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Minnesota Department of Health Minnesota Stroke News Update - Minnesota Stroke System Launch, March 2014


Minnesota Stroke System Newsletter

March 2014

Spring is finally here! You know what that means: walking outside without a winter coat; the singing of birds; and, of course, the launch of the Minnesota Stroke System! After months of preparation, we are ready for implementation.  The first phase of system rollout is the designation of hospitals by the Minnesota Department of Health. Applications will be accepted beginning March 17, 2014.  In this month’s newsletter, we’re going to post answers to questions that we’ve been getting from hospitals as they prepare for designation.

Question Corner

Q: Where do we go to apply?


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 the same TJC or HFAP certification level.

Q: I’m at a certified Primary Stroke Center or Comprehensive Stroke Center. Will I need to submit an application?

Yes. All hospitals must complete an application in order to be recognized by the State of Minnesota stroke system.

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.

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 keeping 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: What is the deadline for applying?

The first deadline is April 1, 2014. However, you can submit your application at any time. We don’t "close" the system to new applications at any time. We’re just going to be issuing designations on a quarterly basis.

Q: Will we have to re-apply every year?

No. Each time you are designated, you’ll be good for a three-year period.

Q: Does getting designated automatically enroll us in the stroke registry?

No. The Minnesota Stroke Registry Program is a separate (but related) quality improvement program. Please contact us for information about joining!

Contact Us:

System/Program Information:

Albert W. Tsai, 651-201-5413

Stroke Readiness/Performance Improvement:

Megan Hicks, 651-201-5436

Minnesota Department of Health


P.O. Box 64882, St. Paul, MN 55164-0882

Delivery: 85 E.7th

Place, Ste. 220 St. Paul, MN 55101


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