Form Approved
OMB No. 0920-1108
Exp. Date xx/xx/xxxx
NOTE: The hospital inventory is subject to annual updates.
Instructions for Paul Coverdell National Acute Stroke Program (PCNASP) Hospital Inventory Survey
The intent of the Paul Coverdell National Acute Stroke Program hospital inventory is to better understand issues associated with acute stoke care. Responses will be used to identify what types of QI interventions work in particular settings, where gaps exist, and how we can better help hospitals with fewer resources. Additionally, this survey will provide vital information to both CDC and State Health Departments about the capacity of hospitals for stroke care. When this survey is submitted to CDC by State Health Departments, it does not contain identifiable hospital information to protect the confidentiality of hospitals. Responses will be aggregated and may be used as additional information to patient-level data collected as part of PCNASP.
This survey should be filled out, or at least reviewed, by the stroke coordinator or other designee involved in stroke care. Because of the goals of the inventory, please base your answers on practical availability and use of the procedures and resources. For example, your hospital might have written care protocols that are used in less than 50% of cases. If so, then the answer to questions in B.2 would be “No”. Alternatively, some procedures employed at your hospital (pre-notification from EMS) might not be formalized, but regularly take place. In this situation, the answer to question C.2 would be “Always”/ “Sometimes”. Throughout the survey, circle radio buttons indicate that you should select one best answer; checkboxes indicate that you should select all answers that apply. This hospital inventory survey is completed by hospitals and then transmitted to their respective State Health Department (PCNASP awardee) as an electronic file or paper form, based on the request of your State Health Department.
Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1108)
Hospital Infrastructure
Hospital code (as assigned through the PCNASP):_______________
What is your hospital’s Rural-Urban Commuting Area (RUCA) code? To determine this, navigate to the Rural Health Information Hub website (https://www.ruralhealthinfo.org/am-i-rural). Enter your hospital’s address in the search bar and click “locate”. Then click on the orange “run report” button in the map. Scroll down to find your hospital’s RUCA Code by census tract (e.g. 1.1) and provide this number for the inventory survey. _____________
Current hospital size (number of licensed beds): ________________
Total number of inpatient discharges (not including observation only, ED patients, ED transfers) in the most recent calendar year: _________________
Total number of acute stroke discharges (primary diagnosis only; see list of ICD-9 and ICD-10 codes in the PCNASP Resource Guide appendix) in the most recent calendar year: _________________
[Optional] Total number of acute ischemic stroke discharges in the most recent calendar year: __________________
[Optional] Total number of TIA discharges in the most recent calendar year: __________________
[Optional] Total number of subarachnoid hemorrhagic stroke discharges in the most recent calendar year: __________________
[Optional] Total number of intracerebral hemorrhagic stroke discharges in the most recent calendar year: __________________
[Optional] Total number of stroke (type unspecified) discharges in the most recent calendar year: __________________
Acute Stroke Care
Does your hospital have a designated acute stroke team? (A stroke team includes at least one physician and one other health care provider such as a nurse or physician extender. The team is available 24 hours per day and can see patients within 15 minutes of being called. The physician can be a neurologist, emergency physician or another specialist, but must have experience and expertise in diagnosing and treating cerebrovascular disease.)
Yes
No
Does
your hospital have a written protocol or care pathway in place for
the following? (select
‘yes’ for all that apply)
a.
Emergency
care of ischemic strokes (including diagnostic imaging and labs)
Yes [[IF YES, GO TO 2ai]]
No [[IF NO, GO TO 2b]]
If yes to (2a), does it include (select all that apply):
Initial stabilization
Diagnostic imaging
Treatment
Labs
b.
Emergency
care of subarachnoid
hemorrhagic strokes (SAH) (including diagnostic imaging and labs)
Yes [[IF YES, GO TO 2bi]]
No [[IF NO, GO TO 2bii]]
If yes to (2b), does it include (select all that apply):
Initial stabilization
Diagnostic imaging
Treatment
Labs
Does your hospital admit most subarachnoid hemorrhagic (SAH) stroke patients?
