Washington State Emergency Cardiac and Stroke System

Hospital Name:      

2017 Application for Level I Stroke Center Categorization

Office of Community Health Systems243 Israel Rd. SE Mailing:Tumwater, WA 98512 PO Box 47853 www.doh.wa.gov Olympia, WA 98504-7853800-458-5281

DOH 346-062 January 2017

The Washington State Emergency Cardiac and Stroke System

Guiding Principles

The Washington State Emergency Medical Services and Trauma Care Steering Committee convened a work group to study emergency cardiac and stroke care in 2006. The work group included emergency medical services providers, emergency physicians, cardiologists, neurologists, nurses, and representatives from the Washington State Hospital Association, American College of Emergency Physicians, and the American Heart Association/American Stroke Association. In response to the study findings, the work group made recommendations for a statewide coordinated emergency cardiac and stroke system similar to the state’s Trauma System.

These principles guided the work group in developing recommendations:

Prevention is the first line of defense against heart disease and stroke. Care is provided based on what is in the best interest of the patient. All Washington residents have a right to optimal care: timely identification, transport,

treatment, and rehabilitation by emergency response and health care professionals trained according to best practice standards.

Racial, ethnic, geographic, age, and socioeconomic disparities are addressed. Market-share is balanced by policies and strategies such as telemedicine that promote broad

provider participation. Regional differences are recognized, but basic elements exist statewide. All components of the system participate in planning and quality improvement. Patient outcomes are valued, and data collection, analysis, and quality improvement practices

demonstrate the quality that the system claims to provide. Cost-savings are achieved where possible.

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Contents

I. General Information …………………………………………………………………..……..….

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II. Application Process…………………………………………………………………………..…...

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III. Application ………………………………………………………………………………………..….

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A. Hospital Profile and Personnel …………………………………………………….…..

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B. Certification Statement ………………………………………………………….………

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C. Categorization Level Criteria Checklist ………………….………………….……

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D. Documentation Checklist…….………………………………………………….….….23

IV. Appendices ……………………………………………………………………………..…..…....25

A. State of Washington Prehospital Stroke Triage Destination Procedure ……………………………………………………………..……… 27

B. Data Collection and Quality Improvement Requirements………………. 29

C. Resources …………………………………………………………………………………….. 31

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I. General Information

What is the Washington State Emergency Cardiac and Stroke (ECS) System?The ECS System is a coordinated systems approach to improving emergency response and treatment for acute coronary syndrome,1 cardiac arrest, and stroke patients. The goal of the system is improve patient outcomes by reducing time to treatment and getting patients into a dedicated system of comprehensive care. The ECS System is based on the same principles as the Trauma System – get the right patient to the right place in the right amount of time to save lives and reduce disability.

State law passed in March 2010 authorizes the ECS System. The law is based on recommendations of the Emergency Cardiac and Stroke Work Group convened by the Emergency Medical Services and Trauma Care Steering Committee in 2006. The law required the Department of Health to support an emergency cardiac and stroke system by 2011, including cardiac- and stroke-specific protocols and destination procedures for emergency medical services (EMS), and encouraging hospitals to voluntarily participate in the system. To participate, hospitals self-identify their cardiac and stroke resources and capabilities by applying for categorization as a Level I, II, or III Stroke Center, or Level I or II Cardiac Center. These levels are defined by the recommendations of the Emergency Cardiac and Stroke Technical Advisory Committee, as required by the law.

Why do we need a system for emergency cardiac and stroke care? Too many people become disabled or die from heart attack, cardiac arrest, and stroke because they don’t get treatment in time.

Most strokes (80%) are caused by clots. In 2008, only four percent of this type of stroke were given the best treatment, the clot-busting drug t-PA.

Primary percutaneous coronary intervention (PCI) is the most effective treatment for most people having a heart attack. PCI includes angioplasty and stenting. In Washington, less than half of all people who have a heart attack get PCI.

Access to resources for diagnosing and treating heart attacks and strokes varies, especially in rural areas.

