Registry. This data shall be in a format and contain all data elements as defined by the Committee. At a minimum this shall include all Stroke patients, but further cases may be included as the system matures. TERM This Letter of Attestation is in effect on the date on which it is signed and remains in effect for a period of three (3) years or if written notification is received revoking the Letter of Attestation with the Regional Stroke Systems Committee. All parties reserve the right to terminate this Letter at any time, with or without cause. Thirty (30) day written notification is required for termination of this Letter.

9 Organization: Insert Hospital Name Here Designation: Comprehensive/Primary/Stroke Support Stroke Center (Choose level) Stroke Center Representative: Stroke Center Representative Contact number: Senior Administrative Representative: Senior Administrative Representative Contact number: Stroke Center medical director: Stoke Center medical director contact number: CEO signature: CEO Name (Printed): Date: Regional Stroke Committee Chair Signature: Stroke Committee Chair Name (Printed): Date:

10 Organization: Insert EMS Agency Name Here Primary EMS Agency Representative: Primary EMS Agency Representative Contact number: EMS Medical Director: EMS Medical Director Contact number: EMS Agency Head signature: Name (Printed): Date: EMS Medical Director Signature: Date:

11 APPENDIX A

12

13 APPENDIX B

14 REFERENCES: 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. American Heart Association - Professional Association American Stroke Association - Disease Specific Society Sep. 20 pages. NGC: Adams HP Jr. del Zoppo G. Alberts MJ. Bhatt DL. Brass L. Furlan A. Grubb RL. Higashida RT. Jauch EC. Kidwell C. Lyden PD. Morgenstern LB. Qureshi AI. Rosenwasser RH. Scott PA. Wijdicks EF. American Heart Association. American Stroke Association Stroke Council. The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists[erratum appears in Stroke Jun;38(6):e38]. Stroke. 38(5): , 2007 May. Sacco RL. Adams R. Albers G. Alberts MJ. Benavente O. Furie K. Goldstein LB. Gorelick P. Halperin J. Harbaugh R. Johnston SC. Katzan I. Kelly-Hayes M. Kenton EJ. Marks M. Schwamm LH. Tomsick T. American Heart Association. American Stroke Association Council on Stroke. The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Stroke. 37(2): , 2006 Feb.. Goldstein LB. Adams R. Alberts MJ. Appel LJ. Brass LM. Bushnell CD. Culebras A. Degraba TJ. Gorelick PB. Guyton JR. Hart RG. Howard G. Kelly-Hayes M. Nixon JV. Sacco RL. American Heart Association/American Stroke Association Stroke Council. American Stroke Association Council on Stroke. The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 37(6): , 2006 Jun. Jauch, E. C., Saver, J. L., Adams, H. P., Bruno, A., Demaerschalk, B. M., Khatri, P.,... & Yonas, H. (2013). 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), Joint Commission. (2013). Disease-Specific Care Certification Manual (2013 ed., text rev.). Oakbrook Terrace, IL: Author. Texas Administrative Code TITLE 25 HEALTH SERVICES PART 1 DEPARTMENT OF STATE HEALTH SERVICES CHAPTER 157 EMERGENCY MEDICAL CARE SUBCHAPTER G EMERGENCY MEDICAL SERVICES TRAUMA SYSTEMS

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