Minnesota Stroke System Toolkit 140116

Toolkit

Minnesota

Stroke System

Hospital Designation

Minnesota Stroke System Toolkit (1/16/2014)

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Table of Contents Background ................................................................................................................................................... 3 Definitions ..................................................................................................................................................... 3 Designation Process ...................................................................................................................................... 4 Special Notes ................................................................................................................................................. 5 Criteria for Acute Stroke Ready Hospital Designation .................................................................................. 9

1. An acute stroke team available or on-call 24 hours a day, seven days a week. ................................. 10 2. Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications. ................................................................................................................................. 11 3. A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures. ........................................... 12 4. Emergency department personnel who are trained in diagnosing and treating acute stroke. ......... 13 5. The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week. ......................................................................................................................... 14 6. The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week. ...................................................................................................................................................... 15 7. Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually. ............... 16 8. A neurosurgery coverage plan, call schedule, and a triage and transportation plan......................... 17 9. Transfer protocols and agreements for stroke patients. ................................................................... 18 10. A designated medical director with experience and expertise in acute stroke care. ...................... 19

Checklist of Criteria and Documentation Required .................................................................................... 20 Minnesota Stroke System Contacts ............................................................................................................ 22 Appendices for Acute Stroke Ready Hospital Designation Criteria ............................................................ 23

Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Criterion 1) ............................................................................................................................................ 24 Appendix B: Example Stroke Code Algorithm (Criterion 2) .................................................................... 25 Appendix C: Example Stroke Code Evaluation Protocol (Criterion 2) .................................................... 26 Appendix D: Example EMS Stroke Protocol (Criterion 3) ....................................................................... 29 Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement (Criterion 3) ... 31 Appendix F: Example Letter Attesting Training of ED Personnel (Criterion 4) ....................................... 32 Appendix G: Training Resources for ED Personnel (Criterion 4) ............................................................ 33 Appendix H: Example Diagnostic Capability Scope of Service (Criterion 5) ........................................... 34 Appendix I: Example Brain Imaging Interpretation Capability Scope of Service (Criterion 6) ............... 38 Appendix J: Example ED Order Set for Administering tPA (Criterion 7) ................................................. 40 Appendix K: Example Hemorrhagic Stroke Conversion from tPA Protocol (Criterion 7) ....................... 48 Appendix L: Example Allergic Reaction to tPA Protocol (Criterion 7) .................................................... 49 Appendix M: Hospitals with Neurosurgery Services in Minnesota and Bordering States (Criterion 8) . 50 Appendix N: Example Neurosurgery Scope of Service (Criterion 8) ....................................................... 52 Appendix O: Example MOA with a Hospital that has Neurosurgery Services (Criterion 8) ................... 54 Appendix P: Example Transfer Protocol with a Primary Stroke Center (Criterion 9) ............................. 55 Appendix Q: Example Letter Attesting a Designated Stroke Medical Director (Criterion 10)................ 56


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Background In 2013, the Minnesota Legislature authorized the Minnesota Department of Health (MDH) to designate

hospitals in Minnesota as “stroke hospitals.” A hospital that meets the criteria for a Comprehensive

Stroke Center (CSC), Primary Stroke Center (PSC), or Acute Stroke Ready Hospital (ASRH) may voluntarily

apply to the commissioner for designation, and upon MDH’s review and approval of the application,

shall be designated as a CSC, PSC, or an ASRH for a three-year period. Hospitals not designated by MDH,

The Joint Commission, or any other nationally recognized certification body may not use the term

“stroke center” or “stroke hospital” in its name or advertising, or shall otherwise indicate that it has

stroke treatment capabilities.

The stroke hospital designation process is the principal component of the Minnesota Stroke System. This

statewide stroke system and designation criteria were developed by the Minnesota Acute Stroke System

Council, convened by MDH and the American Heart Association (AHA) between March 2011 and

December 2012. This voluntary stakeholder group developed criteria and provided invaluable input into

the development of a statewide system that would be specific to Minnesota and meet the unique needs

of our state.

The designation process and thus the launch of the statewide stroke system is scheduled to begin in

2014. This manual serves as a toolkit for hospitals who wish to be designated and recognized by the

Minnesota Department of Health as Acute Stroke Ready Hospitals.

Definitions Acute Stroke Ready Hospitals

An Acute Stroke Ready Hospital has the infrastructure and capability to care for acute stroke, including

administration of intravenous thrombolytic therapy (also known as tissue plasminogen activator “tPA,”

or alteplase). An ASRH has fewer overall capabilities than a Primary Stroke Center, but has staff and

resources able to diagnose, stabilize, treat, and transfer most patients with stroke. Most acute stroke

patients may be transferred to a Comprehensive Stroke Center or Primary Stroke Center post-

treatment.


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Primary Stroke Centers

A Primary Stroke Center has the necessary staffing, infrastructure, and programs to stabilize and treat

most acute stroke patients. A PSC provides acute care to most patients with stroke, is able to provide

some acute therapies, and admit the patient to a stroke unit. The criteria for a PSC are based on the

2011 revised and updated recommendations statement from the Brain Attack Coalition (Alberts, 2011).

Additional functions of a PSC may be to act as a resource center for other facilities in their region. This

might include providing expertise about managing particular cases, offering guidance for triage of

patients, making diagnostic tests or treatments available to patients treated initially at an ASRH, and

being an educational resource for other hospitals and health care professionals in a city or region.

Comprehensive Stroke Centers

A Comprehensive Stroke Center (CSC) has the personnel, infrastructure, and expertise to diagnose and

treat stroke patients who require intensive medical and surgical care, specialized tests, or interventional

therapies. The types of patients who might use and benefit from a CSC include, but are not limited to,

patients with large ischemic strokes, hemorrhagic strokes (in particular patients with suspected

aneurysmal subarachnoid hemorrhage), those with strokes from unusual etiologies or requiring

specialized testing or therapies (e.g., endovascular, surgery) , and/or those requiring multispecialty

management. Additional functions of a CSC would be to act as a resource center for other facilities in

their region. This might include providing expertise about managing particular cases, offering guidance

for triage of patients, making diagnostic tests or treatments available to patients treated initially at a

PSC or ASRH, and being an educational resource for other hospitals and health care professionals in a

city or region. The criteria for a CSC are based on the 2005 Brain Attack Coalition paper on

Comprehensive Stroke Centers (Alberts, 2005).