Heart attack and stroke patients are often transported to the nearest hospital only to be transferred to another hospital. This can delay treatment for hours. Cardiac and stroke patients don’t have hours.

The ECS System addresses all of these problems by reducing time to life-saving treatments. It gets patients to facilities committed to providing the most timely and optimal evaluation and care. Heart attack and stroke patients treated in time will likely need less rehabilitation, suffer fewer disabling conditions like paralysis and congestive heart failure, and can often go home after their hospitalization.

Why should my hospital participate?

1 Acute coronary syndrome includes ST elevation myocardial infarction (STEMI), non-STEMI, and unstable angina.

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EMS needs to know what cardiac and stroke resources hospitals have so they can get their patients to the right treatment in time. By participating, you will be

Strengthening our emergency medical services system. Ensuring people get the treatment they need. Saving lives, reducing disability, and improving quality of life.

The destination and triage tools EMS uses to determine where to take their patients directs them to transport patients only to participating hospitals. Exceptions to the destination triage guidance are for extremely unstable patients or when there is no other option within specified transport times.

People in your community will benefit by having a participating hospital close by. They’ll know that if they go to your hospital, whether they are brought in by family or ambulance, that you’ll do the right thing for them. In some cases, that might mean immediately transferring them. In others, EMS might take them directly to another hospital if it means getting treatment that will save their lives and get them home faster.

You’ll be part of the statewide effort to increase access to quality emergency cardiac and stroke care through an organized system of care. Washington is the only state in the country to have a statewide system for cardiac and stroke care.

How will we know if the ECS System is successful?The 2010 legislation, codified in RCW 70.168.150, requires participating hospitals to “participate in internal, as well as regional, quality improvement activities.” It also requires “participation in a national, state, or local data collection system that measures cardiac and stroke system performance from patient onset of symptoms to treatment or intervention, and includes, at a minimum, the nationally recognized consensus measures for stroke.”

The legislation did not include authority or funding to establish a state data collection system. Together with our many partners in the ECS System, we have instead leveraged existing data collection resources and quality improvement initiatives to evaluate the system’s impact using existing indicators. Many hospitals are participating directly or indirectly in Get With the Guidelines for stroke (GWTG-S), the ACTION-Get With the Guidelines Registry (AR-G) for heart attack, and the Washington Cardiac Arrest Registry to Enhance Survival for cardiac arrest. The Department of Health can use aggregate reports from these sources to evaluate the ECS System. The law also amended the EMS and Trauma System law to expand the scope of the EMS and Trauma Regional Quality Improvement (QI) programs to allow protected discussion and evaluation of regional cardiac and stroke systems and care delivery. All of the Regional QI programs have incorporated cardiac and stroke evaluation to some degree. Participating hospitals should send their cardiac and stroke coordinators to these meetings along with the trauma coordinators.

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How long is the categorization period?Three years.

Can we change our categorization level? Yes, you can apply to change your level anytime. Request a current application from the department contact listed below.

What if we no longer want to participate in the system? You can withdraw at any time. Send written notice to the department contact listed below.

What if we no longer meet the categorization criteria?Notify the department as soon as your status changes, and send written notice to the department contact.

Department Contact:

Matt Nelson, 360-236-2816Matt.Nelson@doh.wa.govDepartment of HealthOffice of Community Health SystemsAttn: Matt NelsonPO Box 47853 Olympia, WA 98504-7853

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II. Application Process

To apply for categorization or re-categorization in the Washington State Emergency Cardiac and Stroke System as a Stroke Center:

1. Complete the application electronically. Complete one application per hospital. One application for multiple hospitals or campuses in a hospital system is not acceptable. A completed application includes:

Hospital and Personnel Profile Certification Statement Criteria Checklist Documentation Checklist Specified documentation. Documentation is only to demonstrate criteria are

met; the content will not be evaluated for clinical accuracy. We might request permission from you to use it for an example of best practices.

