Standards FAQs for Primary Stroke Centers

Review Process

What does the organization need to have ready for the reviewer for an initial stroke review?NewMay 13, 2009

Delivering or Facilitating Clinical Care

Who is required to have the eight hours of continuing stroke education annually?NewMay 07, 2009
Do the eight hours of continuing education have to be Certified Medical Education hours?NewMay 13, 2009
Do the eight hours of education have to be completed at the time of Initial Certification review?NewMay 13, 2009
Is everyone on the stroke unit and team required to complete eight hours of continuing education units (CEUs) on an annual basis?NewMay 13, 2009
Can ACLS training count toward the eight hours of stroke continuing education?NewMay 13, 2009
What is primary source verification?NewMay 13, 2009
In the event a patient fails the bedside swallow screen evaluation and is ordered NPO pending speech therapy (assume the patient arrived on a Friday afternoon) would a barium swallow study suffice for evaluation of swallow until a formal swallow. . .NewMay 13, 2009
Does The Joint Commission require specific Clinical Practice Guidelines?NewMay 13, 2009
Can the organization use the GWTG –Stroke program as our Clinical Practice Guidelines?NewMay 13, 2009
Does the stroke team have to include a board certified neurologist?NewMay 13, 2009
Is the Primary Stroke Center required to have a neurosurgeon?NewMay 13, 2009
Can a (Board Certified) Emergency Department physician order IV thrombolytic using the CPGs and clinical protocols without consulting a neurologist or the stroke team?NewMay 13, 2009
Is the organization required to use the NIH Stroke Scale to assess a stroke patient?NewMay 13, 2009
Who should complete the dysphagia screen?NewMay 13, 2009

Program Management

If a patient enters Emergency Department with symptoms of stroke with onset more than three hours, or even three or four days prior to ED visit, do the CT and labs need to be performed within the 45 minute timeframe required in the standard?NewMay 13, 2009
Can the organization appoint co-medical directors to its Stroke Program?NewMay 13, 2009

Clinical Information Management

The organization contracts with an after hours cleaning service. The organization’s medical records are stored in an unlocked area or on open shelves within a secure area. The after hours cleaning crew members sign confidentiality statements. Is. .NewMay 13, 2009

Performance Measurement

Does the organization need to present data on an initial certification review?NewMay 13, 2009
Does The Joint Commission define Acute Stroke in terms of hours or timeframe of onset of symptoms?NewMay 13, 2009
Does the organization have to use GWTG-Stroke in order to meet its QI criteria?NewMay 13, 2009
How does the GWTG-Stroke program differ from other programs?NewMay 13, 2009
How does the organization submit stroke performance measure data to The Joint Commission?NewMay 13, 2009
What data tool or format should the organization use for measuring stroke care and performance?NewMay 13, 2009
For which patients should the dysphagia screen be performed?NewMay 13, 2009
What data must be reported for the DSC Stroke: 4- Thrombolytic Therapy Administered?NewMay 13, 2009
How can the organization indicate IV Thrombolytic Therapy has been considered for a stroke patient?NewMay 13, 2009
What is the difference between Time Last Known Well and time of symptom onset?NewMay 13, 2009
A patient experiences a stroke several days later after being admitted with another diagnosis. What day is considered to be the first day for compliance with the performance measures?NewMay 13, 2009
Can the organization develop its own performance measures for stroke?NewMay 13, 2009
If the organization administers IA t-PA- does it count in the performance measure for IV t-PA?NewMay 13, 2009
How does the organization evaluate the patient’s perception of care and program effectiveness?NewMay 13, 2009