and - Comprehensive Stroke Center Were racial disparities or demographic differences in treatment/outcomes discussed in the studies? For example, SWIFTPRIME was comprised of primarily Caucasian participants. What affect may this have had on outcomes/results such as mortality? Does administering tpa increase the chance of bleeding during thrombectomy? If you know the patient is going to need thrombectomy shouldn't you exclude the tpa? As a small community hospital that keeps some of its tpa patients utilizing teleneurology: 1) What are more specific guidelines for patients that need to be transferred and those that may remain at our hospital? 2) Since #1 maybe related to severity of stroke and imaging, should all patients that receive tpa have a CTA looking for large vessel occlusion? 3) Or should we use NIHSS screening as a guide? With potential stroke patients a CT of the head/stroke protocol is ordered. Many are negative. At that time should the patient then receive a MRI? Many physicians only order the CT and then do not continue on with the MRI. What is the best practice? Do you have any suggestions to increase recognizing stroke in patients who present with vague symptoms? Many we see are diagnosed with syncope, dizziness, and then stroke is discovered later. CT perfusion is time consuming and seems to work primarily in academic centers, tertiary faculties. How do you see smaller hospitals using this technology? Most lectures I've attended say its not pratical. This is not addressed in the program requirements. Would recommend contacting the sponsor of SWIFTPRIME study for additional details. This is not addressed in the program requirements. Would recommend discussing with program leadership at your organization to determine organizational policy. The Joint Commission is not prescriptive in which patients should be kept or transferred. Organizations need to have criteria on the admission and transfer of patients who have had a stroke. We also suggest looking to organizational policy based on CPG for use of CTA and NIHSS. This is not specifically addressed in the program requirements. We suggest looking to organizational policy and CPG on the use of MRI vs. CT. This is not addressed in the program requirements as it is a clinical judgement discussion that may be necessary at your organization. We recommend visiting the American Heart/American Stroke Association's website at www.heart.org to help clarify the signs and symptoms of a stroke and utilizing resources that can better educate your staff regarding how to identify patients who present with vague symptoms. This is not addressed in the program requirements. We recommend utilizing evidence based guidelines and protocols to drive the practice at your organization. Page 1
and - Comprehensive Stroke Center How do you determine patients who get CTA when presenting to ER within time frame? Is there a certain NIH or "disabling" stroke This is not addressed in program requirements. We recommend symptom that would trigger provider to order CTA along with head accessing clinical practice guideline for the development of an CT? What is the criteria? agreed response to CT/CTA criteria. Any cons to pipeline device? Anticoagulation needed after? Can still get MRI? This is not addressed in the program requirements. Please describe what diagnoses are included in hemorrhagic stroke. This is not addressed in the program requirements. Consider Traumatic brain injury? Which ICD codes? including ICDs that are listed in measures. While this is not specifically addressed in the Comprehensive Stroke Center requirements, these centers are expected to meet the requirements of a Primary Stroke Center. DSDF.3, EP2 in the Primary Stroke Center program states that an emergency department physician performs an assessment for a suspected stroke patient within 15 minutes of patient arrival in the emergency department. For Comprehensive Stroke Centers - does the initial evaluation have to be done by a MD or can it be a PA or NP? Our hospital uses PA's. Regarding CPG's: Is it acceptable to simply copy the Executive Summary pages of the main article on Clinical Practice Guidelines (2013) and use this document for the organization's CPG? Hospital staff needs to have access to the entire CPG, not only the Executive Summary. Page 2
and - Measures TIA cases are not tracked in my patient log. They were not asked for (numbers) on 1st stage of application for recertification either. Labs are no longer part of standards - no benchmark, correct? Are you still looking at data? Should we still be tracking? Abstraction guidelines state to take CT time from film time. CT scanners do not have the ability to be linked to atomic clocks. We have seen negative door to CT times due to clock set time on scanner. How do you reconcile this dirty data? Our system is using the CT completed time from the software with atomic clock times to keep data clean. What if we drip/ship all tpa patients? How do we show outcomes or discharge disposition? TIA patients need to be included as it relates to labs, treatment, and disposition. The Joint Commission when reviewing CSC centers follow the requirements established for response times in accordance with the PSC measures. Laboratory tests as well as other diagnostic testing is completed within 45 minutes of patient presentation with stroke symptoms if ordered by the practitioner. The Reviewers will look for these documented times in patient records while on-site. All CSC centers should follow the measure requirements established for CSC certification. DTN is addressed in the standards. TJC does not have a measure for DTN. ASRH are currently required to collect data for 4 non-standardized measures of their own choosing. Standardized measure development is under consideration. Standardized measures replace non-standardized measures when available. Page 3