Designation Process This application is filled out and submitted electronically through the Minnesota Stroke Registry Tool.

Click here: http://www.stroke.mn.gov/

Hospitals must assign a) a primary contact and b) a secondary contact for the designation application.

The primary contact is responsible for completing the application. This person must establish a

http://www.stroke.mn.gov/


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username and password from the facility administrator for the Minnesota Stroke Registry Tool in order

to complete the application. We require a secondary contact in case the primary contact is unavailable.

MDH will review the submitted application and notify the primary contact within 10 business days of the

application submission date if there are issues with completeness. The Minnesota Stroke System

Designation Committee will evaluate the application and notify the primary contact within 30 days if the

application is approved. Hospitals not meeting the designation criteria will receive notification and a

detailed description of how to respond.

Stroke hospital designation is valid for three years. Designation status must be renewed every three

years through reapplication.

Special Notes Primary Stroke Centers and Comprehensive Stroke Centers

Hospitals which are certified by a nationally-recognized accreditation organization as a Primary Stroke

Center or Comprehensive Stroke Center will be designated by the Minnesota Department of Health with

these same titles. These hospitals must still complete and submit an application to the Minnesota

Department of Health in order to receive their state designation.

Hospitals which are not certified by a nationally-recognized accreditation organization as either a

Primary Stroke Center or Comprehensive Stroke Center are only eligible to be designated by the

Minnesota Department of Health as an Acute Stroke Ready Hospital.

Site Surveys

A sample of designated hospitals will be surveyed every year for the purpose of providing an in-depth

assessment of the capacities and processes for designated Acute Stroke Ready Hospitals. These reviews

are intended to be supportive opportunities for technical assistance, are not meant to be punitive or

regulatory. Surveys will be scheduled well in advance to accommodate both the hospital’s and

reviewers’ schedules. Reviewers will be selected stroke experts based in Primary Stroke Centers or

Comprehensive Stroke Centers who will be able to provide input and insight on issues for which an ASRH

may need improvement. Site surveys will be completed in no more than one day.


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Updates to Agreements, Protocols, and Personnel

Midway through your designation period, a call for updates will be sent to all designated hospitals. This

will be your opportunity to update your hospital designation portfolio. The most current protocols,

written agreements, letters and other documentation which identify staffing requirements should be

submitted to the Minnesota Department of Health at this time.

Data Reporting

Tracking success of the Minnesota Stroke System is essential. Hospitals are currently required to report

data to the Minnesota Department of Health on two stroke patient care indicators, “Door-to-imaging

initiated <25 minutes” and “Time to intravenous thrombolytic therapy.” These indicators are reported

under the auspices of the Minnesota Statewide Quality Reporting and Measurement System (SQRMS),

as part of Minnesota’s 2008 Health Care Reform Act. These two measures will be used to track the

impact of the Minnesota Stroke System.

Hospitals are strongly encouraged to join the Minnesota Stroke Registry Program, a voluntary quality

improvement program of the Minnesota Department of Health. Minnesota participates in the national

CDC Paul Coverdell National Acute Stroke Program, in which additional stroke patient care data are

collected, reported, and used for addressing stroke performance improvement. In 2013, 47 acute care

hospitals in Minnesota were voluntarily participating in this important program. For information on how

to join this program, please contact [email protected].

At this time, no additional data will be required of hospitals or Emergency Medical Service (EMS)

agencies for participation in the Minnesota Stroke System.

mailto:[email protected]


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Performance Improvement

The criteria for Acute Stroke Ready Hospitals are not performance-based. Hospitals are not required, in

order to be designated as an ASRH, to meet time standards for procedures or treatments. The

designation criteria describe merely the capacities and formal processes that a hospital has established

to be able to diagnose and treat acute stroke patients.

Best practices in stroke care, however, are driven by meeting time standards. By meeting the criteria for

acute stroke readiness, your hospital will be in a strong position to meet these time-to-action goals.

These time goals have been published by the American Heart Association/American Stroke Association:

Acute Stroke Care Time Goals

Action Goal

Door to acute stroke team 15 minutes

Door to imaging (initiated) 25 minutes

Door to imaging (interpretation) 45 minutes (CT), 60 minutes (MRI)

Laboratory test results available 45 minutes (of when ordered)

Door to tPA administered* 60 minutes

Door to admission or transfer 3 hours**

Telemedicine*** link established Within 20 minutes (of when deemed necessary)

Availability of neurologist or other physician experienced in acute stroke diagnosis and treatment

Within 20 minutes (either on-site or via telemedicine***)

Availability of vascular neurosurgeon 30 minutes (CSC); 2 hours (PSC); 3 hours (ASRH)

*NQF-Endorsed Measure #1952 **This time goal (door to admission or transfer)is for patients treated with IV tPA. More rapid transfer is indicated for patients not eligible for IV therapy, but may be eligible for intra-arterial therapy. In general, delays in transfer should be avoided. ***Telemedicine may include either telephonic, video linkage, or both. Source: (Jauch et al., 2013). See Table 5 in this guideline. Please note: designation as an Acute Stroke Ready Hospital by the State of Minnesota is NOT contingent on meeting these time standards. These goals are provided here only as a reference for hospitals in their performance improvement efforts.


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Governance

Advisory Committee

The Minnesota Department of Health will appoint an advisory committee whose role will be to advise

the State on matters relating to the Minnesota Stroke System. This committee will monitor progress,

provide recommendations for implementation processes, and advise as needed. Members will be asked

to volunteer their time and expertise for two-year terms, which will be renewable. Every effort will be

made to convene a committee which will appropriately represent both rural and metropolitan areas,

multiple professional specialties, and health systems and organizations. This committee shall have no

greater than 20 members and will meet at least semi-annually.

Designation Review Committee

A smaller group of experts chosen by the Minnesota Department of Health will review and recommend

approval of hospitals for stroke hospital designation by the State. This group will comprise no more than

seven individuals and their role will be to review applications, provide feedback for areas of

improvement, and make recommendations to MDH for approval.

