Minnesota Stroke System Frequently Asked Questions

Programs & initiatives in Health Care
Minnesota Stroke System

Frequently Asked Questions

Q: Is designation required? No. Participation in the system is recommended but remains voluntary.

Q: Is there a cost? No! There is no fee for applying or receiving stroke hospital designation from the Minnesota Department of Health.

Q: Who is eligible to apply? All acute care hospitals and facilities in Minnesota and along the border in North Dakota, South Dakota, Iowa, and Wisconsin with emergency department capabilities are eligible and are strongly encouraged to apply. The intent is for all acute care hospitals to work toward standards that qualify them as "stroke-ready," in order to provide timely and appropriate care for the people in their local community.

Q: Are standalone emergency centers eligible to apply? Yes. Any facility that has 24/7 emergency center capacities should apply.

Q: What is the deadline for applying? We issue designations twice a year. To apply for designation you must submit your application by the April 1 or October 1 deadline.

Q: Will we have to re-apply every year? No. Your designation is valid for three years.

Q: Does getting designated automatically enroll us in the stroke registry? No. All hospitals in Minnesota already submit stroke quality measures into the Minnesota Stroke Registry as part of statewide quality reporting requirements, the CDC Paul Coverdell National Acute Stroke Program, or both. Find out more information about the stroke registry here.

Q: Our hospital is not certified by The Joint Commission as a Primary Stroke Center. Can we apply for Primary Stroke Center designation from the state? No. Only hospitals that are currently certified by a national accreditation body as Primary Stroke Centers or Comprehensive Stroke Centers may receive those same designations from MDH. Currently, the only national accreditation organizations that certify hospitals as Primary or Comprehensive Stroke Centers are The Joint Commission, DNV, and HFAP.

Q: Will there be a site survey for the designation? Yes. First, hospitals submit an electronic application. This application includes documentation that demonstrates how each of the required criteria are being met. Within three years of the hospital’s designation, a site visit will be arranged, aimed at providing support, feedback and technical assistance on the implementation of the hospital’s stroke program.

Q: I'm confused about the relationship between designation, quality reporting, and the stroke registry. Are they the same things? No. They are inter-related activities that utilize the same web-based platform; yet are separate initiatives:

  • A hospital participates in the Minnesota Stroke System by getting designated as an Acute Stroke Ready Hospital.
  • Participation in the stroke system (i.e., getting designated) is not the same as participating in the Minnesota Stroke Registry. It also does not mean you are automatically reporting data for statewide quality reporting.
  • Submitting your stroke quality measure data (SQRMS) is required by state law. Reporting data does not mean you automatically are designated.
  • Participation in the Minnesota Stroke Registry does not mean you are automatically designated, but DOES mean your stroke quality measure reporting requirements are covered.

For more information, contact us at health.stroke@state.mn.us.

Designation Criteria Questions

Q: What are the criteria for an acute stroke ready hospital?

  1. An acute stroke team available or on-call 24 hours a day, 7 days a week
  2. Written stroke protocols or algorithms for acute treatment in the Emergency Department
  3. Collaboration with EMS
  4. Education on identification and treatment of acute stroke
  5. The capacity to complete basic laboratory tests 24 hours a day, 7 days a week
  6. The capacity to perform and interpret brain imaging studies 24 hours a day, 7 days a week
  7. Demonstrate collection and utilization of data for performance improvement
  8. Transfer protocols and agreements for stroke patients
  9. A designated stroke program leadership team, with stroke coordinator and medical director

Q: Do we really need to have a designated stroke coordinator? Yes. In order for a program to be organized and for you to move towards improving care, there must be a designated person in charge of stroke work for the facility. This person will be in charge of reviewing stroke cases for opportunities for improvement, for coordinating educational opportunities, for convening meetings to address stroke cases and changes of process at your hospital, and for being responsible for looking at your processes and protocols and updating annually.

Q: Are we required to submit data in order to be designated? Submitting stroke quality measure data (SQRMS) is required by state law. In order to be designated, you must submit your last three years of stroke quality measure data (SQRMS). At this time, we do not require participation in the registry, though we highly recommend it to help expand and develop your stroke program at your facility. It will also allow you to easily submit the required data for designation.

Q: Criteria #4 states that education on identification and treatment of acute stroke must be provided. Who specifically should be trained and how often? At a minimum you will be asked to provide two hours of education per year, or two education trainings per year, for all members of your Acute Stroke Team. We recommend, in addition, that all of your acute care staff involved in the care of stroke patients be provided the same educational opportunities. These do not need to be accredited CEUs, any training done can be considered.  At MDH, we provide educational sessions that will count toward these requirements, including our QI webinars, stroke workshops every fall, and Annual Stroke Conference in the summer.

Q: Our emergency department is usually staffed by mid-level providers, not physicians. Will that negate our ability to be designated? No. We recognize that several hospitals have licensed independent practitioners in lieu of physicians staffing their emergency departments. We expect these providers to be trained to carry out stroke protocols and utilize other resources (e.g., consults with off-site stroke experts) as available to them.

Q: Our emergency department is usually staffed by locums. We can't necessarily verify or dictate that they meet education requirements. What should we do? We recognize that many hospitals use locum tenens providers to staff their emergency department. We expect that these providers are trained in basic diagnosis and treatment procedures for stroke patients. However, we are not in a position to verify that all providers meet education recommendations. We encourage you to train your emergency department charge nurses to be able to guide and review your stroke protocol with locum tenens. In addition, we encourage you to develop a one-page overview of your stroke protocol which includes key telephone numbers and a flow diagram of your process.

Q: For criteria #6 – “The capacity to perform and interpret brain imaging studies 24 hours a day, 7 days a week” – Do we need to have on-call staff and radiology response times? Yes, you need to have documentation stating the response times by on-call staff, such as CT techs, as well as the read back times for radiology, and whether a stroke is a STAT read. We understand that contracts with radiology may not spell these out, so we will accept a letter from your CEO stating the above requested items.

Q: Do we need to have agreements with the same centers for endovascular and neurosurgery? No. You may have agreements with any certified Primary or Comprehensive Stroke Center that can meet the 24/7 availability for neurosurgery and endovascular therapy. This can mean you have more than one agreement in place for each service.

Q: If we have a transfer protocol with a hospital, are we bound to send every patient to that hospital? What if the patient prefers to go elsewhere? The intent of the transfer agreement is so your hospital has a plan in place to efficiently get the patient out the door to the next most appropriate facility. This criterion does not require all of your patients to go only to the hospital with which you have a transfer agreement. If the patient wishes to go elsewhere, that’s fine – we just want you to have a process in place to move the patient quickly.

Q: We’re a Primary Stroke Center that is providing neurosurgical services to several hospitals. Can we provide the same letter to them? Yes. We expect that multiple Acute Stroke Ready Hospitals will have agreements with the same Primary Stroke Center (and the neurosurgery group that services that hospital).The letter just needs to be signed by both your CEO and the CEO at the acute stroke ready hospital

Q: Does our “designated stroke medical director” need to be a physician? No. He or she can be any professional within your facility who will champion and lead the stroke program at your facility. The responsibilities are many – to ensure that your protocols are up to date, staff are adequately trained, data are reviewed, and that you are continually improving your care processes. This role can be played by anyone who has the commitment to actively champion your stroke work.

For more information, contact us at health.stroke@state.mn.us.


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