and - Measures Can there be clarification related to which measures need documentation to occur "in the moment" or within "x" amount of time and which ones are okay to document at discharge or make amendments to after discharge? Can you please provide written answers to all the questions you addressed verbally on your slides? (You speak fast.) Your slides don't provide enough information. Some patients have difficult placement. May not be discharged for 30 days. How does this effect numbers collection? For hemorrhagic strokes what else, specifically, should we measure? What benchmark targets do organizations use? AHA/ASA benchmarks? JCAHO benchmarks or organization benchmark stroke targets for 8 domains? The measure population for both stroke (STK) core measures and comprehensive stroke (CSTK) measures is determined by the ICD-9- CM Principal Diagnosis Code assigned to the patient at discharge. All measure data should be verified retrospectively to ensure that discharges with ICD-9-CM Principal Diagnosis Codes for ischemic and hemorrhagic stroke are included in the measure population. Theses codes are detailed in Appendix A, Table 8.1 and Table 8.2 of the Specifications Manual for National Hospital Inpatient Quality Measures. Concurrent data collection promotes timely intervention when improvement opportunities are identified. Concurrent data collection is beneficial for time-sensitive measures, such as STK-4 Thrombolytic Therapy or the CSTK measures. Data collected concurrently should still be verified retrospectively as stated above. The CSTK presentation provided text answers to 9 frequently asked questions. Without a specific question, we are unable to address this request further. Monthly data points are required for each measure. Cases are selected from all stroke discharges for the month. Hemorrhagic strokes patients are included in 3 of the 8 stroke core measures (STK-1, STK-8, STK10) and 3 of the 8 CSTK measures (CSTK-03, CSTK-04, CSTK-06). The Joint Commission is not prescriptive regarding other performance measure data collection for ischemic or hemorrhagic stroke patients. Aggregate measure rates for the stroke core measures are available on Quality Check and the CMIP trend reports accessed via The Joint Commission Connect extranet. Benchmarks for the comprehensive stroke measures have not been established. Page 4
and - Measures Do observation patients fall into the stroke core measures? This is specifically in regards to our TIA patients? How is tpa utilization rate calculated? What's the denominator? All ischemic patients who arrive at ED or all ischemic patients arriving at ED within 4.5 hours? Patients admitted to the hospital as inpatients and discharged with an ICD-9-CM Principal Diagnosis Code for stroke (Appendix A, Table 8.1 and Table 8.2) are included in the measure population. If a TIA patient in observation is then admitted to the hospital and assigned an ICD-9-CM Principal Diagnosis Code on Table 8.1 (ischemic stroke), then the case is included in the measure population. STK-4 denominator: Acute ischemic stroke patients whose time of arrival is within 2 hours (less than or equal to 120 minutes) of time last known well. Page 5
and - Primary Stroke Center Assessing TIA - we use NIHSS or do you recommend ABCD2? Or both? How would the silent stroke be treated? Does anyone have examples of Clinical Practice Guidelines used by their facility? The CPG's state that door to Neurology should be < 15 minutes, but this does not account for the use of telemedicine. Is there a time expectation for door to Neuro if Neuro is to be telemedicine? Protocol is to activate telestroke during CT. "Respond to bedside within 15 minutes." Is this from patient arrival or time that code stroke was activated? How often should neuro checks and vitals be monitored in ER for a non-tpa candidate? Person performing NIHSS - is this person required to have "education" or "certification"? Is POCT INR testing suggested for use in stroke patients when determining eligibility for IV tpa? Designated practitioner at bedside - can it be a RN or triage RN? Can telestroke service records be used for JC information - NIH, inclusion/exclusion criteria, LKW documentation for tpa or reasons for not administering? The Joint Commission is not prescriptive as to the type of screening used. We recommend reviewing available CPGs. This is not addressed in the program requirements. We recommend reviewing available CPGs. CPG's are available through the national clearing house for CPG's. Many organizations utilize the AHA CPG's. The time