We typically transfer SAH patients
We typically admit these patients
We admit or transfer depending on staff availability or other factors (please describe): ___________________________________
c. Emergency care of intracerebral hemorrhagic (ICH) strokes (including diagnostic imaging and labs)
Yes [[IF YES, GO TO 2ci]]
No [[IF NO, GO TO 2cii]]
If yes to (2c), does it include (select all that apply):
Initial stabilization
Diagnostic imaging
Treatment
Labs
Does your hospital admit most intracerebral hemorrhagic (ICH) stroke patients?
We typically transfer ICH patients
We typically admit these patients
We admit or transfer depending on staff availability or other factors (please describe): ___________________________________
d. IV tPA (alteplase)
Yes
No
e.
Endovascular therapy
Yes
No
f.
Admission orders
Yes
No
g.
Dysphagia screening
Yes
No
h.
Discharge planning protocols
Yes
No
i. Post-discharge follow-up care protocols
Yes
No
Does your hospital have a neuro- intensive care unit?
Yes [[IF YES, GO TO 3a]]
No [[IF NO, GO TO 4]]
If yes to (3), does your hospital have a neurointensivist to manage care for stroke patients?
Yes
No
Do all stroke patients receive continuous ECG monitoring for at least 24 hours during admission?
Yes
No
Does your hospital have neurosurgical services on-staff?
Yes [[IF YES, GO TO 5a]]
No [[IF NO, GO TO 6]]
If yes to (5), does your hospital have neurosurgical services available 24/7 (may be on-site or at a remote location)?
Always [[IF ALWAYS, GO TO 6]]
Sometimes [[IF SOMETIMES, GO TO 6]]
Never [[IF NEVER, GO TO 5b]]
If never to (5a), does your hospital have neurosurgical services available within 2 hours of patient arrival (may be on-site or at a remote location)?
Always
Sometimes
Never
Does your hospital have stroke neurointerventional capabilities?
Yes
No
Does your hospital provide neurointerventional treatment for (select all that apply):
Intra-arterial alteplase
Catheter-based reperfusion/mechanical thrombectomy
Emergency Medical Services (EMS) Integration
Is there a written plan for receiving patients with suspected stroke via EMS (This should include how the ED receives a call in advance of arrival and may include other information on assigning high priority code to ensure rapid evaluation and transport.)?
Yes
No
Does pre-notification by EMS regarding a suspected stroke case lead to activation of the stroke team?
Always
Sometimes
Never
No pre-notification
Does pre-notification lead to activation of written stroke care protocols (e.g. notification to pharmacy, “clearing” of CT scanner)?
Always
Sometimes
Never
No pre-notification
4. Does your hospital enter EMS run sheets into a Coverdell-specific in-hospital data collection tool (e.g., GWTG, state-based system)?
Always
Sometimes
Rarely
Never
5. Do you have a formal process for data feedback to EMS agencies?
Yes [[IF YES, GO TO 5a and 5b]]
No [[IF NO, GO TO 6]]
a. If yes to (5), how is the feedback provided to EMS agencies? (select all that apply)
Fax
Phone
In-person (for example, at a meeting or during a case review)
Other (please specify): ________________________
If yes to (5), for what patient population is feedback provided? (select all that apply)
Patients transported by EMS with a final diagnosis of stroke with pre-notification of possible stroke
Patients transported by EMS with a final diagnosis of stroke without pre-notification of possible stroke
Possible stroke patients for whom EMS pre-notified the hospital, regardless of the final diagnosis
Unknown
Other (please specify): ________________________
6. Does your hospital have an EMS coordinator?
Yes
No
7. [Optional] To what extent has the interaction between the ED and EMS providers changed during the past calendar year, compared to the prior calendar year, with respect to the following:
a. Communication
Substantial improvement
Minimal improvements
No improvement
Minimal decline
Substantial decline
b. Data exchange
Substantial improvement
Minimal improvements
No improvement
Minimal decline
Substantial decline
Transitions of Care
Do you utilize a transition of care summary with stroke patients during discharge? (The National Transitions of Care Coalition (NTOCC) defines a transition of care summary as a method of communication between sending and receiving providers and patient/family/caregivers. Use of a transition of care summary has been proven to reduce readmission rates and decrease medical errors.)
