Minnesota Stroke System
Frequently Asked Questions

Q: Is designation required? No. Participation in the system - that is, getting designated, is 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 hospitals to work towards meeting standards to be considered "stroke-ready" 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? Our next deadline is October 31 for Round 4. You can submit your application at any time throughout the year. We don’t “close” the system to new applications at any time. We will issue designations on a quarterly basis.

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. The Minnesota Stroke Registry Program is a separate quality improvement program. Find out more about this voluntary program 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. In addition, MDH will designate those hospitals at their same TJC or HFAP certification level.

Q: Will there be a site survey for the designation? Not at this time. Hospitals will submit an application electronically which will include documentation that will show us how you meet each of the criteria. In the future we plan to conduct in-person site visits for renewals. We also plan to conduct in-person visits to a sample of hospitals, to provide support and technical assistance to designated facilities.

Q: I'm confused about the relationship between the designation, quality reporting, and the stroke registry. Are they the same things? These are inter-related but different, separate initiatives. All three utilize the same web-based tool. However....

  • Submitting your stroke quality measure data (SQRMS) is required by statute. Doing so does not mean you automatically get designated, nor does it mean you are participating in the stroke registry program.
  • Participation in the stroke system (i.e., getting designated) does not mean you are automatically in the Minnesota Stroke Registry Program and has nothing to do with stroke quality measure reporting.
  • Participation in the Minnesota Stroke Registry Program 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.

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Designation Criteria Questions

Q: What are the criteria for an acute stroke ready hospital? 1) an acute stroke team available 24/7; 2) a written protocol for acute stroke triage and diagnosis; 3) a written plan for triage and transport by your primary EMS agency; 4) emergency department personnel trained in stroke diagnosis and treatment; 5) labs, EKG, and chest x-ray 24/7; 6) CT imaging and interpretation 24/7; 7) a written emergency stroke treatment protocol; 8) a neurosurgery coverage plan; 9) a transfer protocol; 10) a designated medical director.

Q: Are we required to submit data in order to be designated? Not to be an Acute Stroke Ready Hospital. All hospitals are, however, required to submit data on two stroke measures as part of statewide quality reporting requirements.

Q: For criteria #8 – “A neurosurgery coverage plan, call schedule, and a triage and transportation plan” – does our documentation need to include the actual call schedule? Those schedules change a lot! No. The intent of this criteria is that the neurosurgical group that you have an agreement with has a clear plan for 24/7 coverage. We do not need to see the actual call schedule. Your documentation needs to demonstrate to MDH simply that you have an agreement and a plan in place with a tertiary care hospital and/or neurosurgical service.

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.

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Q: Criteria #4 states that our ED personnel need to be trained in stroke. Who should be trained? The intent of this criterion is that staff in your emergency department who will be directly involved in triaging, diagnosing, treating, and monitoring the patient should be up to date with stroke treatment guidelines. We leave who that is to your discretion.

Q: How much training should our ED personnel receive? The Brain Attack Coalition recommends a minimum of four hours of education on stroke every year for the key staff in the emergency department. We encourage at least four hours per year for your staff, but we will not be collecting information about contact hours from you.

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: 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. This criterion does not require all of your patients to go only 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: Does our “designated medical director” need to be a physician? No. He or she can be any professional 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.

Q: I heard about a new requirement for comprehensive and primary stroke centers. What is that about? In order to be designated as a Comprehensive or Primary Stroke Center in the Minnesota Stroke System, the hospital must participate in the Minnesota Stroke Registry Program. Hospitals may use the American Heart Association Get With The Guidelines-Stroke Program for data collection. To find out more about how to join, please visit the Minnesota Stroke Registry Program site.

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Updated Friday, August 01, 2014 at 07:46AM