is the same regardless if the neuro specialist is in house or providing an assessment via telemedicine. The time frame is from the time of the patient arrival or when the stroke is first noted on an inpatient unit. The organization can establish their own time frame based on order sets or physician orders. The individual should have a minimum level of education. Most organizations utilize the on-line NIHSS certification program which can be completed in a short period of time. The organization can determine who will provide the education on site. The individual teaching the program should have enough knowledge to provide the education and determine competency of students attending the program. The determination of the use of POCT or lab diagnostic testing can be determined by the organization's stroke team. It would need to be a nurse who is part of the stroke team and is qualified and trained as determined by the organization. Yes. The records must be a part of the patient's permanent medical record and should be available to the ED staff in a reasonable amount of time. Most facilities utilize an EMR in which telestroke documentation can be added directly into the record. During a an onsite review, the Reviewer will expect to see the documentation on the chart. Page 6
and - Primary Stroke Center In preparation for PSC designation we have a stroke education SIM The organization can determine how often the staff repeats lab. If all associates complete SIM lab prior to designation, how soon education. Most facilities require an annual update by their staff to after receiving PSC do we need to repeat education? assure staff competency. For a multi-facility health system interested in obtaining PSC certification what is the appropriate FTE dedication needed (approximately 400-500 patients/year)? What is the "gold standard" for inpatient stroke alerts? ED MD responding? Hospitalist responding? What type of education is needed for them? How is the NIHSS in 15 minutes feasible when door to CT is being pushed? For a ~7 minute assessment, this is a large stretch for some facilities and their staff due to a myriad of reasons. Is TJC recognizing this as a difficulty? Can you clarify: when is the initial NIHSS assessment to be performed? Is it within 15 minutes? How much time? Is there a link to the tpa algorithm that is large enough to clearly add when printed out? For the two times a year that ED staff needs education, if staff doesn't comply, does it still count? To appropriately utilize ED resources, can labs and imaging studies be ordered appropriately - for instance, the patient brought to the ED with right hemiparesis and aphasia starting 3 days prior to presentation be scanned routinely? The Joint Commission does not determine the number of FTE's that should be allotted for the care of stroke patients. This is the decision of the facility's clinicians and leadership. Many facilities have established stroke teams made up of individuals trained in stroke care. This may be a neurologist, neuro resident, RN, respiratory care, pharmacy, etc. Facilities can utilize the ED MD if their ED staffing is appropriately staffed and the ED MD can assess the patient within 15 minutes. Some facilities utilize the hospitalist who should be trained in stroke care. The NIHSS is not required to be completed within 15 minutes. The organization can do a modified NIHSS prior to the patient going to CT but this is not required. A NIHSS should be completed prior to the administration of tpa to establish a baseline for the patient. See the answer above. A tpa algorithm can be obtained through the manufacturer. We do not provide a link. The question is not clear. We believe your question is that if the ED staff fails to attend education in accordance with the standards does it still count as an RFI. The answer is yes. It is up to the facility's leadership to assure that staff are in compliance. The standard reflects the level of care for an "acute" stroke patient. A patient would not be considered acute if they had symptoms for three days prior to admission to the ED. If telemed doing NIHSS as initial - do BRN do it too? The telemed MD can do the NIHSS. However, the ED nurse should establish a baseline for the patient and repeat the NIHSS in accordance with the established CPG's or order sets at your facility. Page 7
and - Primary Stroke Center Where do you look specifically at survey to find DSSE1 - Ep1 - involve patients in decisions about their case? Is it mandatory for PSC to have in-house neurology if it uses teleneurology? If a patient is admitted with acute ischemic stroke as diagnosed on MRI and no tpa given, what testing is indicated if symptoms worsen 24 hour later? Should repeat CT be performed or better to wait up to 5 hours for MRI? Does The Joint Commission prefer a PowerPoint presentation for the opening ceremony to give an overview of the stroke program or a different type of presentation? Please define the educational requirement for nurses and ED staff: what qualifies as education? What modalities can be used? What is considered a "stroke nurse"? Which requires 8 hours of education? The patient tracer methodology allows the reviewer to assess this standard in a