Always
Sometimes
Rarely
Never
Does your hospital conduct post-discharge follow-up on patients discharged to home?
Yes [[IF YES, GO TO 2a]]
No [[IF NO, GO TO NEXT SECTION]]
If yes to (2), how long after discharge does this follow-up typically take place?
1-7 days
8-14 days
15-21 days
22-30 days
>30 days
Do you follow-up with (select all that apply):
All patients discharged home
A sample of patients discharged home
Only cases that were treated with IV alteplase
Only cases that were treated with IV alteplase and/or thrombectomy
Other: (text)
Does your hospital utilize an inventory of community resources to make referrals for post-stroke needs?
Yes
No
Certification and Education
1. Does your hospital have the following residency or fellowship programs?
Neurology
Yes
No
Other residency/ fellowship program
Yes
No
2. Is your hospital currently certified as a Joint Commission Acute Stroke Ready Hospital (JC ASRH), Joint Commission Primary Stroke Center (JC PSC), Joint Commission Comprehensive Stroke Center (JC CSC), Joint Commission thrombectomy capable stroke center (TSC) or other similar organization such as Det Norske Veritas (DNV) or Healthcare Facilities Accreditation Program (HFAP)? (select all that apply)
JC ASRH
JC PSC
DNV PSC
HFAP PSC
JC CSC
DNV CSC
JC
thrombectomy-capable stroke center (TSC)
3. Does your state/county/region/locality have a stroke designation program? (select all that apply)
Yes, state stroke designation program [[IF YES, GO TO 3a]]
Yes, county/regional/local-level stroke designation [[IF YES, GO TO 3a]]
No, there is no state/county/regional/local-level designation program [[IF NO, GO TO 4]]
If yes to (3), is your hospital currently designated by that entity as a stroke center or stroke capable/ready hospital? (select all that apply)
Stroke Center (State designation)
Stroke Capable/Ready (State designation)
Stroke Center (County/regional/local designation)
Stroke Capable/Ready (County/regional/local designation)
4. Does your hospital receive stroke consultation services from another hospital via telemedicine?
Yes, only when in-house neurology is not available [[IF YES, GO TO 4a]]
Yes, because we do not have in-house neurology [[IF YES, GO TO 4a]]
No, we have 24/7 in-house neurology coverage [[IF NO, GO TO 5]]
[Optional] If yes to (4), what mode does the telemedicine consult take place? (select all that apply)
Telephone call
Interactive video/videoconference
Other (e.g., teleradiology), please specify: __________________________
Does your hospital provide stroke consultation services to other hospitals via telemedicine?
Yes, we provide telestroke consultation services and can receive patients that we have provided consultations on [[IF YES, GO TO 5A]]
Yes, we provide telestroke consultation services but cannot receive patients in any cases [[IF YES, GO TO 5A]]
No, we do not provide telestroke consultation services [[IF NO, GO TO 6]]
[Optional] If yes to (5), what mode does the telemedicine consult take place? (select all that apply)
Telephone call
Interactive video/videoconference
Other (e.g., teleradiology), please specify: __________________________
[Optional] Does your hospital provide community education on stroke signs and symptoms and importance of calling 911?
Yes
No
Data Abstraction
What process is used for case identification? (select one best answer)
Prospective only
Retrospective only
Combination
Who is responsible for data abstraction? (select all that apply)
Physician
Stroke nursing staff/stroke team member
Medical records staff
QI department staff
Other hospital staff (please specify): _____________
Outsourced
What process is used for data abstraction? (select one best answer)
Mostly or completely concurrent with care
Mostly or completely retrospective
Roughly
equal-- data collected concurrent with care and retrospective
Does your hospital sample cases to abstract for data that is submitted to Coverdell?
Yes [[IF YES, GO TO 4a]]
No [[IF NO, GO TO 5]]
If yes to (4), please briefly describe your sampling method (e.g. following The Joint Commission’s requirements), including the percentage of cases that are sampled.
________________________________________________________________________________________________________________________________________
What electronic health record system does your hospital use for stroke cases?