Working Groups

Small working groups will be convened by the Minnesota Department of Health and the American Heart

Association to address and work to implement specific components of the system. These working

groups (committees or task groups) will be time-bound and limited in scope. Their role will depend on

the subject at hand. We anticipate working groups to be formed around these topic areas:

- EMS training and protocol adoption

- Hospital Performance Improvement

- Provider Education

- Data Reporting and Evaluation


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Criteria for Acute Stroke Ready Hospital Designation


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1. An acute stroke team available or on-call 24 hours a day, seven days a week. Rationale: An acute stroke team (AST) is a key component of an Acute Stroke Ready Hospital. Studies have shown the importance of such a response team to provide organized care in a safe and efficient manner. The presence of an AST is an independent predictor of the ability to administer intravenous thrombolytic therapy and improve the outcomes of stroke patients. References: (Jauch et al., 2013), (Alberts et al., 2011), (Alberts et al., 2013). Requirements:

1. The AST may be staffed by a variety of healthcare personnel depending on the resources available at a particular facility, but should include a minimum of one nurse and one physician. Hospitals not staffed with an emergency department physician may assign a licensed independent practitioner (LIP) instead of a physician.

2. Members of the AST should be available and/or on-call 24 hours a day, seven days a week. 3. The existence and operations of the AST should be supported by a written document that provides

information about administrative support, staffing, notification plans, and care protocols. Recommendations, Allowances, and Notes:

1. Each member of the AST should have some training and expertise in acute stroke care. Examples might range from a nurse (or advanced practice nurse) with prior experience in a neuroscience ICU, an emergency department nurse who has completed continuing education units (CEU)/CME in areas of acute stroke care, and physicians who have attended regional or national courses in areas of acute stroke care.

2. The AST is primarily responsible for responding in the emergent setting to patients with an acute stroke, and initiating diagnostic testing and immediate care, not ongoing in-hospital care.

3. Different members may rotate on the team depending on staffing levels and patient needs. 4. Physician expertise in stroke can be provided via a telemedicine link with another facility, but if this is

done, there should be at least one physician on site to supervise patient care, order medications, and manage other emergent issues.

5. Although the AST does not have to be led by or include a neurologist or neurosurgeon, it is recommended that the AST include personnel with experience and expertise in areas of cerebrovascular disease.

6. The AST should respond to suspected acute stroke patients who are in the emergency department OR in-hospital.

7. While their presence in the hospital is preferred, critical members of the AST may reside outside of the hospital as long as they can be at the bedside within 15 minutes of being called.

8. If locum tenens are used as emergency department providers, the names of these providers are not required in your documentation.

9. In all cases, the hospital’s disciplines and departments, which will be available 24/7 to respond to an AST activation, should be listed.

10. The hospital should support the development of a call-log for the AST that captures key data points such as the number of AST activations, response times, and patient diagnosis, treatments and/or disposition. A worksheet for “real time” collection of response times may be helpful in collecting these data.

Documentation Requirements: A letter on hospital letterhead signed by the CEO or chief medical officer listing the position titles of the members on the acute stroke team. Appendices: Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Pg. 24)


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2. Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications. Rationale: A written stroke protocol is essential to ensure that all stroke patients receive organized care in a safe and efficient manner. A written protocol also ensures that important care elements are not omitted, and that prohibited medications or treatments are not administered. References: (Jauch et al., 2013), (Alberts et al., 2011), (Alberts et al., 2013). Requirements:

1. A written protocol should include standardized order sets that deal with aspects of acute diagnosis, such as checks of vital signs and neurologic function, blood work, and brain imaging studies.

2. These protocols should encompass care in the ED as well as in-hospital. Separate protocols for ED and inpatient are acceptable. Protocols should be developed by a multidisciplinary team and reviewed, and if necessary revised at least once a year to reflect changes in medical knowledge, care standards, and guidelines.

3. At a minimum, a written protocol for ischemic stroke must be submitted. Recommendations, Allowances, and Notes:

1. The protocols can be paper-based or computer-based, depending on the standard practice at a specific facility. If computer-based, a paper-version must be submitted to the Minnesota Department of Health.

2. Written protocols should ideally address all types of strokes (i.e., ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage). However, the minimum requirement for Acute Stroke Ready Hospital designation is a written protocol for ischemic stroke only.

Documentation Requirements: All stroke protocols that are used for triage and treatment of acute stroke patients in the emergency department. Appendices: Appendix B: Example Stroke Code Algorithm (Pg. 25) Appendix C: Example Stroke Code Evaluation Protocol (Pg. 26-28)


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3. A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures. Rationale: In most settings, a patient with a stroke is taken to the hospital by EMS personnel. The ability of EMS personnel to recognize patients with a possible stroke, communicate their findings to the receiving hospital, and stabilize and transport such patients is a key element of an Acute Stroke Ready Hospital. Data from recent studies have shown that EMS communication and notification to the ED that a potential stroke patient is en-route can shorten door-to-imaging and door-to-needle times, both of which are key parameters in receiving IV TPA therapy. References: (Jauch et al., 2013), (Acker et al., 2007), (Alberts et al., 2013). Requirements:

1. The written plan or EMS stroke protocol should detail how patients with a suspected stroke will be triaged and routed to the most appropriate hospital.

2. The written plan should include a plan for notification to the hospital emergency department when a suspected stroke patient is being transported.

3. The written plan should detail assessments and interventions to be performed. Recommendations, Allowances, and Notes:

1. EMS personnel should have specific training in the recognition of possible stroke patients, including the use of an accepted field assessment tool (e.g., Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen (LAPSS)). Training in such stroke protocols should ideally occur at least annually with a minimum educational exposure of two hours per year if possible, or as often as indicated by protocol updates. We recommend that the Acute Stroke Ready Hospital provide or facilitate access to this type of training to their local EMS agencies.

2. Key elements of a written plan include documenting assessment of stroke symptoms (e.g., Cincinnati Prehospital Stroke Scale findings), the time of symptom onset (the clock-time of the time last known to be well), the use of concomitant medications, and other major medical conditions.

3. Identifying timing goals for on-scene time and transport, as well as identifying interventions that can aid in timely thrombolytic therapy is recommended.

Documentation Requirements:

1. A written plan or protocol for the primary EMS agency that transports to your facility. 2. A letter on hospital letterhead co-signed by the hospital’s primary EMS agency and the hospital CEO or

chief medical officer acknowledging a triage and transportation agreement for potential stroke patients. Appendices: Appendix D: Example EMS Stroke Protocol (Pg. 29-30) Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement (Pg. 31)


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4. Emergency department personnel who are trained in diagnosing and treating acute stroke. Rationale: Most patients with acute stroke will enter the ASRH through the emergency department. It is essential for emergency department providers have protocols for the acute diagnosis, stabilization, monitoring and treatment of stroke patients. Staying up to date on current guidelines of care is vitally important in order to ensure proper care for all patients can be given. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. Emergency department personnel should have education annually and as needed to ensure staff are aware of protocol updates related to the care of patients with cerebrovascular disease.