variety of ways including interviewing staff, looking for documentation in records and interviewing patients and family members. If teleneurology is able to meet your patients' needs, in-house neurology is not required. We recommend that the patient be treated as a stroke alert and a CT should be completed within the required time frames. We routinely see facilities provide their program overview in the opening conference in a power point presentation, however this is not required. Staff in specialty areas who treat stoke patients (ED, ICU, stroke unit) should receive training as determined by the medical director and the stroke team. This may include NIHSS, dysphagia screening, tpa administration, neuro checks, etc. The organization can determine the methodology. Many facilities utilize on-line training courses, faceto-face education, skills days, etc. We are not sure what the writer is referring to as a "stroke nurse". Many organizations consider staff who have undergone training such as listed above a stroke nurse, other facilities require a national certification. All members of the core stroke team are required to have 8 hours of stroke education a year. What is the purpose of modified NIHSS on arrival? It's not a screening tool. Why not use an established screening tool like Cincinnati Stroke Scale or FAST? Do we still need to be meeting "timeliness" goals (door to CT reported, etc.) for subacute, >10 hours from time last known well stroke patients? The Joint Commission is not prescriptive as to the type of screening tool the facility utilizes on arrival of a stroke patient to the ED. A NIHSS should be performed prior to the administration of tpa. No. The requirements are for "acute" stroke patients who may be candidates for tpa. Page 8
and - Primary Stroke Center If a physician in the ED documents s/s started 2 days ago - do they need to also say "this is why I am not giving tpa" since the patient is out of the window? MD education - what is typically used specific to stroke? Who would require the 8 hours of education annually? What is the most problematic or cited standard the JC is finding in survey? The requirements for documentation are included in the standards such as inclusion/exclusion requirements, alternatives to treatment, discussions with the patient/family member and the reason for not giving tpa. MD's routinely attend medical conferences, seminars, continuing education programs. Stroke articles can be used hour for hour for CEU credit. The education should be documented in APA format with the name of the article, author, date of the publication, journal, journal pages, etc. Neuro assessments/reassessments, tpa monitoring, failure to follow CPG's. Page 9
and - Process What are your opinions on administering the tpa while still in CT after the CT has been read? For some hospitals this is a best practice. Best practice for tracking/acquiring MD education (including knowledge of program). Best practice for obtaining stroke log information - what surveyors need? Does the ED physician have to complete NIHSS on tpa patients? CMS states using P.O.C. PT/INR in all stroke patients is off label use of the machine. How is this being addressed by JC and ASA? What is the best way to find patients for your stroke log? Using admitting diagnosis? If an inpatient stroke alert is used? What is the best way? What is the definition of neuro checks? Many healthcare organizations provide tpa to patients while the patient is still in the CT suite. The practice has resulted in quicker turn around times for tpa administration. Healthcare organizations track MD education in a variety of methods. Several hospitals have tracked the education through their medical staff office via computerized method. The Joint Commission will accept a list of programs attended with the name of the program, date, where the MD attended the education, and the number of hours of education. If an organization accepts journal articles, the information noted above must be included as well as the name of the journal, date of publication, pages, author, and other APA format information. Many healthcare organizations have begun to utilize computerized stroke logs available through their EMR or via outside vendors. This practice decreases the amount of time spent manually collecting the information. No. The standards allow staff (MD, RN, APN, PA) to complete the NIHSS if they have attended education as designated by the healthcare organization. On March 13, 2015, CMS has temporarily withdrawn S&C 15-11 (Off- Label/Modified Use of Waived Blood Glucose Monitoring Systems) that was originally issued on November 21, 2014 and reissued as a draft only for comment. Healthcare organizations utilize different collection methods. Organizations collect the data through their EMR, manually or by ICD code. For inpatient stroke patients, they would still be coded as a "stroke". An organization may use the NIHSS or other evidence based tool. Page 10