2. Print out the completed application on 8 ½ x 11 white paper, double-sided where possible.

3. Get the required signatures on the Certification Statement.

4. For initial categorization: put the application in a binder with labeled, tabbed dividers between each section: Profile, Certification, Checklist, and each type of documentation in the order specified on the Documentation Checklist. Make one copy. The copy does not need to be in a binder or tabbed.

5. For re-categorization: Print the required documents listed in Step 1.

6. Mail the completed application to:

Department of HealthOffice of Community Health SystemsAttn: Matt NelsonPO Box 47853Olympia, WA 98504-7853

Street address (for FedEx, UPS, etc.): 111 Israel Road SETumwater, WA 98501

We will review your application for completeness and confirm your categorization or re-categorization in writing or contact you if we have questions within 60 days. We’ll call the contact person listed on the Hospital Profile for questions.

Questions? Please call or email Matt Nelson 360-236-2816, Matt.Nelson@doh.wa.gov.

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Thank you for participating in the Emergency Cardiac and Stroke System and being a part of the statewide effort to ensure all Washington citizens have access to quality acute stroke care.

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III. Application for Level I Stroke Center Categorization

A. Hospital and Personnel Profile

Hospital Name:      EMS/Trauma Region*:      Mailing Address:       City:       Zip:      Physical Address:       City:       Zip:      Phone:       County:      Application Contact and Title:      Phone:       Email:      

Hospital Administrator/CEO:      Phone:       Email:      Stroke Program Medical Director:      Phone:       Email:      Stroke Coordinator:      Phone:       Email:      ED Medical Director:      Phone:       Email:      ED Nursing Director:      Phone:       Email:      

*EMS/Trauma Region KeyRegion: Includes the following counties: Contact name - email:Central King Rachel Cory – rachelcory@comcast.netEast Ferry, Stevens, Pend Oreille, Lincoln,

Spokane, Adams, Whitman, Asotin, Garfield

Rinita Cook - Rcook@ncecc.org

North Whatcom, Skagit, San Juan Island, Snohomish

Martina Nicolas - martina@northregionems.com

North Central Okanogan, Chelan, Douglas, Grant Rinita Cook - Rcook@ncecc.orgNorth West Clallam, Jefferson, Kitsap, Mason Rene Perret - rene@nwrems.orgSouth Central Yakima, Kittitas, Benton, Franklin,

Walla Walla, ColumbiaZita Wiltgen - zitawiltgen@screms.org

Southwest Wahkiakum, Cowlitz, Clark, Skamania, Klickitat, South Pacific

Zita Wiltgen - swems@comcast.net

West Pierce, Thurston, Lewis, Grays Harbor, North Pacific

Anne Benoist – anne@wrems.com

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B. Certification Statement

I,       (CEO/COO), on behalf of       (hospital), voluntarily agree to participate in the Washington State Emergency Cardiac and Stroke System as a Level I Stroke Center. Our hospital is committed to improving emergency response and treatment of stroke. We will work with emergency medical services and other hospitals in our area to streamline triage and transport of stroke patients and participate in regional quality improvement activities, as available.

I certify that:

A. The information and documentation provided in this application is true and accurate.

B1. This hospital meets the criteria to be categorized as a Level I Stroke Center as defined in the criteria checklist, and provides these services 24/7.

-OR-

B2. This hospital is certified as a Comprehensive Stroke Center by one of these national accrediting organizations (check one):

Joint Commission; Certification period:      

DNV Healthcare Inc.; Certification period:      

HFAP; Certification period:      

C. We will participate in a national, state, or local data collection system that measures cardiac and stroke system performance from patient onset of symptoms to treatment or intervention, as required by RCW 70.168.150.

D. We will notify the Department of Health immediately if we are unable to provide the level of stroke service we’ve committed to in this application.