Recommendations, Allowances, and Notes:

1. We have purposely omitted a specific number of hours required because we understand that this is a very difficult criterion to meet. In addition, we acknowledge that ensuring locums meet this requirement is nearly impossible. Therefore, the key part of this requirement is that the hospital should ensure key staff is knowledgeable of current acute stroke treatment protocols.

2. This requirement might be met in a variety of ways, including on-line continuing education units (CEU)/CME, attendance at grand rounds, lunch-time lectures, regional and national meetings, and various educational courses.

3. For hospitals with a very low volume of stroke patients, consideration should be given to running mock ‘stroke codes’ with various clinical scenarios. This might serve to keep personnel and protocols up-to-date with current stroke care guidelines, refresh their memory, and address logistical issues that could affect stroke care.

Documentation Requirements: A letter on hospital letterhead signed by the CEO or chief medical officer attesting that at least one staff provider per shift has received training in current stroke diagnosis and treatment guidelines. Appendices: Appendix F: Example Letter Attesting Training of ED Personnel (Pg. 32) Appendix G: Training Resources for ED Personnel (Pg. 33)


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5. The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week. Rationale: The ability to perform and complete basic laboratory testing on patients with a stroke is essential for diagnosing metabolic and infectious disorders that can masquerade as a stroke syndrome, to ensure stroke patients can be treated with the proper acute medications, and to determine the possible etiology of some types of stroke. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. Ability to complete basic lab tests, electrocardiogram, and a chest x-ray at all times (24 hours a day, seven days a week).


1. Basic tests such as a complete blood count, chemistries, coagulation studies, pregnancy test, EKG, and a chest x-ray must be available 24/7.

2. These basic tests are not mandatory to be conducted on all patients, and only need to be performed under specific circumstances. Please consult the 2013 American Heart Association guidelines for details.

3. More advanced testing in the ED such as a toxicology screen might be helpful in some cases. 4. An ASRH should be able to complete basic laboratory tests, an EKG, and chest x-ray (if needed) within 45 minutes

of them being ordered. Documentation Requirements: A “Scope of Service” OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. Appendices: Appendix H: Example Diagnostic Capability Scope of Service (Pg. 34-37)


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6. The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week. Rationale: Brain imaging confirms the absence of contraindications to thrombolytic therapy and may help diagnose hemorrhagic stroke. This is an essential function of an Acute Stroke Ready Hospital. In most cases, the first (and perhaps only) imaging study readily available will be a non-contrast head CT scan. This type of scan is usually sufficient to rule-out other conditions that could present with stroke-like symptoms such as a hemorrhagic stroke, large abscess, or tumor. When performed acutely, a head CT will often be either negative or show only subtle changes in cases of ischemic stroke, especially if the stroke is small or very acute. A head CT is very sensitive and accurate for the diagnosis of most types of hemorrhagic stroke (i.e., intracerebral hemorrhage or subarachnoid hemorrhage). References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. Acute brain imaging capabilities and interpretation services must be available on a 24/7 basis. 2. Personnel interpreting such scans should be board-certified radiologists with experience and expertise in reading

head CTs and brain MRIs. Recommendations, Allowances, and Notes:

1. Reading may be performed by on-site personnel or via a tele-radiology process. 2. It is recommended that brain imaging with a non-contrast head CT or MRI be performed and read within

45 and 60 minutes (respectively) of it being ordered.

Documentation Requirements: A “Scope of Service” OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation. Appendices: Appendix I: Example Brain Imaging Interpretation Capability Scope of Service (Pg. 38-39)


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7. Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually. Rationale: An ASRH should be able to deliver several acute therapies that can improve outcomes for patients with a variety of strokes. In addition, the stroke-ready hospital should have an organized set of protocols to address various clinical presentations and complications which may arise in acute stroke patients. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. Protocol for the diagnostic work-up, intervention (including alteplase dosing and administration guidelines), and patient monitoring required for IV thrombolytic therapy.

2. Guidelines for identification of contraindications to thrombolytic therapy and blood pressure management prior to and during IV thrombolytic therapy. This may be a part of OR adjunct to the protocol.


1. Protocols should be reviewed and updated at least annually using current published care guidelines from organizations such as the American Heart Association, the American Academy of Neurology, the Congress of Neurosurgeons, as well as other organizations.

2. In some cases, the use of telemedicine/telestroke and related technologies will aid the treating clinicians and help guide therapy.

3. The hospital should consider developing performance indicators for therapies and protocols. 4. The protocol should specific performance measures. To that end, it is strongly recommended that timing

goals be identified for key elements of assessment, work-up, and treatment. Examples:

1. Intravenous tPA protocol for acute ischemic stroke 2. Ischemic to hemorrhagic stroke conversion, post-tPA infusion 3. Measures to reverse coagulopathies in patients with hemorrhagic strokes 4. Development of symptomatic systemic bleeding 5. Development of allergic reaction to tPA (angioedema) 6. Assessment of initial neurological function and stroke severity 7. Control or reduction of elevated intracranial pressures in appropriate patients 8. Control of seizures 9. Treatment of blood pressures (too high or too low) 10. Stabilization of other vital functions or metabolic derangements

Documentation Requirements: A protocol that addresses at least one emergent therapy listed above.

Appendices: Appendix J: Example ED Order Set for Administering tPA (Pg. 40-47) Appendix K: Example Hemorrhagic Stroke Conversion from tPA Protocol (Pg. 48) Appendix L: Example Allergic Reaction to tPA Protocol (Pg. 49)


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8. A neurosurgery coverage plan, call schedule, and a triage and transportation plan. Rationale: Some patients who present to an Acute Stroke Ready Hospital will need acute or eventual neurosurgical evaluation and treatment, particularly those with large ischemic strokes, cerebellar strokes, intracerebral hemorrhages, or subarachnoid hemorrhages. A neurosurgeon may not be readily available in many cases. A plan for addressing potential neurosurgery cases will ensure an organized and timely transfer of care for this type of stroke patient. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. Written agreement between the ASRH and at least one hospital that has neurosurgery coverage consistent with the Primary Stroke Center or Comprehensive Stroke Center recommendations.