and - Process There have been rumors that door to tpa will change from 60 minutes to 45 minutes, is this true? Do you need a back up lab system on site if your analyzer goes down? RE: DSPR5 / EP 3 It has been the stance of the JC that credentialing by proxy is sufficient by telemedicine partners. We do not get much comfort from quality departments at stroke hospitals when truly accepting by proxy. Will the JC ever firmly state that proxy is the standard? What could be the role of stroke coordinators that do not have a clinical background as far as patient care? Since AHA/ASA has not addressed the new package insert for Activase (yet), do we follow package insert in administration of tpa (to the letter of the law) or do we continue to follow AHA guidelines? i.e., BP parameters - exclusions. 1) Do you have a definition/time frame of a stat brain MRI/MRA/CTA order "to completion? (DSDF 3 EP 3). 2) Do you have specific examples of process improvements (stroke) for patient satisfaction survey results? The American Stroke Association has introduced "Target: Stroke Phase II Honor Roll" which has a secondary goal of door-to-needle times of 45 minutes or less in at least 50% of eligible patients. This has not yet been considered for incorporation into the stroke program requirements. No. The organization needs to have a back up plan for how they would manage any patient who needs a diagnostic lab test. Each healthcare organization should work with the facility that is providing these services to assure that they have a collaborative agreement that is acceptable to both parties. The stroke coordinator is usually a clinical individual who can monitor the care provided to patients, work with healthcare partners to establish order sets, update clinical practice guidelines, and work with other healthcare professionals to provide acceptable patient outcomes. We rarely see a stroke coordinator who is not a clinician. Non-clinical individuals may be used to collect data or other functions as determined by the organization. Organizations should follow established clinical guidelines for treating and monitoring stroke patients. The organization would need to define a time frame for "STAT". Requirements for the completion of imaging state the inclusion of the results being reported to a member of the stroke team. Time frames for CT and MRI are listed in the requirements. Organizations collect patient satisfaction data in a variety of ways. Some programs ask these questions during follow-up phone calls or after the patient has been discharged, others send out a separate patient satisfaction survey to customers, still others utilize the services of outside companies who complete telephone calls with patients after discharge. Page 11
and - Process Can you assist in defining a dedicated stroke unit? Is it ok to say telemetry beds or does there have to be a designated unit? Are glucoses completed by EMS acceptable or do you have to complete in the ED? Organizations need to identify stroke beds which may be used for stroke patients. These beds should be readily available for stroke patients in a unit where staff who are caring for these patients are trained to care for stroke patients. Glucose results collected by EMS are acceptable based on the organizations approval by their stroke team or medical director for the stroke team. How many people are required to be on a stroke team? How should we define who should be on these teams? We had a facility that recently received a "recommendation" for not having a CPG relevant to TIA's. If you treat all presenting with symptoms of stroke - resolved or not the same why would we need an individual CPG? What is the definition of "quickly" when referring to CT, MRI and CT perfusions? Why are vaccinations listed as a secondary prevention for women? We do not require any particular number of staff to be on a stroke team. Some organizations have several individuals, others maintain a stroke team with key stakeholders. Organizations routinely determine who should be on the stroke team based on their involvement with the stroke program. The individuals are routinely the stroke coordinator, medical director, quality staff, clinical staff from specific departments such as the ED, pharmacy, lab, and leadership. The stroke team is determined by the organization and routinely meets to review data, order sets, clinical practice guidelines, processes, etc. The care provided to a stroke patient, TIA, ischemic, SAH, ICH, tpa require different types of care, therefore the clinical practice guidelines should be utilized to develop and treat patients based on diagnosis. The Joint Commission has set time parameters for the assessments and diagnostic procedures to be completed in the standards. The standards do not utilize the word "quickly" in any of our standards pertaining to the stroke programs. The presenter provided a list which could have been in any order on the slide. It does not designate significance. Is there a formal document describing similarities and differences of data requirements for CMS/JC/GWTG? We need one. Is there a certain percentage of patients that have to be on the "stroke unit"? We currently do not provide such a document as the requirements for CMS, TJC and GWTG change on a routine basis. No. All patients with a diagnosis affiliated with a stroke should be on the stroke unit in order to assure staff who are trained to care for stroke patients can provide the necessary care. Page 12