Transcript Slide 1

Primary Stroke Service
(PSS): A Primer
Joanne LaBelle, RN, MS, CPHQ, HRM
Online Module
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Bureau of Infectious Disease Prevention,
Response and Services
Massachusetts Department of Public Health
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
In accordance with the ACCME Standards for
Commercial Support of CME, the speakers for
this course have been asked to disclose any
relevant relationships with commercial entities
that are either providing financial support for
this program or whose products or services are
mentioned during their presentations.
Both presentation authors have
nothing to disclose.
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Learning Objectives
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Define the purpose of PSS regulations.
State the importance of documenting the time of
last known well (LKW) or symptom onset.
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Describe the PSS survey process.
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Identify requirements of the PSS regulations.
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Recognize the signs and symptoms of stroke.
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List life-style changes for preventing stroke.
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Introduction:
Why do we have PSS?
What is PSS designation?
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PSS is Primary Stroke Service.
MA State PSS regulations passed in
2004:
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PSS designated hospital MUST have the
capacity to accurately diagnose and treat
stroke, 24 hours/day, 7 days/week.
EMS services are directed to take possible
stroke patients to PSS hospitals.
Emergency diagnostic & therapeutic services
are provided by a multi-disciplinary team.
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Importance for Clinical Staff
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Required services must be available
24/7… makes the provider’s job easier!
Validates that the hospital is meeting
minimum standards for stroke care,
allowing EMS to bring possible stroke
patients in for care.
PSS participation provides comparison
data to assist in the QI process.
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History of PSS Designation
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March 2004: PSS regulations developed
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September 2004: PSS designation begins
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July 2005: PSS data collection begins
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July 2005: Adoption of EMS Point of Entry
(POE) plan
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As of February 2012, 70 of the 72 eligible
MA acute care hospitals are PSS designated
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PSS Hospitals in MA
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Regulatory requirements
PSS Ongoing Monitoring
Monitoring is done through periodic survey
visits.
Unannounced surveys are conducted for:
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A stroke-related reported event.
A patient complaint related to stroke care.
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PSS Survey Process
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Tours of ED and CT area
Review of:
Selected medical records
 Protocols
 Stroke Committee meeting minutes
 Community & provider education records
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Interviews with:
Stroke coordinator & physician champion
 Members of the stroke committee
 Care providers
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Provider’s Participation
in a PSS Survey
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The surveyor may tell registration staff
that he/she is having a stroke and is
brought through the ED care system.
The surveyor asks each provider
encountered, “What is your role?”
Be sure to accurately describe the good
work you do!
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Update to Regulations (2004)
DHCQ 04-4-440 (2004):
 Document LKW in 100% of patients with suspected
ischemic stroke, regardless of ED arrival time.
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100% of patients with suspected ischemic stroke
presenting within 3 hours of symptom onset are
evaluated for IV-tPA eligibility.
All ischemic stroke patients receiving IV-tPA are
treated as rapidly as is safe and feasible, with the
goal of IV-tPA within 60 minutes of ED arrival.
Under EMS POE plans, patients experiencing acute
stroke symptoms are brought to PSS hospitals.
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Update to Regulations (2005)
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EMS Stroke POE plans implemented statewide.
Hospitals temporarily without CT capacity are not
treated as a PSS hospital while CT is down.
Unless the patient requires immediate
stabilization, the hospital needs to notify EMS of
the diversion status.
PSS hospitals are required to collect data on all
eligible patients starting on or before July 1st.
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Update to Regulations (2006)
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PSS strongly encourages clinical review of all
phases of stroke data collection and reporting.
Data element added: Hemorrhagic complications
occurring within 36 hours of the administration
of IV-tPA.
If transferring a patient post-IV-tPA, the sending
hospital must contact the receiving hospital for
complications occurring after transfer, and enter
into registry.
Written transfer follow-up protocols are required.
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PSS: Expanding the IV-tPA Window
2009 Update:
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PSS does not have the authority to
recommend or to prohibit use of IV-tPA in the
expanded time window (3-4.5 hours).