2. Written neurosurgery call schedule and a clear triage and transportation plan for those patients in need of acute neurosurgical services.


1. This is an area where tele-radiology and urgent transfer of patients after they are stabilized would be most appropriate and effective.

2. Considering the remote locations of some ASRHs, and other logistical challenges with emergent transfer, we recommend that neurosurgical services be available to such patients within three hours (by ground transport) of when it is deemed necessary.

3. A coverage plan may involve either transporting the patient to a facility with a neurosurgeon readily available, or having a neurosurgeon go to the Acute Stroke Ready Hospital.

Documentation Requirements:

1. A neurosurgery coverage plan OR a “Scope of Service” from a hospital with neurosurgery services. 2. A letter of understanding/agreement from at least one hospital or neurosurgery group with whom you

have an agreement for transfer. Appendices: Appendix M: Hospitals with Neurosurgery Services in Minnesota and Bordering States (Pg. 50-51) Appendix N: Example Neurosurgery Scope of Service (Pg. 52-53) Appendix O: Example MOA with a Hospital that has Neurosurgery Services (Pg. 54)


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9. Transfer protocols and agreements for stroke patients. Rationale: Many stroke patients at an Acute Stroke Ready Hospital will require emergent transportation to a Primary Stroke Center or Comprehensive Stroke Center. In some cases, the transfer will occur as soon as possible after acute therapy is initiated; in other cases the patient might require a longer stay at the ASRH if s/he is medically unstable. Even in such cases, transfer to a Primary Stroke Center or Comprehensive Stroke Center with more resources should occur as soon as possible, since a higher level of care is likely to ultimately benefit even the unstable patient. Written transfer protocols and agreements ensure that ground or air transportation arrangements are unambiguous, expectations for en-route care are clear, and appropriate documentation on the patient is provided to the receiving hospital. References: (Jauch et al., 2013), (Alberts et al., 2013). Requirements:

1. At least one written transfer agreement exists between the Acute Stroke Ready Hospital and a Primary Stroke Center or Comprehensive Stroke Center that contains key information such as contact personnel, phone numbers, hours of operation, transportation options, etc.


1. It is recommended that such transfers occur within three hours of the patient presenting to the Acute Stroke Ready Hospital, to allow time for the initial diagnosis, stabilization, discussions with family and outside facilities, and the arrangement of transportation. Patients who may be candidates for intra-arterial therapy should be transferred as quickly as possible after IV thrombolytic therapy has been initiated, or it has been determined that the patient is not a candidate for IV therapy.

2. Some patients will be transferred while they are receiving various acute medications or shortly after such medications are administered (i.e., ‘drip and ship’). This treatment paradigm has been used in many cases of IV tPA therapy, and may be applicable to other therapies such as neuroprotective agents and perhaps coagulopathy reversal treatments. In such cases, close attention and documentation should be provided about the type of therapy, dosing, time of initiation and completion.

3. During the transfer, the patient must be accompanied by qualified personnel who have training directly related to any therapy being administered.

4. There are some patients and circumstances in which the transfer of a patient might be superfluous. This might include patients who are obviously moribund, those who decline further treatments, end-of-life situations (e.g., severe dementia, diffuse cancer), and patient or family refusal, among others. The option of transfer should be offered to all patients in whom further medical therapy can reasonably be expected to lead to improved outcomes and reduced complications.

5. Specific transfer criteria and expectations for care en-route should also be part of the transfer agreement. 6. If past experience shows that the receiving hospital(s) is often on diversion due to lack of bed space, then

additional receiving hospitals should be part of the transfer agreement. 7. General transfer agreements are acceptable so long as they are applicable to stroke patients.

Documentation Requirements: A transfer protocol applicable to stroke patients. Appendices: Appendix P: Example Transfer Protocol with a Primary Stroke Center (Pg. 55)


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10. A designated medical director with experience and expertise in acute stroke care. Rationale: Medical leadership for the stroke program at an Acute Stroke Ready Hospital is essential. Although leadership by a neurologist or neurosurgeon might be beneficial in many cases, the distribution of these specialists is likely to limit their availability at many ASRH facilities. Others who might lead such a program include emergency medicine physicians, internists, pharmacists, and radiologists. In some settings, advance practice nurses have been very successful in leading a stroke center. Whoever the leader is, they should have demonstrated experience and expertise in the care of patients with cerebrovascular disease. References: (Jauch et al., 2013), (Albert et al., 2011), (Alberts et al., 2013). Requirements:

1. A designated medical director with experience and expertise in acute stroke care for the hospital. Recommendations, Allowances, and Notes:

1. An Acute Stroke Ready Hospital may consider a medical “advisor” to serve in this role – who may or may not be primarily located at the facility itself. However, this person should be regularly engaged with the staff and administration at the ASRH. “Regular engagement” is defined by consistent review of data (quarterly) with key staff; involvement in protocol adoption; consistent communication.

2. A telestroke coverage relationship with the medical director is acceptable. 3. The medical director should ideally have at least six hours per year of educational time in the area of

cerebrovascular disease. Specialized training might include completion of a fellowship or other specialized training in the area of cerebrovascular disease, attendance at national courses, prior experience in a neuroscience ICU, etc.

4. Specific areas in need of change that a medical director for stroke might address include enhanced staffing of the emergency department, improvement of infrastructure, investment in tele-technologies, partnering with other facilities to enhance transfer of patients, and educational programs.

Documentation Requirements: A letter on hospital letterhead co-signed by the designated medical director and CEO or chief medical officer attesting that s/he will serve in this capacity for the hospital. Appendices: Appendix Q: Example Letter Attesting a Designated Stroke Medical Director (Pg. 56)


20

Checklist of Criteria and Documentation Required

Criterion Documentation Required Completed?

1. An acute stroke team available or on-call 24 hours a day, seven days a week.

A letter on hospital letterhead signed by the CEO or chief medical officer listing the position titles of the members on the acute stroke team.

2. Written stroke protocols, including triage, stabilization of vital functions, initial diagnostic tests, and use of medications.

All stroke protocols that are used for triage and treatment of acute stroke patients in the emergency department.

3. A written plan and letter of cooperation with emergency medical services regarding triage and communication that is consistent with regional patient care procedures.