Allscripts
Centricity
Cerner
Computer Programs and Systems Inc (CPSI)
eClinicalWorks
Epic Systems
McKesson
Meditech
NextGen Healthcare
Other (please specify): ____________________
Data Use
Who receives data reports on your stroke quality of care? (select all that apply)
Hospital CEO/ upper management
Hospital Board
Chief Nursing Officer (CNO)
Stroke Team
Physician Stroke Champion
Chief of Medicine
Other (please specify): _________________
How many systematic quality improvement interventions were implemented by hospital staff as a result of quality of care data reports? Please briefly describe each one (e.g. if there was one that was particularly successful, and if it addressed a specific problem).
Number: ______________
Description: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
[Optional] In the most recent calendar year, have you run additional analyses (beyond what was required for reporting) on your hospital’s own stroke data?
Yes [[IF YES, GO TO 4]]
No [[IF NO, GO TO 5]]
Quality Improvement (QI) Participation
Did you participate in any QI activities (e.g. QI training, networking meetings, learning collaboratives) offered through the State health department Coverdell program?
Yes [[IF YES, GO TO 1a]]
No [[IF NO, GO TO NEXT SECTION]]
If yes to (1), how many? ________
[Optional,
but can be used for process and outcome performance measure (POPM)
data collection]
Has your stroke team implemented structured quality improvement
strategies (e.g. PDSA (Plan-Do-Study-Act) cycles, small tests of
change, lean, six-sigma) to improve
quality of care in the
most recent calendar year?
Yes [[IF YES, GO TO 2a]]
No
[[IF
NO, GO TO 3]]
a.
If yes to (2),
Describe the problem(s) addressed _________________________________________________________________
Briefly describe results _________________________________________________________________
Was this a helpful way to address the problem?
Yes
No
Why or why not? _________________________________________________________________
What
challenges did you encounter?
_________________________________________________________________
_________________________________________________________________
[Optional, but can be used for process and outcome performance measure (POPM) data collection] As a result of participating in the registry the most recent calendar year, what stroke policies or system changes has your hospital implemented? _____________________________________________________
a. Have you assessed the impact of any of these changes, for example, by examining changes in data/performance measures?
Yes
No
[Optional] To what extent do you have buy-in from upper management (i.e. hospital CEO/board/upper management) to implement stroke QI initiatives? (select one best answer)
A great deal of support
A fair amount of support
Little support
No support
[Optional] Do you have other QI initiatives that are not directly related to stroke care at your hospital?
Yes [[IF YES, GO TO 5a-5c]]
No [[IF NO, GO TO NEXT SECTION]]
If yes to (5), are your stroke QI initiatives integrated with other QI initiatives in your hospital?
Yes
No
If yes to (5), compared to other QI initiatives, how important/prioritized are QI initiatives around stroke?
Much more important
A little more important
Equally important
A little less important
A lot less important
If yes to (5), how do you think other hospital QI initiatives affect your stroke QI initiatives?
Complement
Hinder
Do not affect
Hospital Retention
What reasons or incentives are most important in your hospital’s decision to participate in (if new) or continue to participate in the Coverdell Stroke Registry? (select the three most important reasons)
Opportunities for professional development/learning (conference calls, journal articles, etc)
Opportunities for networking/information sharing with other hospitals
Desire/Need to enhance the quality of stroke care we provide
Financial incentive / opportunity to compete for additional funds
Allows/facilitates my hospital becoming/maintaining Stroke Center designation
Access to and/or training on the GWTG tool
Request/interest from upper management/administration
Opportunity to benchmark my hospital against others in the state
Hospital recognition
Other: ________________________________________________________
Contact Information
(This information is not forwarded beyond the State Health Department staff, is not entered into any database, and will only be used to contact you if we have questions about your inventory.)
Name:
______________________________________________
Position /
Title: _______________________________________
Phone:
______________________________________________
Email:
______________________________________________
What is the best
way to reach you?
Phone
If by phone, when are the best days and times to reach you? ___________________________________________________
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Chang, Tiffany (CDC/ONDIEH/NCCDPHP) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |