- Who is required to have the eight hours of continuing stroke education annually?
This requirement applies to the core stroke teams as defined by your organization. The core team is typically comprised of staff responsible for oversight of the stroke program, protocol, and CPGs.
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- Do the eight hours of continuing education have to be Certified Medical Education hours?
The continuing education hours can be accomplished through various methods such as Grand Rounds, Seminars or Conferences, & literature review. Certified Medical Education (CME) is not specifically required. The methods used for continuing education may not have CME attached, but need to be specific to stroke.
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- Do the eight hours of education have to be completed at the time of Initial Certification review?
Yes, part of the assessment of qualified practitioner would include completion of the eight hours annually at the time of the initial review.
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- Is everyone on the stroke unit and team required to have eight hours of CEUs on an annual basis?
Eight-hours of continuing education are NOT required for the stroke unit staff and multi-disciplinary team that may be providing care to stroke patients.
The eight hours of annual continuing education is required for the staff that comprises the CORE stroke team. The ASA expert panel recommends that this team have eight hours of CEUs from conferences that provide updates on (acute) stroke care. The team may be limited to one physician stroke champion, and a nurse coordinator or larger and multi-disciplinary team. The program defines the core stroke team.
Stroke education is provided at various levels (in concentric circles). The core stroke team, as defined by the organization, is the center of the circle and is REQUIRED to have the eight hours of continuing education. The ASA expert panel would recommend that this team have eight hours of CEUs from conferences that provide updates on acute stroke care. At least 80% of the Emergency Department staff (next circle) is required to have knowledge of the organizations acute stroke protocol (PR.3 EP5 and DF.1 EP6). The staff that provides direct care to the stroke patient (next circle) should receive stroke education, but not necessarily eight hours. This would be critical care staff, neurology unit staff, step-down staff or wherever the stroke patient may receive care in your organization. Nurses on non-stroke units, where stroke patients are not routinely cared for, and ancillary staff such as housekeeping and dietary (last circle) need to understand the signs and symptoms of stroke. In addition, they need to understand how to activate the organization’s emergency response team.
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- Can ACLS training count toward the eight hours of stroke continuing education?
The education needs to be specifically related to stroke and the total number of stroke specific material covered in ACLS may be only two hours. The ACLS training may only be every two years vs. annually. The hours for ACLS should be counted only for the year in which the certification was attained.
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- What is primary source verification?
Primary Source verification applies only to licensure/certification or registration required to practice a profession. Current licensure/certification or registration is verified at the time of hire or renewal via a secure electronic communication. Telephone verification is acceptable, if that verification is documented. Primary Source verification will be obtained from State licensing boards or a primary source of information to be verified may be designated to an agency with the role of communicating credentials information. The delegated agency then becomes acceptable to be used as a primary source.
Primary Source verification is not required for organizational requirements such as cardiopulmonary resuscitation (CPR) advanced cardiac life support (ACLS) or pediatric advanced life support (PALS) or clinical certifications such as peripherally inserted central catheter (PICC) line certification.
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- Does The Joint Commission define Acute Stroke in terms of hours or timeframe of onset of symptoms?
The Joint Commission does not specifically define Acute Stroke in terms of hours; however, the population for the purpose of performance measure is defined by the ICD-9-CM principal diagnosis coded. Tables 1-3 in the Appendix of the Stroke Performance Measure Implementation Guide list the applicable ICD-9-CM codes.
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- 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, does the CT and labs need to be performed in 45 minute timeframe required in the standard?
The Joint Commission expectation is as follows: “80% of acute stroke patients have a diagnostic brain image (head CT) completed (and results reported to or reviewed by a member of the stroke team) within 45 minutes of it being ordered, when clinically indicated, (in acute hemorrhagic or ischemic stroke resuscitation candidates).” Once a patient is determined not to be a TPA candidate, then the expedited CT and labs are not required.
Therefore, if, in the judgment of the treating physician(s), expedited CT is not required, the rationale for this decision should be documented in the medical record, and the team should proceed accordingly. However, in the event of unknown time of symptom onset, the recommendation would be to treat the patient as a candidate for thrombolytic therapy until time of symptom onset is known.
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- 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 study could be performed on Monday by speech therapy? Or, are we required to have 24/7 coverage by speech therapy?
It is up to the organization’s policy to determine how they would cover services on the weekend and whether a barium swallow study or other assessment (clinical bedside exam by a trained staff, simple water swallow test, Burke water swallow test, SSA, etc.,) are appropriate.
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- Does The Joint Commission require specific Clinical Practice Guidelines?
It is up to your organization to select appropriate Clinical Practice Guidelines (CPGs), however if your organization participates in the “Get with the Guidelines-Stroke,” you must follow those specific guidelines.
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- Can we use the GWTG –Stroke program as our Clinical Practice Guidelines?
Essentially, the GWTG - Stroke program is designed to be a multi-faceted program that hospitals can use. It does include the data collection tool for the performance measures (called the PMT or Patient Management Tool) and the guidelines are tied to it. If you use “GWTG - Stroke” as your clinical practice guidelines, you must be able to cite which acute treatment protocols you are basing your practice on.
Link to FAQs on GWTG-Stroke: http://www.strokeassociation.org/presenter.jhtml?identifier=301396313963.
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- Do I have to use GWTG-Stroke in order to meet my QI criteria?
No, this is not required.
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- What is different about the GWTG-Stroke program over other programs?
GWTG- Stroke program is a product of the AHA designed as a data collection tool and benchmarking database that helps ensure continuous quality improvement of acute stroke treatment and ischemic stroke prevention. The GWTG- Stroke version corresponds with the numerator and denominator statements for the stroke performance measures as prescribed by The Joint Commission. Other programs may have different definitions for these measures.
