The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN  AUERBACH
COMMISSIONER	
Circular Letter: DHCQ 08-07-493
TO:	Chief Executive Officers, Acute Care Hospitals
FROM:	Paul I. Dreyer, Ph.D., Director
DATE:	July 16, 2008
RE:	Primary Stroke Services 

It has been over three years since Primary Stroke Service (PSS) regulations (105 CMR 130.1400 - 130.1413) were fully implemented in Massachusetts.  Since then, we have seen significant improvements in the timely evaluation of patients presenting with acute ischemic stroke and in the use of intravenous tissue plasminogen activator (t-PA), the only FDA approved therapy shown to be beneficial in acute ischemic stroke. 

We are currently reviewing Primary Stroke Services as part of ongoing licensure activities.  We are particularly concerned about the timely submission of required acute stroke data and note that some hospitals have insufficient resources available to collect and enter data elements in a timeframe that is compliant with regulatory requirements.  We are also interested in information regarding the hospital’s 24 hour availability of resources to support the PSS program, and the hospital’s PSS performance review and quality improvement activities.  We therefore request that you complete the attached PSS Licensure Attestation (also available online at http://www.mass.gov/dph/dhcq).

Department representatives will review the submitted materials and contact the hospital as necessary to discuss attestation review findings.  The Department is also reviewing hospital PSS data to identify outliers.  On-site reviews may also be conducted to verify compliance with regulatory requirements and to examine outliers.

Please return one completed PSS Licensure Attestation for each campus of your hospital no later than 
August 20, 2008 to:

Ms. Lucille Gunn
Massachusetts Department of Public Health 
Division of Health Care Quality
99 Chauncy Street, 2nd Floor
Boston, MA 02111

For questions about information in this correspondence please contact Gail Palmeri at 617-753-8230, or email:  gail.palmeri@state.ma.us

Primary Stroke Service Licensure Attestation

Name of Hospital:	
______________________________________________________________________	
Address:				
	Street	City, State	Zip Code	
Name of Campus:	
______________________________________________________________________	
Address:				
	Street	City, State	Zip Code	
Name of CEO (please print):  				

Attestation:
The undersigned hereby attests that, pursuant to the hospital’s responsibility as a licensed Primary Stroke Service, the hospital ensures 24-hour availability of resources to patients presenting with acute stroke at the above-named facility; is in compliance with the regulatory requirements of 105 CMR 130.1400 - 130.1413 and can provide verification of the accuracy of the responses; and the data submitted by this hospital to the PSS registry is an accurate representation of care delivered. 

___________________________________	
______________________________	
______________	
Name of CEO, or Designee and Title (please print)	Signature	Date	

PART I

Name of Primary Stroke Director:		Title:		
				
Phone #:	
	E-Mail:	

Name of Contact Person:		Title:		
				
Phone #:		E-Mail:		
				
PART II

Please attest to the following capabilities as they pertain to your Primary Stroke Service:
WRITTEN CARE PROTOCOLS
	
1.	Does the hospital currently use written care protocols for acute stroke?	 Yes	      No	

2.	
Where are written care protocols available?

  Emergency Department   

  Intensive Care Unit     

  Electronic (on-line)       

  Other____________________________   		

ACUTE STROKE RESPONSE TEAM	

  3.	
Does the hospital have an Acute Stroke Response Team to evaluate patients presenting with symptoms of acute stroke? 	
 Yes	      No	

4.	Does the hospital have an on-call system and/or schedule to access the Acute Stroke Response Team?	
 Yes	      No	

5.	
Is the Acute Stroke Response Team available 24 hours per day, 7 days per week?

      If not, please describe coverage.___________________________________	
 Yes	      No	

6.	
Does the Acute Stroke Response Team act on requests for consult within 15 minutes of the notification to assess an ED patient for acute stroke?
  All the time
  Most of the time
  Some of the time
  Never		

7.	Which of the following persons respond to acute stroke patients in the ED? (Please check all that apply)
  Physician(s)
  ED
  Neurologist
  Hospitalist/Intensivist
  Other(s)_______________________________________________
  Nurse Practitioner
  Nurse (s)
  Physician’s Assistant

  Other(s)_________________________________________________		

8.	
Does the hospital use telemedicine videoconferencing for neurological evaluation of acute stroke patients?  
  All the time
  Most of the time
  Some of the time
  Never

9.	
What is the system and sequence for notifying and activating the Acute Stroke Response Team?  (Please check all that apply)
  ED calls as soon as they are notified by EMS, prior to patient’s arrival
  After patient arrival, the Stroke Team is notified, without MD input
  Patient is first seen by ED doctors and, if stroke is suspected, then Stroke 
Team is notified
  Other: ____________________________________________________

THROMBOLYTIC TREATMENT		

10.	Who orders thrombolytics for stroke patients? (Please check all that apply)
  Physician
	  ED Physician
	  Neurologist
	  Hospitalist/Intensivist
  Nurse Practitioner
  Physician’s Assistant
  Other(s)_________________________________________________

