Minnesota Stroke System
Frequently Asked Questions

Q: Is designation required? No. Participation in the system 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 acute care 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 deadlines are the last day of each the first month of each new quarter. Applications are accepted at any time. We 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. 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? Not at this time. Hospitals submit an electronic application which includes documentation that attests that or demonstrates how each of the criteria are met. 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 state law. Reporting data 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. Also, it does not mean you are automatically reporting data for statewide quality 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.

Back to Top

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? No We do not required data to be submitted in order to be an Acute Stroke Ready Hospital. All Minnesota 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.

Back to Top

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 key 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: 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: 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.

Back to Top

Click Here to Return to Main Minnesota Stroke System Page

Updated Tuesday, February 03, 2015 at 10:41AM