Revision: Time target data does not need to be
collected on an ongoing basis for all targets.
However, it is expected that time target data
is reviewed as part of the improvement
process to assess delays in IV-tPA treatment.
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Update to Regulations
2010 – 2011:
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Public release of hospital-specific
performance data on the rate of eligible
patients receiving IV-tPA for ischemic stroke
in a PSS-designated ED.
Instructions on how to create PSS hospital
reports included allowing hospitals to review
the information to be publically reported,
prior to the release.
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Time Targets
PSS Time Targets
Category 1: Ongoing data collection required
Recommendation
ED door-to-needle
time for IV
thrombolytic (tPA)
treatment
Time from door to CT
scan or MRI scan
performance
Time Targets
within 60 min of patient
arrival in ED
within 25 min of
admission
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PSS Time Targets (continued)
Category 2: When delays in care are identified, use the time targets as
part of a quality improvement drill-down to resolve the delays.
Recommendation
Time Targets
Time from patient arrival at ED to notification of Acute
Stroke Team (AST), i.e., making the call to the team
within 15 min of
arrival
Time from completion of CT scan or MRI scan to
interpretation by physician
within 20 min of
scan completion
Time from order of ECG to performance through
completion of ECG and interpretation
within 45 min of
being ordered
Time from order of lab tests to completion of tests, report
of results, and interpretation
within 45 min of
being ordered
Time from notification of AST to response of team
member by phone, video or at patient bedside to assess
patient as appropriate
within 15 min of
being called
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PSS Time Targets (continued)
Category 2: When delays in care are identified, use the time targets as
part of a quality improvement drill-down to resolve the delays.
Recommendation
Time Targets
Time from order of chest X-Ray, if indicated, to
performance through completion of chest X-Ray and
interpretation
within 45 min of
being ordered
Time from order of neurosurgical evaluation to start of
evaluation; includes transfer to another hospital for such
evaluation, if applicable
within 2 hours of
being deemed
clinically
necessary
Neurosurgical intervention
as needed
urgently
Public PSS Data
Public Release of PSS Data
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Aggregate data released in 2009:
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Timeliness of Arrival to the ED
Treatment with IV-tPA
Brain Imaging
Timeline:
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July 2009 release: 2006-07 aggregate data.
September 2009 release: 2007-08 aggregate data.
Hospital-specific data released in 2010 & 2011:
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Treatment with IV-tPA
Comparison by region, bed size & teaching status
Timeline:
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June 2010 release: 2007-08 data.
October 2011 release:2008-09 & 2009-10 data.
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Improvement in rates of IV-tPA
use at PSS hospitals (2006-2010)
Timeframe
# Hospitals
# Eligible
patients
% Eligible received
tPA
2006-07
64
838
68.3%
2007-08
68
1019
61.7%
2008-09
68
1092
71.1%
2009-10
68
1113
79.8%
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Rate of Eligible Patients Receiving IV-tPA at PSS
Hospitals
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2006-07
2007-08
2008-09
2009-10
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PSS and Protocols
What are the PSS requirements
related to protocols?
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The hospital must develop and implement written
protocols for acute ischemic and hemorrhagic strokes
based on previously published guidelines and/or
developed by a multidisciplinary team.
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Protocols must be available in the ED and other areas
likely to assess/treat acute stroke patients.
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All protocols/standard order sets must be reviewed and,
if needed, revised at least annually.
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What protocols
are required by PSS?
Examples include:
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EMS communications plan
Identification of acute stroke team and triage plan
Patient clinical assessments, vital functions, monitoring
Systems to promptly perform diagnostic tests
Use of medications
Time target goals
Telemedicine services
Post-admission care
Patient/family education
IV-tPA follow-up process
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What is expected re: follow-up
for IV-tPA complications?
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Written protocols are jointly developed by hospitals
routinely transferring and receiving patients.
At a minimum, the protocol includes:
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The title of the contact at the transferring hospital,
The title and contact information for the
representative at the receiving hospital providing
information on the complications.