Chair, Governing Entity (Hospital Board) Date

Chief Executive Officer Date

Stroke Program Medical Director Date

Stroke Program Coordinator Date

Emergency Department Medical Director Date

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested PersonnelStroke Program Medical DirectorMust be a physician. A neurologist or clinician with significant experience in diagnosing and treating cerebrovascular disease is strongly recommended.Stroke Program Coordinator List of stroke coordinator responsibilities Acute stroke team, as designated by the stroke center medical director, available 24 hours a day, seven days a week within 15 minutes. Acute stroke team means the team of physicians and nurses who respond within 15 minutes to assess and treat acute stroke.

Description of the acute stroke team. If there is a separate “core” stroke team, describe both teams and their roles in the stroke program.

Emergency Department personnel trained in diagnosing and treating acute stroke Neurologist available 24 hours a day, seven days a week: on-site within 20 minutes of notification of patient’s arrival; or by telemedicine (e.g., phone, video-conference) within 20 minutes of notification of patient’s arrival and on-site within 45 minutes if needed.Neurosurgeon on-site w/in 30 minutes of notification of patient’s arrival 24 hours a day, seven days a weekBoard-certified vascular neurologist; or ABPN-certified neurologist who has completed 12 months of formal training in vascular neurology, or who devotes a minimum of 25% of practice time to vascular neurologyVascular surgeonNeuroradiologyInterventional/endovascular physician(s)Critical care medicine or neurocritical care physiciansPhysical medicine and rehabilitation physicianStaff (in-person or remotely) to read CT/MRI within 45 minutes of arrival 24 hours a day, seven days a week. Diagnostic radiologyPhysical therapy Occupational therapySpeech therapy

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested Staff stroke nurses(s)Radiologic Technologist with post-primary pathway certification in CTDiagnostic CapabilitiesECG and Chest X-ray CT or MRI performance w/in 25 minutes of order 24 hours a day, seven days a week. CT or MRI completed and results reported to stroke team within 45 minutes of order 24 hours a day, seven days a week. MRI with diffusionMR angiography/MR venographyCT AngiographyDigital cerebral angiographyTranscranial doppler Transesophageal echoCarotid artery imaging Intracranial and extracranial vascular imaging Interventional and Surgical TherapiesIV thrombolytic therapyIA thrombolytic therapy Carotid endarterectomyTreatment of intracranial aneurysmPlacement of intracranial pressure transducerPlacement of ventriculostomyHematoma removal/drainingEndovascular ablation of intracranial aneurysms/arterial venous malformationsEndovascular Rx of vasospasmStenting/angioplasty of extracranial vessels or referral mechanism/protocolStenting/angioplasty of intracranial vessels or referral mechanism/protocolInfrastructureWritten stroke protocols/order sets/procedures/algorithms for assessment and treatment of ischemic and hemorrhagic strokes, which include:

Stroke protocols/order sets, procedures/algorithms, etc. for each action

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested -stroke team activation process (from prehospital notification and for “walk-ins”)-initial diagnostic tests (e.g., FAST screen at triage, NIH stroke scale, CT)-administration of medications (e.g., t-PA)-swallowing assessment prior to oral intake

or process listed.

Transfer protocols or guidelines that include criteria specific to transferring stroke patients, although there should be no reason to transfer stroke patients from a Level I other than disasters, equipment failure, or severe staffing shortage.

Transfer protocols according to criterion. General EMTALA transfer protocols or guidelines that don’t specifically address stroke transfers are not adequate documentation.

Stroke unit. Practitioners working in the stroke unit demonstrate evidence of initial and ongoing training in the care of acute stroke patients. Stroke units may be defined and implemented in a variety of ways. The stroke unit does not have to be a specific enclosed area, but will be a specified unit to which most stroke patients are admitted (Joint Commission). Refer to the 2014 Guidelines for the Early Management of Patients with Acute Ischemic Stroke for further guidance on stroke units.

Description of stroke unit, including staffing, operation, admission/discharge, care protocols, census, and outcome data.

Organizational/administration supportCoordination with Emergency Medical Services, e.g., working with county EMS councils, regional councils, or medical program directors on cardiac care and transport policy and procedures, system activation, training, data collection, and quality improvement.

