The Commonwealth of Massachusetts

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

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
TIMOTHY R. MURPHY
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	
Circular Letter: DHCQ 06-5-460

 TO:	     Chief Executive Officers 
 	     Acute Care Hospitals 
 FROM:   Paul I. Dreyer, Ph.D. 
     Associate Commissioner 
 DATE:    May 25, 2006 
 RE: 	     Primary Stroke Services 
The purpose of this memo is to update you on information regarding designated Primary Stroke Services (PSS).  The Department of Public Health (DPH) promulgated licensure regulations for Primary Stroke Services in March 2004.  To date, 68 hospitals (including multi-campus facilities) have applied for and been designated as providers of Primary Stroke Services.  Two additional hospitals are preparing for survey by the end of 2006.
 DPH Primary Stroke Services (PSS) Data
As required by regulation (see 105 CMR 130.1410(B)), designated hospitals "shall collect and analyze data, as defined by the Department, on patients presenting to the Emergency Department with acute ischemic stroke who arrived within 3 hours of symptom onset, to identify opportunities for improvement in the service."  Additionally, according to 130.1410(C) 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." 
•	Accurate and complete data is critical to the usefulness of the registry for assessing and improving stroke services.  It is imperative that the Licensure Registry Coding Instructions (see PSS Resource/Contact Information) are used as a guide for entering data.  The Department strongly encourages clinical review of all phases of stroke data collection and reporting, e.g., review of stroke data collection forms (information abstracted from clinical records) prior to electronic data entry, subsequent review of data entered in the online registry, and ongoing review of data reports to improve accuracy and completeness of entered data.  
•	All designated Primary Stroke Service hospitals are required to collect data on all eligible patients (as defined in Licensure Registry Coding Instructions), and electronically enter the data in the PSS data registry.  This includes patients who initially presented to your hospital's Emergency Department within 3 hours of symptom onset even if they are subsequently transferred (e.g., received tPA (tissue plasminogen activator) at your hospital and are then transferred). 
•	Symptom onset, or "last seen well time," must be documented in the patient's medical record in all cases of suspected ischemic stroke, regardless of time of ED arrival.
PSS Data Entry Timeline
Please note effective immediately, the Department is extending the timeline for stroke data to be entered in the PSS registry. The current data entry deadline is one month from the last day of the month in which the patient was discharged.  The revised data entry deadline is two months from the last day of the month in which the patient was discharged.  (For example, all patients discharged in the month of May, up to May 31, must have data entered and completed by July 31.)
PSS Data Registry Element - Hemorrhagic Complications
The Department has added a data element to the Primary Stroke Service Data Registry for collection of information regarding hemorrhagic complications of thrombolytic therapy which occur within 36 hours of the administration of the thrombolytic.  The collection of this information must begin no later than June 30, 2006.  Should a patient be transferred to another hospital after administration of thrombolytic therapy, the sending hospital is required to contact the receiving hospital in order to determine whether or not the patient experienced a hemorrhagic complication after transfer; and to subsequently enter that information in the PSS Registry.  
Written protocols must be jointly developed between hospitals that routinely transfer patients to identify the process and person(s) at the sending hospital responsible for contacting and collecting the information, and the person(s) responsible for providing the information at the receiving hospital.  
Please note that this data sharing is permitted under the HIPAA Federal Privacy Rule.  As with any HIPAA questions we recommend you check with your facility privacy officer for detailed guidance regarding these requirements.
Technical Support Meeting
Technical support for acute stroke performance improvement is available to hospitals with designated Primary Stroke Services.  A hospital meeting has been planned for June 14, 2006, offered by the DPH, Heart Disease and Stroke Prevention and Control Program's Coverdell Stroke Registry team.  Improving acute ischemic stroke care as required for primary stroke service designation will be the focus of the state's stroke hospital quality improvement collaborative, SCORE, for the next 6-9 months.  For more information please contact          Tracy Evans at 617-624-5414, or email: tracy.evans@state.ma.us .
PSS Contact/Resource Information
The Massachusetts Primary Stroke Service hospital licensure regulations at                         105 CMR 130.1400-.1413 (which were distributed as part of Circular Letter                      DHCQ: 04-04-440), Licensure Registry Coding Instructions, Data Definitions and                Data Collection Form, are available on the Division of Health Care Quality webpage: http://www.state.ma.us/dph/dhcq/hcqskel.htm .
For questions regarding data entry issues please contact the Outcome Sciences Help Desk    at 888-526-6700, Winfred Kao at 617-621-6440, or email:  WKao@outcome.com .
For questions about information in this letter please contact Gail Palmeri at 617-753-8230, or email:  gail.palmeri@state.ma.us .