Information on the timeline and follow-up process.
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Is a generic transfer
agreement acceptable?
A transfer agreement must:
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Describe the responsibilities of each hospital.
Be signed by the Stroke Service Director, the
Medical Director of each hospital or designee, and
the CEO of each hospital or designee.
If there is no reference to the transfer of stroke
patients in the generic transfer agreement, an
addendum must be written. A representative from
both the sending and receiving hospitals must sign
the addendum.
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Stroke Committee
How do the Stroke Committee and
Acute Stroke Team differ?
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Stroke Committee:
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A Committee designated by the governing body
that includes the physician serving as Stroke
Service Director or Coordinator. The Committee
provides oversight for the Stroke Program and
care outcomes.
Acute Stroke Team
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Physician(s) and other health care professionals,
e.g., nurse, physician's assistant, or nurse
practitioner, with stroke expertise who are
available to respond and evaluate patients
presenting with acute stroke symptoms.
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What is the responsibility of
the Stroke Committee?
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Annual review, and revision if needed, of all
stroke protocols and order sets.
Review of reports including:
 Number and types of stroke patients,
 Nature of any complications of IV-tPA,
 Compliance with PSS regulations,
 Adherence to time targets
Based on data reports, direct the QI efforts to
improve patient care.
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Education Expectations
What are the ongoing qualifications
for the Stroke Service Director?
A licensed physician with acute stroke expertise
defined any of the following:
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Completion of a stroke fellowship.
Participation (as an attendee or faculty) in at least 2
regional, national, or international stroke courses or
conferences annually.
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5 or more peer-reviewed publications on stroke.
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8 or more CMEs annually in the area of cerebrovascular disease.
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Or,other criteria approved by the governing body of
the hospital.
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What are the continuing education
requirements for providers?
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Hospitals must provide education for ED
physicians, nurses, allied health professionals,
and EMS personnel in acute stroke prevention,
diagnosis and treatment.
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The education is a minimum of 1 hour/year of
formal stroke education.
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Hospitals are encouraged to partner with other
hospitals.
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What does PSS consider
“formal education”?
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Acceptable methods:
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Speaker forums (e.g., lectures, Stroke Grand Rounds)
Videos and audio conferences
Outside conferences
Webinars, e-learning modules
Stroke Morbidity and Mortality Meetings
Certification/recertification for ACLS and NIHSS
Demonstration of compliance:
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Attendance sheets, topic and content outline
If not a live presentation:
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A post-test is given, results are maintained
A system is in place to respond to participant’s questions
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Why does PSS require
community outreach?
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To increase the number of patients
eligible for IV-tPA, more timely ED
arrival is important.
To share important information with
the community, including:
Risk factors
 Stroke signs and symptoms
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What are the guidelines for
community education?
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Community education to the public must be
targeted to the needs of each hospital’s
community.
A significant percentage of the catchment
areas population need to receive stroke
education outreach.
The required content must be covered:
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Stroke prevention
Recognition of stroke symptoms, and/or
Treatment of stroke
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How do you document
community education?
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Acceptable methods:
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Newsletters/Mailings and Newspapers
Public Service Announcements
Stroke education materials provided at community
events
Education provided to area health care providers
Speaker Forums
Demonstration of compliance:
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Log of the number of brochures used
Attendance sheets for live presentations
Copies of publicity for public events
Summary documentation of public events
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Signs and Symptoms of Stroke
Vague Symptoms
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Patients presenting with vague neurological
symptoms may not be considered as having a
possible stroke.
REMINDER: Vague neurological symptoms
may be due to stroke.
Patients presenting with vague neurological
symptoms should have an assessment and
documentation re: potential for a stroke.
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Examples: Vague Symptoms
A list provides a trigger to facilitate an appropriate
assessment and diagnostic treatment:
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Acute mental status change,
Acute gait disturbance,
Acute speech disturbance,
Vertigo, Syncope, Dizziness
Giddiness,
Diplopia,
Expressive aphasia,
Headache,
Limb weakness and/or fall with unknown reason,
Numbness/tingling,
Possible seizure,
Weakness.
