The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
10 West Street, Boston, MA 02111
617-753-8000

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	

Circular Letter: DHCQ 05-06-450

TO:		Chief Executive Officers
		Acute Care Hospitals

FROM: 	Paul I. Dreyer, Ph.D.
		Associate Commissioner

DATE:		June 21, 2005

RE:		Primary Stroke Services

The purpose of this memo is to update you on several key areas in the implementation of regulations for Primary Stroke Services.  The Department of Public Health promulgated licensure regulations for Primary Stroke Services in March 2004.  Please refer to the hospital licensure regulations at 
105 CMR 130.1400-.1413 which were distributed as part of Circular Letter DHCQ: 04-04-440.  The 
April 13, 2004 letter may be viewed on the Division of Health Care Quality webpage at:
    http://www.mass.gov/dph/dhcq/cicletter/cir_letter_404440.htm 

To date, 54 hospitals (including multi-campus facilities) have applied for and been designated as providers of Primary Stroke Services.  Fifteen additional hospitals plan to be prepared for survey by the end of 2005.  Effective July 1, 2005, Emergency Medical Services (EMS) Regional Stroke Point-of-Entry Plans will be implemented statewide.  EMS staff will determine the transport destination of patients experiencing acute stroke symptoms based on Regional Stroke Point-of-Entry Plan criteria. 

In preparation for implementation of the Stroke Point-of-Entry Plans, please note:  

•	As a condition of designation as a Primary Stroke Service, the hospital is required to sign a contract with the data management vendor, Outcome Sciences, Inc.  If your hospital received provisional designation and has not established a contract to date, you are advised to promptly make arrangements for completion of the contract and submit a signed copy to the Department.  You may contact Winfred Kao at 617-621-6440 or email at WKao@outcome.com if you have any questions regarding this issue.

•	As a provision of the regulations under 130.1410(B), designated hospitals “shall collect and analyze data, as defined by the Department, on patients presenting to the ED with acute ischemic stroke who arrived within 3 hours of symptom onset, to identify opportunities for improvement in the Service.”  Additionally, 130.1410(C) states the hospital “shall submit data in a manner defined by the Department and in accordance with protocols established by the Department in an advisory bulletin.”

The data must be entered electronically if your hospital is linked to the Outcome Sciences data collection system.  If the system is not yet available at your hospital, the data should be collected manually through use of the enclosed data collection form and entered on line when the hospital is linked to the Outcome Sciences system.  Please note, the coding instructions and form are available on the Division of Health Care Quality webpage: http://www.state.ma.us/dph/dhcq/hcqskel.htm 

All designated Primary Stroke Service hospitals are required to collect data on all eligible patients starting on or before July 1, 2005.  

The Department is proposing the addition of a data element for the collection of information related to hemorrhagic complications of thrombolytic therapy.  Should a patient be transferred to another hospital after administration of the medication, contact with the receiving hospital would be required in order to obtain this information.  Only a small percentage of patients within the limited subset of stroke patients who receive thrombolytic therapy experience complications (projected to be less than 10 patients per year on average per hospital).  The Department projects that minimal additional efforts on the part of hospitals will be required and therefore does not expect that the collection of this information will be overly burdensome.  The Massachusetts Hospital Association is collecting comments or concerns you may have regarding this measure and will be contacting you separately.
Finally, the Department has received inquiries regarding transport of patients with symptoms of acute stroke during periods of ambulance diversion.  As of July 1, 2005, ambulance services will transport patients presenting with symptoms of acute stroke to the nearest designated Primary Stroke Service (PSS) hospital as defined in regional point of entry plans, regardless of the diversion status of that hospital.  

Hospitals temporarily without CT capacity (e.g., diversion web site shows that CT is down) will not be treated as PSS hospitals while the CT is down.  However, please note in accordance with Point-of- Entry Plans patients may be transported to the nearest hospital regardless of CT status under certain conditions:

If the patient will arrive at the next nearest PSS hospital more than two hours after symptom onset.

If a patient has symptoms such as depressed level of consciousness, compromised airway control, known hypoglycemia, suspected severe hypoglycemia, it may be more appropriate to transfer to the nearest receiving hospital for acute stabilization.

Should you have questions about this letter, please contact Ms. Gail Palmeri, Program Manager, at 
617-753-8000.

Enclosure