A written plan or protocol for the primary EMS agency that transports to your facility. A letter on hospital letterhead co-signed by the hospital’s primary EMS agency and the hospital CEO or chief medical officer acknowledging a triage and transportation agreement for potential stroke patients.

4. Emergency department personnel who are trained in diagnosing and treating acute stroke.

A letter on hospital letterhead signed by the CEO or chief medical officer attesting that at least one staff provider per shift has received training in current stroke diagnosis and treatment guidelines.

5. The capacity to complete basic laboratory tests, electrocardiograms, and chest x-rays 24 hours a day, seven days a week.

A “Scope of Service” OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation.

6. The capacity to perform and interpret brain injury imaging studies 24 hours a days, seven days a week.

A “Scope of Service” OR letter on hospital letterhead signed by the CEO or chief medical officer delineating availability of the specified services and hours of operation.

7. Written protocols that detail available emergent therapies and reflect current treatment guidelines, which include performance measures and are reviewed and updated annually.

A protocol that addresses at least one emergent therapy listed above.

8. A neurosurgery coverage plan, call schedule, and a triage and transportation plan.

A neurosurgery coverage plan OR a “Scope of Service” from a hospital with neurosurgery services. A letter of understanding/agreement from at least one hospital or neurosurgery group with whom you have an agreement for transfer.

9. Transfer protocols and agreements for stroke patients.

A transfer protocol applicable to stroke patients.

10. A designated medical director with experience and expertise in acute stroke care.

A letter on hospital letterhead co-signed by the designated medical director and CEO or chief medical officer attesting that s/he will serve in this capacity for the hospital.


21

References

Stroke Systems of Care Alberts, M., Wechsler, L., Lee Jensen, M., Latchaw, R., Crocco, T., George, M., & …Walker, M. (2013, November).

Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the Brain Attack Coalition. Stroke (00392499). doi: 10.1161/STROKEAHA.113.002285

http://stroke.ahajournals.org/content/early/2013/11/12/STROKEAHA.113.002285.full.pdf Alberts, M., Latchaw, R., Jagoda, A., Wechsler, L., Crocco, T., George, M., & …Walker, M. (2011, September). Revised and

updated recommendations for the establishment of primary stroke centers: a summary statement from the Brain Attack Coalition. Stroke (00392499), 42(9), 2651-2665. http://stroke.ahajournals.org/content/42/9/2651.long

Alberts, M., Latchaw, R., Selman, W., Shephard, T., Hadley, M., Brass, L., & … Walker, M. (2005, July). Recommendations

for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke (00392499), 36(7), 1597-1618. http://stroke.ahajournals.org/content/36/7/1597.long

Schwamm, L., Pancioli, A., Acjer, J., Goldstein, L., Zorowitz, R., Shephard, T., & … Adams, R. (2005, March).

Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Stroke (00392499), 36(3), 690-703. http://stroke.ahajournals.org/content/36/3/690.long

Emergency Medical Services Acker, J., Pancioli, A., Crocco, T., Eckstein, M., Jaunch, E., Larrabee, H., & … Stranne, S. (2007, November).

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 (00392499), 38(11), 3097-3115. http://stroke.ahajournals.org/content/38/11/3097.long

Lin, C., Peterson, E., Smith, E., Saver, J., Liang, L., Xian, Y., & … Fonarow, G. (2012, August). Patterns, predictors,

variations, and temporal trends in emergency medical service hospital prenotification for acute ischemic stroke. Journal of the American Heart Association, 1(4):e002345. doi:10.1161/JAHA.112.002345. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487363/

Clinical Management Guidelines Adams, H., Del Zoppo, G., Alberts, M., Brass, L., Furlan, A., & … Wijdicks, E. (2007, May). Guidelines for the early

management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke (00392499), 38(5), 1655-1711. http://stroke.ahajournals.org/content/38/5/1655.long

. Jauch, E., Saver, J., Adams, H., Bruno, A., Connors, J. Demaerschalk, B., & … Yonas H. (2013, March). Guidelines for the

early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke (00392499), 44(3), 870–947. http://stroke.ahajournals.org/content/44/3/870.long

Summers, D., Leonard, A., Wentworth, D., Saver, J., Simpson, J., Spilker, J., & … Mitchell, P. (2009, August).

Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke (00392499), 40(8), 2911-2944. http://stroke.ahajournals.org/content/40/8/2911.long

http://stroke.ahajournals.org/content/early/2013/11/12/STROKEAHA.113.002285.full.pdf

http://stroke.ahajournals.org/content/42/9/2651.long




http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487363/





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Minnesota Stroke System Contacts

Minnesota Stroke System Coordinator: Megan Hicks ([email protected]) Data Collection and Reporting: Jim Peacock ([email protected]) Performance Improvement Support:

- Megan Hicks, Minnesota Department of Health ([email protected]) - Katie Sahajpal, American Heart Association ([email protected])

Minnesota Stroke Registry Program: Albert Tsai ([email protected])







23

Appendices for Acute Stroke Ready Hospital Designation Criteria


24

10,000 Lakes Hospital

555 Lady Slipper Drive

Loon, MN 55555

January 20, 2014

Minnesota Department of Health:

This letter is attesting that 10,000 Lakes Hospital has an acute stroke team available or on-call 24 hours a day,

seven days a week. The role of the acute stroke team is to respond to patients in the emergency department, or

in-hospital presenting with stroke symptoms. The team’s role is to initiate diagnostic testing and provide the

appropriate action of care in a well-timed and coordinated manner in accordance with hospital protocols for

the treatment of stroke patients. Additionally, the ED physician and critical care nurse of the acute stroke team

complete four hours of stroke education annually.

The members on the acute stroke team include:

Neurologist, available via telemedicine if not onsite or available within 15 minutes

Emergency Department Physician

Stroke Trained Nurse

Radiologist

Pharmacist

Charge Nurse (day time hours only)

Stroke Coordinator (day time hours only)

If you have any questions regarding 10,000 Lakes Hospital’s acute stroke team, please don’t hesitate to

contact me.

Sincerely,

John Smith, CEO


Appendix A: Example Letter Listing the Position Titles of the Members on the Acute Stroke Team (Criterion 1)


25

Appendix B: Example Stroke Code Algorithm (Criterion 2)


26

Appendix C: Example Stroke Code Evaluation Protocol (Criterion 2)


27


28


29

Appendix D: Example EMS Stroke Protocol (Criterion 3)


30


31



Loon, MN 55555

February 12, 2014


This letter is acknowledging that 10,000 Lakes Hospital and Regional Emergency Medical Services has established

a triage and transportation agreement for potential stroke patients. Our organizations have developed an EMS

Stroke Protocol that supports the transition of care from pre hospital to the emergency department handoff. Key

components of the protocol include:

EMS personnel neurologic assessment using Cincinnati Prehospital Stroke Scale.