Description of how you work with EMS in your community, e.g., attendance at county and/or regional EMS council meetings, copies of county EMS stroke patient care procedures, joint training, etc.

Laboratory or point of care testing 24 hours a day, seven days a week and results within 45 minutes Intensive care unit 24 hours a day, seven days a weekOperating room coverage 24 hours a day, seven days a week and ready within 2 hours of notificationInterventional services coverage 24 hours a day, seven days a weekStroke clinicPhysical therapyOccupational therapySpeech therapyProvides community/regional resources for guidance and recommendations

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested Training and EducationMinimum of 8 hours education (preferably CME/CNE) per year related to cerebrovascular disease for stroke team. The stroke team means the staff designated as the stroke team by the stroke medical director. This may be a “core” stroke team different from the acute stroke team of physicians and nurses who respond within 15 minutes to assess and treat acute stroke. Actively participate in professional educationStroke-related education for emergency department personnel involved in stroke diagnosis and treatment to ensure competence, as determined appropriate by the stroke medical director. Public education at least once per year on stroke-related topics such as prevention, risk factors, signs and symptoms, and the importance of getting treatment right away and calling 911. Education could be provided through hospital newsletters, pamphlets, videos in the hospital or other places, public service announcements, newspaper articles, billboards, etc. See Appendix C for resources and the Stroke Education Toolkit on the ECS System website.

Example from previous year

Patient education on stroke (e.g., signs and symptoms, importance of calling 911, prevention, post-stroke care, etc.)

Copy of stroke patient education

Performance Measurement and Quality ImprovementInternal Stroke Care Quality Improvement (QI) Provide a description of your stroke QI

activities. This should include: The type and source of data used to

guide the process (e.g., internal or external patient data registries).

Participants in the internal QI process (preferably a multi-disciplinary group).

The process, e.g., monthly meetings with case reviews, data presentations, PDSA’s, root cause analysis, etc.

An example of a stroke case reviewed during the previous categorization period. Please include a summary of the

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested case, the issue identified, discussion and conclusion, action plan developed to address deficiencies or improve processes, evaluation of the action plan and issue resolution (loop closure). The example may be a system issue, a physician or nursing practice issue or an unfavorable patient outcome. Please mark as confidential, and remove all patient and practitioner identifiers.

Participation in regional quality improvement activities. The ECS law amended RCW 70.168.090(2) to allow existing regional EMS and trauma quality assurance (QA) programs to evaluate cardiac and stroke care delivery in addition to trauma care delivery.

Description of participation in regional QI activities.

Participation in a national, state, or local data collection system that measures stroke system performance from patient onset of symptoms to treatment or intervention,2 and includes, at a minimum, the nationally recognized consensus measures for stroke. See Appendix B for consensus measures and acceptable data collection systems.

Documentation or description of data collection system that measures stroke system performance from patient onset of symptoms to treatment or intervention, and includes the nationally recognized consensus measures for stroke. If you use Get With the Guidelines for stroke, a copy of your participation agreement will suffice. Whichever data collection tool you use, you should be able to collect, measure, and use for quality improvement, the following data elements and indicators:

Percent of stroke patients who arrive

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested by EMS

Percent of stroke patients with pre-arrival notification from EMS

Average door to needle time Number and percent of ischemic

stroke patients eligible for t-PA who get treated (STK-4)

Percent t-PA administered within 60 minutes of arrival

Percent transferred/admitted Discharge disposition: percent of

patients discharged to home, home with home health/hospice, SNF

National Stroke Inpatient Quality Measures for admitted patients

o Venous thromboembolism (VTE) prophylaxis

o Discharged on antithrombotic therapy

o Anticoagulation therapy for atrial fibrillation/flutter

o Thrombolytic therapy o Antithrombotic therapy by

end of hospital day 2 o Discharged on statin

medicationo Stroke education o Assessed for rehabilitation

Evaluation of performance on treating stroke according to current guidelines.Brain Attack Coalition Guidelines

Documentation or description of how you evaluate adherence to stroke guidelines.