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- Does the stroke team have to have a board certified neurologist?
No, a board certified neurologist is not required. It is recommended that the physician educated and trained in the treatment of stroke. A neurologist is preferred, but the program is not required to have a Board Certified neurologists or neuro-radiologist.
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- Is the Primary Stroke Center required to have a neurosurgeon?
No. The Primary Stroke Center is not required to have a neurosurgeon; however, there must be a referral mechanism in place to provide for neurosurgical care within two hours.
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- Can a (Board Certified) Emergency Department physician order IV t-PA using the CPGs and clinical protocols without consulting a neurologist or the stroke team?
Yes. However, it is recommended that the stroke team physician approve the clinical protocols or pathways.
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- What data tool or format do you need to use for measuring stroke care and performance?
You can use any tool, providing you collect the specified data elements using the data definitions specified by The Joint Commission. You may find the implementation guide on The Joint Commission website helpful in this regard.
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- Can we appoint co-medical directors to our Stroke Program?
This is acceptable. However, be prepared to explain the clinical decision-making process in place involving two medical directors, including the process for dispute resolution, within the program.
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- For which patients should the dysphagia screen be performed?
The Disease-Specific Care Measure Set states that a screen for dysphagia should be performed on all ischemic and hemorrhagic stroke patients prior to being given anything by mouth. Therefore, the patient must remain NPO until a dysphagia screen has been completed.
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- Who should complete the screen for dysphagia screen?
A staff member competent to perform the test should complete the dysphagia screen.
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- What data must be reported for the Disease-Specific Care Stroke t-PA measure?
The performance measurement has a primary rate and a secondary rate.
The primary rate consists of all patients with acute ischemic stroke whose time from symptom onset to arrival in the emergency department is less than three hours and who were considered for IV t-PA administration.
This includes:
1. Patients who were considered but determined to be ineligible to receive IV t-PA
2. Patients who were offered IV t-PA
3. Patients who received IV t-PA
The secondary rate consist of the number of patients with acute ischemic stroke whose time from symptom onset to arrival in the emergency department is less than three hours and who received IV t-PA.
For additional information, the measure specification detail and data directory is available in the implementation guide posted on the web.
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- Are we required to use the NIH Stroke Scale to assess a stroke patient?
The National Institutes of Health Stroke Survey (NIHSS) is an appropriate assessment tool used to determine the neurological status of a stroke patient. However, your organization must determine what neurological assessment tool will be utilized.
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- How can the organization indicate t-PA has been considered for a stroke patient?
Best practice would be to implement a consistent (documentation) process that assures t-PA was addressed for the stroke population. The program needs to determine their own documentation requirements---some sites utilize check boxes for the indicators that apply, other sites utilize narrative statement as to the appropriateness of the therapy to the specific patient situation.
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- Do I need to present data on an initial certification review?
Beginning July 1, 2007, on the initial review, you are required to have a four-month track record of stroke data and must be able to demonstrate the ability to collect and analyze data.
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- What do I need to have ready for the reviewer for an initial stroke review?
- List of patients for the past four months with Ischemic Stroke- including age, gender, and ethnic origin, if possible
- List of Ischemic Stroke patients who received t-PA within the past four months
- List of patients for the past four months with Hemorrhagic Stroke-including age, gender, and ethnic origin, if possible
- List of patients for the past four months with TIAs -including age, gender, and ethnic origin, if possible
- List of staff that provide care to stroke patients- ER staff, Critical Care staff, step-down staff, stroke unit staff, PT, OT, SLP and indicate which staff are scheduled to work on the day of the initial review.
- List of physicians who provide care to and/or treat stroke patients, including ED physician(s), neurologist, neuro-interventionalist (if applicable), neurosurgeon, and hospitalist.
- List of the program’s core stroke team members.
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- A patient experiences a stroke several days later after being admitted with another diagnosis, what do I consider the first day for compliance with the performance measures?
The first day is considered the day the patient was assessed with stroke symptoms.
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- Can the organization develop its own performance measures for stroke?
Yes. An organization can develop additional performance measures, but they must report on the four measures mandated by The Joint Commission.
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- If my organization administers IA t-PA- does it count in the performance measure for IV t-PA?
No. The performance measure is specific to IV t-PA.
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- How does the organization evaluate the patients’ perception of care and program effectiveness?
Patient satisfaction tools and phone surveys are methods use to evaluate patient perception of care. Program-specific perception of care, for example, may be obtained through a stroke patient-specific satisfaction survey that is not related to a survey of the general nursing unit where the patient received care.
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- Medical Records Security After Hours
We contract with an after hours cleaning service. Our medical records are stored in an unlocked area or on open shelves with in a secure area. The after hours cleaning crew members sign confidentiality statements. Is this acceptable or should we store the records under lock and key?
While the Joint Commission does not survey against specific HIPAA regulations, the standards do require compliance with applicable law and regulation. IM.2.10 requires organizations to maintain the privacy and confidentiality of information. When an organization's staff is not present to monitor medical records storage areas, alternative approaches may be employed to protect privacy and confidentiality. Examples of such approaches may include ensuring that any individuals who are authorized to perform their duties in areas where medical records are stored, including contracted staff, understand their role in maintaining security and confidentiality, having such individuals sign a confidentiality statement, and ensuring that all medical records should be closed and stored appropriately so that patient information would not be visible to unauthorized individuals.The organization needs to ensure that the medical records area is secured once the cleaning crew members have completed their duties.
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