Notification of CODE STROKE and estimated time of arrival to receiving hospital.

Documentation of medical history including time last known well, use of concomitant medications,

other major medical conditions.

Stabilization of patient and use of interventions including blood glucose monitoring and obtaining

IV access when appropriate.

Patient information communication handoff process upon arrival at receiving hospital.

Feedback mechanism to advise EMS on accuracy of stroke identification and patient outcomes.

If you have any questions regarding the agreement between 10,000 Lakes Hospital and Regional Emergency

Medical Services, please don’t hesitate to contact me.

Sincerely,

________________________ ________________________ ________________________ Signature Signature Signature

John Smith, CEO Mary Young, EMS Medical Director Steve Allen, Director of Transportation

10,000 Lakes Hospital Regional Emergency Medical Services Regional Emergency Medical Services

Appendix E: Example Letter Acknowledging EMS Triage & Transportation Agreement

(Criterion 3)


32

App



Loon, MN 55555

February 23, 2014


This letter is attesting that 10,000 Lakes Hospital has established a stroke education protocol in the Emergency

Department to ensure that at least one staff provider per shift is knowledgeable of current stroke diagnosis

treatment guidelines. Clinicians will receive initial and ongoing education requirements to maintain competency

in the area of cerebrovascular disease. The scheduling department ensures that at least one qualified clinician per

shift is available for the acute diagnosis, stabilization, monitoring and treatment of stroke patients. Additionally,

10,000 Lakes Hospital will perform at least one mock code stroke per year to aid in hands-on training and

identify opportunities for improvement.

If you have any questions regarding 10,000 Lakes Hospital stroke education protocol, please don’t hesitate to

contact me.

Sincerely,

John Smith, CEO


Appendix F: Example Letter Attesting Training of ED Personnel (Criterion 4)


33

American Heart Association http://www.heart.org/HEARTORG/

My American Heart for Professionals offers online activities; most are free. They offer NIHSS

certification. There is a $10 fee per test for non AHA members and free for AHA members.

The OnlineAHA.org site offers two courses related to stroke: Acute Stroke Online ($25) and Stroke

Pre-hospital Care Online ($20)

The Internet Stroke Center http://www.strokecenter.org/

The Internet Stroke Center provides health professionals with multiple tools and educational

presentations about stroke assessment, stroke treatment and management. Website supported by

NINDS, Washington University in St. Louis School of Medicine and UT Southwestern Medical

Center. The NIHSS training DVD can be ordered through this site. The cost is $50. They also offer a

Know Stroke Community Education kit ($10), Spanish Stroke Toolkit for lay health educators ($35),

and NIHSS pocket guide for health professionals ($1.75).

National Stroke Association http://www.stroke.org/site/PageNavigator/HOME

The National Stroke Association offers programs that will meet The Joint Commission and other

certifying organization requirements for stroke education. The cost varies by the program. For

example there are 10 nurse modules that cost $20 per module (AANN members pay $15). They also

offer programs for physicians, EMS, and rehabilitation.

Medscape http://www.medscape.com

Medscape is a reliable source for CME and continuing education for physicians and other health

professionals.

AIS Virtual Patient Builder & Health Stream Stroke Modules http://www.activase.com/

Genentech’s AIS Virtual Patient experience is a free tool that supports professionals in boosting their

diagnostic skills through practice in building virtual patient charts, calculating NIHSS scores,

interpreting CT Scans, and determining potential treatment options and managing patient discussions.

The Health Stream Stroke Modules prove free access to education materials and training on acute

ischemic stroke and Activase. (Click on Resource Center Interactive Tools).

Appendix G: Training Resources for ED Personnel (Criterion 4)

http://www.heart.org/HEARTORG/

http://www.strokecenter.org/

http://www.stroke.org/site/PageNavigator/HOME

http://www.medscape.com/

http://www.activase.com/


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Appendix H: Example Diagnostic Capability Scope of Service (Criterion 5)


35


36


37


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Appendix I: Example Brain Imaging Interpretation Capability Scope of Service (Criterion 6)


39


40

Appendix J: Example ED Order Set for Administering tPA (Criterion 7)


41


42


43


44


45


46


47


48

Appendix K: Example Hemorrhagic Stroke Conversion from tPA Protocol (Criterion 7)


49

Appendix L: Example Allergic Reaction to tPA Protocol (Criterion 7)


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Minnesota Hospitals- Current as of 11/15/2013

Hospital Contact Phone Email Address For patient

questions or transfers:

Abbott Northwestern Hospital Tim Hehr Amy Castle

(612) 863-4854 (612) 241-7361

[email protected] [email protected]

800 28th St, MR 39304, Minneapolis, MN 55407

(612) 863-1000

Essentia Health St. Mary’s Medical Center Diane Roach (218) 786-4230 [email protected]

407 E. Third St Duluth, MN 55805

Fairview Southdale Hospital Marnee Shepard (952) 924-1430 [email protected]

6401 France Ave S Edina, MN 55435

HealthEast St. Joseph’s Hospital Tess Sierzant (651) 326-3415 [email protected]

45 W. 10th St St. Paul, MN 55102

Hennepin County Medical Center Donna Lindsay (612) 873-8712 [email protected]

701 Park Ave S Minneapolis, MN 55415

(612) 873-4262

Mayo Clinic St. Mary’s Hospital Kari Bottemiller (507) 255-0513 [email protected]

1216 Second St SW Rochester, MN 55902

Mayo Clinic Health System- Mankato Lindsay Hennek (507) 304- 7165 [email protected]

1025 Marsh Street Mankato, MN 56001

North Memorial Medical Center Darcy Ellis (763) 581-3656 [email protected]

3300 Oakdale Ave N Robbinsdale, MN 55422

Regions Hospital Carol Droegemueller (651) 254-3703 [email protected]

640 Jackson St St. Paul, MN 55101

St. Cloud Hospital Melissa Freese (320) 255-5772 [email protected]