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C. Stroke Center Level I Criteria ChecklistClick on the box in the “Met” column to indicate your hospital meets the criterion. Documentation or a description of how you’ll meet the criteria is requested only if noted.

Participation Criteria for Level I Stroke Center Categorization Met Documentation Requested 2009 Science Advisory expanding the window for treatment from 3 to 4.5 hours Measurement of performance on at least two relevant patient care benchmarks each year. Documentation of patient care benchmarks

measured in the previous year.

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D. Documentation Checklist Please arrange the documentation in the order specified and place a tabbed, labeled, divider between each.

List of stroke coordinator responsibilities.

Description of the acute stroke team. If there is a separate “core” stroke team, describe both teams and their roles in the stroke program.

Written stroke protocols: stroke team activation process (from prehospital notification and for walk-ins) order set(s) (may be called protocols or procedures) for assessment and treatment of

ischemic and hemorrhagic strokes initial diagnostic tests (e.g., FAST screen at triage, NIH stroke scale, CT) administration of medications (e.g., t-PA) swallowing assessment prior to oral intake

Transfer protocols or guidelines specific to stroke patients, although there should be no reason to transfer stroke patients from a Level I other than disasters, equipment failure, or severe staffing shortage. General EMTALA transfer protocols or guidelines that don’t specifically address stroke transfers are not adequate documentation.

Description of stroke unit, including staffing, training, operation, admission/discharge, care protocols, census, and outcome data.

Coordination with EMS. Description of how you work with EMS in your community, e.g., participation in county and/or regional EMS council meetings, copies of county EMS stroke patient care procedures, joint training, etc.

Example of public education materials/messaging on stroke from previous year.

Example of stroke patient education

Description of your stroke QI activities. This should include:

The type and source of data used to guide the process (e.g., internal or external patient data registries).

Participants in the internal QI process (preferably a multi-disciplinary group). The process, e.g., monthly meetings with case reviews, data presentations, PDSA’s, root

cause analysis, etc. An example of a stroke case reviewed during the previous categorization period. Please

include a summary of the case, the issue identified, discussion and conclusion, action plan developed to address deficiencies or improve processes, evaluation of the action

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plan and issue resolution (loop closure). The example may be a system issue, a physician or nursing practice issue or an unfavorable patient outcome. Please mark as confidential, and remove all patient and practitioner identifiers.

Documentation or description of data collection system that measures stroke system performance from patient onset of symptoms to treatment or intervention, and includes the nationally recognized consensus measures for stroke. If you use Get With the Guidelines for stroke, a copy of your participation agreement will suffice. Whichever data collection tool you use, you should be able to collect, measure, and use for quality improvement, the following data elements and indicators:

Percent of stroke patients who arrive by EMS Percent of stroke patients with pre-arrival notification from EMS Average door to needle time Number and percent of ischemic stroke patients eligible for t-PA who get treated (STK-4) Percent t-PA administered within 60 minutes of arrival Percent transferred/admitted Discharge disposition: percent of patients discharged to home, home with home

health/hospice, SNF National Stroke Inpatient Quality Measures for admitted patients

o Venous thromboembolism (VTE) prophylaxis o Discharged on antithrombotic therapy o Anticoagulation therapy for atrial fibrillation/flutter o Thrombolytic therapy o Antithrombotic therapy by end of hospital day 2 o Discharged on statin medicationo Stroke education o Assessed for rehabilitation

Documentation or description of how you evaluate adherence to stroke guidelines.

Documentation of two patient care benchmarks measured in the previous year.

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IV. Appendices

A. State of Washington Prehospital Stroke Triage Destination Procedure (web version is

clearer than appendix)

B. Data Collection and Quality Improvement Requirements

C. Resources

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APPENDIX A

The purpose of the Prehospital Stroke Triage and Destination Procedure is to identify stroke patients in the field and take them to the most appropriate hospital, which might not be the nearest hospital. Stroke treatment is time-critical – the sooner patients are treated, the better their chances of survival and recovering function.