11.	
Under what circumstances will your ED physicians order thrombolytics for stroke patients?  
  With Neurology backup by phone
  With Neurology back up by telemedicine
  Neurology must be present
  No neurologist necessary
 Other_________________________________________________________

12.	
Are stroke patients transferred to another hospital for intravenous t-PA administration?
  All the time
  Most of the time
  Some of the time
  Never

13.	
Are stroke patients transferred to another hospital after administration of thrombolytics in your hospital’s ED?
  All the time
  Most of the time
  Some of the time
  Never
	a) Briefly describe reason(s): ________________________________
                             _____________________________________________________

14.	
If an acute stroke patient who has received thrombolytic therapy is transferred from your hospital, does your hospital routinely contact the receiving hospital in order to determine whether or not the patient experienced a hemorrhagic complication after transfer?
  All the time
  Most of the time
  Some of the time
  Never		

NEUROIMAGING SERVICES & INTERPRETATION		
15.	Can a CT (or MRI) scan be performed 24 hours per day, 7 days per week (except during routine equipment maintenance)?	 Yes	      No	

16.	How often are CT/MRI technologists available and the CT scanner/MRI unit is operational for rapid imaging during night and weekend hours?
  All the time
  Most of the time
  Some of the time
  Never

17.	
Are neuroimaging interpretation services available within 25 minutes of scan completion 
24 hours per day, 7 days per week?
  All the time
  Most of the time
  Some of the time
  Never		

18.	
Does the hospital use teleradiology services?  
-	Please describe frequency of use (e.g., weekends, evenings, etc.) 

__________________________________________________________
	
 Yes	      No	

NEUROSURGICAL SERVICES		

19.	
Has the hospital developed and implemented written protocols for timely patient access to neurosurgical evaluation and/or intervention, including patient transfer to another hospital?

Name of Hospital   _____________________________________

Date of Agreement _____________________________________

 Yes	      No	

PRIMARY STROKE SERVICE (PSS) REVIEW		
20.	Does the hospital have a PSS Quality Review Committee?	 Yes	      No	

21.	
Identify members of the PSS Quality Review Committee:
	  Physician(s)
	  Neurologist
	  ED physician
	  Other(s): ___________________________________
	  Nurse(s)
	  Physician assistant(s)
	  Nurse practitioner(s)
	  EMS personnel
  Other(s): _________________________________________
	
 Yes	      No	

22.	
How often does the Committee meet?
  Monthly
	  Quarterly
	  Bi-annual
	  Annual
	  Other:  _________________________________________________

Provide the date(s) of the Committee meeting(s) in 2007/2008:_____________

		

 
QUALITY IMPROVEMENT		

23.	
Does the PSS Committee review the following:		
	•	the number of stroke patients	 Yes	      No	
	•	types of strokes evaluated	 Yes	      No	
	•	nature of any complications of thrombolytic therapy	 Yes	      No	
	•	compliance with regulatory requirements, including adherence to time targets	 Yes	      No	
	•	PSS protocols	 Yes	      No	
	•	Reasons why patients did not receive t-PA	 Yes	      No	

24.	Do PSS Committee minutes reflect the above information?	
 Yes	      No	

25.	What is the date of the last review of PSS protocols? ___________________		

26.	
Is data collected on all patients who presented to the ED within 3 hours of symptom onset and were ultimately diagnosed with ischemic stroke or TIA (ICD-9 codes 433-436), whether or not t-PA was administered and/or the patient was admitted?
	
 Yes	      No	

27.	
Does the hospital typically enter all required PSS data in the data registry:
	  Less than or equal to 1 month after patient discharge
	  Less than or equal to 2 months after patient discharge
	  Greater than 2 months after patient discharge

28.	
Is data used to identify opportunities for improvement in the stroke service?
	
 Yes	      No	

29.	
Has the hospital made changes to the stroke service based on findings of the data analysis?

a) Provide examples of how findings of data analysis have been used to improve the hospital’s stroke service in 2007-2008:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 Yes	      No	

CONTINUING HEALTH PROFESSIONAL EDUCATION

30.	
Briefly describe hospital-based staff education (e.g., topics covered, dates, # of attendees) that has been provided to address the needs of physicians, nurses, allied health professionals, and Emergency Medical Services (EMS) personnel in acute stroke prevention, diagnosis and treatment in 2007-2008. (Attach additional sheet(s) if necessary.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

COMMUNITY EDUCATION

31.	
Briefly describe community education information (e.g., topics, methods, scope, dates) that has been provided to the public regarding prevention of stroke, recognition of stroke symptoms, and/or treatment of stroke in 2007-2008. (Attach additional sheet(s) if necessary.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please mail the completed Attestation to:

Ms. Lucille Gunn
Massachusetts Department of Public Health 
Division of Health Care Quality
99 Chauncy Street, 2nd Floor
Boston, MA 02111

For questions about information in this correspondence please contact Gail Palmeri at 
617-753-8230, or email:  gail.palmeri@state.ma.us.