1406 6th Avenue N. St. Cloud, MN 56303

St. Luke’s Hospital Tera Manguson Stan Sadenwasser

(218) 249-5993 (218) 249-5221


915 East First Street Duluth, MN 55805

United Hospital Tim Hehr Amy Castle

(612) 863-4854 (612) 241-7361


333 North Smith Ave St. Paul, MN 55102

(651) 241-8400

University of Minnesota Medical Center – Fairview

Angi Heyer (612) 273-4102 [email protected] 420 Delaware St SE, Minneapolis, MN 55454

(612) 624-6666

Appendix M: Hospitals with Neurosurgery Services in Minnesota and Bordering States (Criterion 8)

















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Bordering State Hospitals- Current as of 12/18/2013

Hospital Contact Phone Website

For patient questions or

transfers: Wisconsin:

Gundersen Lutheran Hospital- La Crosse (608) 775-9000 www.gundersonhealth.org/neuroscience/neurosurgery

Wisconsin: Mayo Health System- La Crosse

(608) 392-9831 http://mayoclinichealthsystem.org/locations/la-crosse/medical-services/neurosurgery

Iowa: Mercy Medical Center- North Iowa

(641) 428-7000 http://www.mercynorthiowa.com/surgical-services

North Dakota: Essentia Health- Fargo

(701) 364-8900 http://essentiahealth.org/ndAvenueClinic/Neurosurgery1.aspx

North Dakota: Sanford Health- Fargo

(701) 234-2000 http://www.sanfordhealth.org/MedicalServices/Specialties/Neurosurgery http://www.sanfordhealth.org/Locations/691049837

North Dakota: Altru Health System- Grand Forks

(701) 780-2300 http://www.altru.org/services/neurology/

South Dakota: Sanford Neurosurgery and Spine Clinic- Sioux Falls

(605) 328-8660 http://www.sanfordhealth.org/MedicalServices/Specialties/Neurosurgery

South Dakota: Avera McKennan Hospital- Sioux Falls

(605) 322-2000 http://www.avera.org/clinics/neurosurgery/

http://www.gundersonhealth.org/neuroscience/neurosurgery

http://mayoclinichealthsystem.org/locations/la-crosse/medical-services/neurosurgery

http://www.mercynorthiowa.com/surgical-services

http://essentiahealth.org/ndAvenueClinic/Neurosurgery1.aspx

http://www.sanfordhealth.org/MedicalServices/Specialties/Neurosurgery

http://www.sanfordhealth.org/Locations/691049837

http://www.sanfordhealth.org/MedicalServices/Specialties/Neurosurgery

http://www.avera.org/clinics/neurosurgery/


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Appendix N: Example Neurosurgery Scope of Service (Criterion 8)


53


54

01/22/2014 01/22/2014

_______________________ _________ _______________________ _________ Signature Date Signature Date

John Smith, CEO Michael Johnson, Chief Medical Officer

10,000 Lakes Hospital Boundary Waters Hospital

Appendix O: Example MOA with a Hospital that has Neurosurgery Services (Criterion 8)

MEMORANDUM OF AGREEMENT

THIS MEMORANDUM OF AGREEMENT (the “MOA”) is made and entered into as of January

22, 2014 between 10,000 Lakes Hospital and Boundary Waters Hospital.

A. PARTIES. The parties in this agreement are 10,000 Lakes Hospital, a Critical Access Hospital,

and Boundary Waters Hospital, a Joint Commission Certified Primary Stroke Center.

B. PURPOSE. This MOU is a voluntary agreement among the hospitals that establishes an

agreement for transfer for stroke patients requiring neurosurgical evaluation and/or treatment.

C. AGREEMENTS. 10,000 Lakes Hospital agrees to perform neurological assessment and

diagnostic procedures to determine neurosurgical intervention eligibility according to current

guidelines. 10,000 Lakes Hospital agrees to the established transfer protocol to access

neurosurgical consultation with Boundary Waters Hospital, including, but not limited to:

1. Consultation through tele-radiology as an initial point of contact.

2. Providers from both hospitals discuss the physiological status of the patient and decide

on the appropriate medical procedures and mode of transfer (air or ground).

3. 10,000 Lakes Hospital contacts the appropriate aero medical or ground transportation

and obtains at ETA.

4. 10,000 Lakes Hospitals makes copies of all available documentation to accompany the

patient (examples include the EMS run sheet, CT scans, and lab results).

D. TRANSFER PROTOCOL. An Interfacility Transfer Agreement supplements this MOA.

E. TERMS. The term of this agreement is for three (3) years, commencing on date of final

signature. Either party may terminate this relationship, with or without cause, upon fifteen (15)

days written notice to the other party


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Appendix P: Example Transfer Protocol with a Primary Stroke Center (Criterion 9)


56



Loon, MN 55555

January 24, 2014


This letter is attesting that 10,000 Lakes Hospital has designated Rachel Coleman to serve as a stroke Medical

Director. Rachel brings clinical leadership in neuroscience ICU and emergency medicine, and currently serves

as the Director of Emergency Services at 10,000 Lakes Hospital. Rachel has also completed a Neuroscience

Nurse Practitioner Fellowship. In serving the role of the medical director, Rachel is responsible for enhancing

staff education of stroke, the development and maintenance of stroke protocols, data and case review of stroke

patients, and partnering with other facilities to enhance the care for patients.

Sincerely,

______________________ ______________________

John Smith, CEO Rachel Colman, Director of Emergency Services

10,000 Lakes Hospital 10,000 Lakes Hospital

Appendix Q: Example Letter Attesting a Designated Stroke Medical Director (Criterion 10)


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Disclaimer Statement

The Minnesota Stroke System Toolkit has been prepared by the Minnesota Department of Health (MDH)

as a guide to assist hospitals in meeting stroke hospital designation criteria. The toolkit contains

documents, examples, and links associated with or originating from other government agencies,

nonprofit organizations, private businesses, and individuals. MDH does not endorse any content,

viewpoints, products, or services linked from this toolkit.

Although we go to great lengths to make sure the toolkit is accurate and useful, the information is not

intended to be used strictly verbatim without careful review; rather, the documents are resources that

are meant to guide processes and support stroke hospital designation. MDH makes no claim that all

information in this toolkit is up-to-date or that the information provided is applicable to your

organization’s unique circumstances. MDH shall not be held responsible for any losses caused by

reliance on the accuracy, reliability or timeliness of information in the toolkit.

Minnesota Stroke System Toolkit 140116

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