For strokes caused by a blocked blood vessel in the brain (ischemic, the majority of strokes), clot-busting medication (tPA) must be administered within 4.5 hours from the time the patient was last known well, a treatment that can be given at Washington DOH Level 1, 2 or 3 stroke centers (see a list of categorized hospitals here).

Patients who present to EMS with a severe stroke are more likely to have blockage of a large vessel and can benefit from mechanical clot retrieval (thrombectomy). Thrombectomy must begin by 6 hours since last known well, and is a more complex intervention, available only in Level I and a small number of Level II stroke centers.

There are 3 key elements to determine the appropriate destination hospital:

FAST stroke screen to identify a patient with a high probability of stroke. Stroke Severity Score to determine if a patient meets criteria for “severe” stroke. Time since Last Known Well (LKW) which helps determine eligibility for tPA and thrombectomy.

STEPS to determine destination:

1) Do a FAST Stroke Screen Assessment: (Facial droop, Arm drift, Speech changes, Time since LKW) is a simple way to tell if someone might be having a stroke. If FAST is negative, stroke is less likely, and standard destination procedures apply. If FAST is positive (face or arms or speech is abnormal), it’s likely the patient is having a stroke, and the EMS provider moves on to assessing stroke severity.

2) Assess severity: The stroke severity assessment scores the FAST stroke screen. Patients get points for deficits:

Facial droop gets 1 point if present, 0 points if absent;

Arm drift (have patient hold arms up in air) gets 2 points if an arm falls rapidly, 1 point if slowly drifts down and 0 points if the arms stay steady;

Grip strength gets 2 points if no real effort can be made, 1 point if grip is clearly there but weak, and 0 points if grips seem of full strength.

3) Add up the points: A score > 4 is interpreted as “severe.”

4) Determine time since LKW: Use the LKW time as opposed to when symptoms were first noticed. For patients who woke up in the morning with symptoms and were well when they went to bed, time LKW is the time they went to bed. If stroke symptoms occur when the patient is awake, LKW could be the same time the symptoms started if the patient or a bystander noticed the onset. LKW time could also be before symptoms starting if a patient delays reporting symptoms or, for example, someone discovers a patient with symptoms but saw the person well 2 hours earlier.

5) Determine Destination:

Time since LKW < 6 hours and “Severe” (score > 4): this group benefits from preferential transport to a thrombectomy stroke center. The patient should be taken directly to the nearest thrombectomy stroke center provided it is no more than 15 extra minutes travel compared to the nearest stroke center.

Time since LKW < 6 hours but NOT “Severe” or Time since LKW > 6 hours (regardless of severity): these patients should be taken directly to the nearest Level 1 or Level 2 stroke center provided it is no more than 15 extra minutes travel compared to a nearer Level 3 stroke center.

6) Notification: Immediately notify the destination hospital of incoming stroke. If the patient is within 6 hours LKW, call a stroke alert according to county operating procedures or locally determined protocol.

7) Document: key medical history, medication list and next of kin phone contacts; time on scene; FAST assessment completed and results (or reason why not); blood glucose level; LKW time (including unknown); and whether the hospital was notified from the field and if it was a stroke alert.

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Appendix B. Data Collection and Reporting Requirements

The Emergency Cardiac and Stroke System (ECS) law requires participating hospitals to “participate in a national, state or local data collection system that measures cardiac and stroke system performance from patient onset of symptoms to treatment or intervention.” These data cover time intervals and processes along the continuum of care for the acute event: onset of symptomsdispatchEMStransfer hospitaltreating hospitalinterventionoutcome.

By checking how well the system works along the entire continuum of care, we’ll find where the delays or obstacles are and target improvements where they’re needed. A recent study suggests that monitoring performance and participating in a quality improvement program that includes recognition is better at identifying hospitals providing timely and appropriate stroke care than stroke center certification.