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Could this be a stroke?
If YES: Using the eligibility criteria, if the patient
screens-in as IV-tPA appropriate, begin...
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If the patient may be appropriate for IV-tPA, begin
and DOCUMENT informed consent. Inform the
patient he/she may be a candidate for IV-tPA and
provide the patient/family with information.
Follow the protocol for an acute stroke evaluation,
including activating the stroke team and the
implement the stroke standard order set.
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Could this be a stroke?
If NO, Using eligibility criteria, screen for the
appropriateness of IV-tPA. If the patient would not be
eligible due to a contraindication or minimal deficit,
document in the chart!
For example:
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DOCUMENT the reason why you believe the
diagnosis is not a stroke.
If uncertain, document if the patient is diagnosed
with a stroke, the reason he/she would not be
eligible for IV-tPA. For example, “Stroke considered,
however, if this is a stroke, IV-tPA is not appropriate
because the symptoms are too mild.”
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Dysphagia Screening
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Screen for dysphagia on ALL potential stroke
patients, as they may have impaired
swallowing.
If the patient passes the screen, oral
medications and oral nutrition MAY be given if
deemed appropriate. If the patient fails the
screen, maintain the NPO status and request a
Speech and Language Therapist’s assessment.
Use the vague symptom list to identify patients
that MAY be discharged as a stroke patient.
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LKW and Symptom Onset
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LKW: “Last known well" (LKW) is used to identify
when the patient was either last seen or last known
to be at baseline (usual state of health). This may
change with various observers. If the last known well
time cannot be identified, document it is not known.
Time of symptom onset: The time when a patient
experiences the start of symptoms, in the company
of an individual able to verify that the patient was
functioning normally up until the start of symptoms.
LKW and symptom onset MAY be the same if
someone witnesses the exact time symptoms begin.
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Stroke Diagnosis: FAST
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F (Face): Ask the person to smile. Does one side of
the face droop?
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A (Arms): Ask the person to raise both arms. Does
one arm drift downward?
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S (Speech): Ask the person to repeat a simple phrase.
Is their speech slurred or strange?
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T (Time): Time is brain. If you observe any of these
signs, call 911 immediately.
FAST materials available at:
http://massclearinghouse.ehs.state.ma.us/heart-diseaseand-stroke-prevention
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Stroke Prevention:
Modifiable Risk Factors
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High blood pressure
Atrial fibrillation
High cholesterol
Diabetes
Atherosclerosis
Circulatory Problems
Tobacco use and smoking
Alcohol use
Physical inactivity
Obesity
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Stroke Prevention: NonModifiable Risk Factors
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Age (over age 55)
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Gender (male)
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Race, high risk:
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African American,
Hispanic or
Asian/Pacific Islander
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Family history
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Previous stroke or TIA
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Fibromuscular dysplasia
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Patent foramen ovale
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Basis of Regulations
Based on elements of the Brain Attack
Coalition’s nationally recognized consensus
statement
Reference:
Alberts MJ, Hademenos G, Latchaw RE, Jagoda
A, Marler JR, et al. Recommendations for the
establishment of primary stroke centers. JAMA.
2000;283:3102-3109
Link to Abstract:
http://jama.ama-ssn.org/content/283/23/3102.abstract
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Resources
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All regulations, Circular Letters,
maps, FAQs, etc mentioned in this
presentation are available in one
easy location to all participants of
the SCORE Collaborative:
http://bit.ly/pssregs (password
required)
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CEU’s and CME’s
The Bureau of Infectious Disease
Prevention, Response and Services,
Massachusetts Department of Public
Health, designates this educational
activity for a maximum of 1 CME/CEU
credit, upon successful completion of
the post-test, available at:
http://bit.ly/PSSModule
Questions, Comments…
Joanne LaBelle, RN, MS, CPHQ, HRM
Massachusetts Department of Public
Health
250 Washington Street, 4th Floor
Boston, MA 02108
Tel: (617) 624-5953
[email protected]
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