Reporting to the Department of Health is not required. As noted in the introductory section of this application, the department was not funded for centralized data collection and analysis. We will get aggregate reports from Get With the Guidelines for Stroke, COAP, and Pacific Northwest CARES to get a state level view of ECS System performance.

To measure how well the ECS System achieves the goals of reducing time to treatment and improving stroke outcomes without adding significant burden to hospitals, the ECS Technical Advisory Committee recommended a small set of data elements and measures that are generally consistent with national measures and registries. Data collection systems/registries used by hospitals and regional systems should, at a minimum, be able to collect, analyze, and trend:

Percent of stroke patients who arrive by EMS Percent of stroke patients with pre-arrival notification from EMS Average door to needle time Number and percent of ischemic stroke patients eligible for t-PA who get treated (STK-4) Percent t-PA administered within 60 minutes of arrival Percent transferred/admitted Discharge disposition: percent of patients discharged to home, home with home

health/hospice, SNF National Stroke Inpatient Quality Measures for admitted patients

o Venous thromboembolism (VTE) prophylaxis o Discharged on antithrombotic therapy o Anticoagulation therapy for atrial fibrillation/flutter o Thrombolytic therapy o Antithrombotic therapy by end of hospital day 2 o Discharged on statin medicationo Stroke education o Assessed for rehabilitation

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APPENDIX B

The data collection tools or registries that meet these recommendations include:

NationalGet With the Guidelines – Stroke. This QI program and patient management tool is the most comprehensive off-the-shelf data collection system available for stroke. In addition to core measures, GWTG measures time from onset, mode of arrival, advance notification from EMS, transfer status, and discharge status. This option is the most comprehensive, it’s used nationally, and it comes closest to meeting the requirements in the law. In 2013, nearly 60 hospitals in WA used GWTG-Stroke. We’re hoping they will re-enroll for 2014.

StateThere is no state stroke registry available at this time.

Local (For Level III only) Participation in data collection for a regional stroke system of care. For example, the

Level III is a referral hospital for a Level I or II Stroke Center and transfers most of their stroke patients to the Level I or II, or participates in a telestroke system. The lower level stroke center provides the necessary process data (e.g., time of symptom onset, time of arrival at hospital, time of t-PA administration) to the Level I or II Stroke Center to which the patient was transferred. The Level I or II Stroke Center includes the patient in their data collection system.

If a Level III is not transferring stroke patients, and doesn’t participate in Get With the Guidelines for Stroke, it must track the CMS core stroke measures at a minimum. This could be done using an internal registry or database where patient data is collected and used to evaluate process and outcomes for quality improvement purposes. Monitoring performance on these measures would then be used in the required stroke quality improvement. Including the onset to treatment and outcomes measures recommended by the ECS TAC (above) is strongly encouraged to improve the local system of care from onset to treatment and rehabilitation.

Other data collection systems not listed here may also meet the reporting requirement. To determine whether a data collection system meets the requirement or for any other questions about cardiac data collection systems, please contact Matt Nelson, 360-236-2816, Matt.Nelson@doh.wa.gov.

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Appendix C. Resources

Stroke Systems of CareWashington State Emergency Cardiac and Stroke System

Recommendations for the Establishment of Stroke Systems of Care

Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care

A Policy Statement From the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council

Stroke Treatment GuidelinesGuidelines for the Early Management of Acute Ischemic Stroke 2009 Science Advisory expanding the window for treatment from 3 to 4.5 hours

National Guidelines Clearinghouse

Brain Attack Coalition Guidelines

Multifocus Stroke Websites (Assessment, Treatment, Sample Protocols and Orders, Training, Conferences, Public Education, Prevention, etc.)Target: Stroke

Brain Attack Coalition

American Stroke Association

National Stroke Association

National Institute for Neurological Disorders and Stroke

NIH Stroke Scale - Training DVD

Washington State Heart Disease and Stroke Prevention Program

Public Education

Stroke Education Toolkit

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

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APPENDIX C