Hospital Identification Form
Hospital name
Project Manager
Date
To become a unit that consistently treats stroke effectively and safely, evidence and experience has
shown that effective co-ordination of resources and processes have to take place.
This document captures important information about your hospital’s structure regarding stroke
management. It was designed to analyse the current situation in your hospital in terms of treatment of
stroke and to compare it with best practice standards.
The form should be filled out by the members of the hospital steering committee during the project
kick-off meeting. Answers to the various questions should reflect the current state and not the desired
future state of stroke management in the hospital.
The Angels initiative provides various tools including protocols, training resources, quality monitoring
using the Quick initiative auditing tools etc. to assist in the action plan implementation as and where it
is needed.
All information contained within this form is strictly confidential and will only be used within the context
of the QUICK & Angels initiatives.
All information will remain strictly confidential and will only be used to help you create an action plan.
.
For internal use only. Subject to local medical and legal approval.
Hospital Profile
Hospital Resources & Structure
When was the stroke unit
established?
Satellite hospitals referring
patients to this stroke unit
Population pool within the
hospital’s geographic
coverage
Yes
Yes
24h
Emergency ward
Physiotherapy
MRI
Occupational therapy
CT Scanner
Speech therapy
Clinical laboratory
Psychology
Dieticians
Yes
Beds
Patients
per
nurse
Occup.
Rate %
Stroke
pt. Ave.
LOS
Intensive Care Unit
High Care Ward
Stroke Unit
General Ward
Other beds available
to stroke patients
Occup. Rate = Average Occupancy rate
Stroke pts. Ave. LOS = Length of Stay or in other words the average time stroke patients spend in the ward
For internal use only. Subject to local medical and legal approval.
Hospital Profile
Strokes treated per year
Week
Month
Year
Previous
year
Suspected strokes
Ischaemic stroke %
Haemorrhagic
stroke %
% of patients getting
thrombolysis
% of patients on
which MRI is
performed first line
Restrictions/ Limitations
Please provide details of any restrictions / limitations that might exist in terms of?
Only certain staff e.g. doctors are allowed to order lab, imaging or other tests
Slow or cumbersome patient admission procedures
Reimbursement of hospital stay
Contacting specialists or other departments
Hospital administration issues e.g. financial / political / resource reasons to not treat stroke
For internal use only. Subject to local medical and legal approval.
Hospital Profile
Hospital layout
Make a rough drawing of the layout of the hospitals showing the relevant wards & departments
For internal use only. Subject to local medical and legal approval.
rofile
Typical stroke patient flow
For internal use only. Subject to local medical and legal approval.
How do patients typically arrive at the hospital?
What % arrives by ambulance?
Where does the diagnosis of stroke typically take place?
Does it include a cross examination with stroke witnesses by the Neurologist, Radiologist,
Emergency Medical Services, Laboratory Medicine or Emergency Physician?
Describe the tests and evaluation procedures typically followed. Who, what, how.
Describe the treatments typically given in acute stroke. Who, what, where.
Describe where patients are typically treated after the acute event. Ward, admission requirements, hand
over procedures etc.
Access to rt-PA
-PA
For internal use only. Subject to local medical and legal approval.
Is rt-PA available and reimbursed at the hospital?
Provide details on obtaining informed consent from patients for the use of rt-PA.
Is consent needed? How is consent typically obtained from patients / family members? Are any
specific tools used e.g. forms, consent aids, etc. Who obtains consent? When is consent obtained?
Where rt-PA is typically stored?
Who can dispense rt-PA?
Who will typically administer rt-PA?
alyst
Stroke Catalyst
For internal use only. Subject to local medical and legal approval.
Speciality
Experience in treating stroke
Availability (Working hours)
Back-up doctors when Stroke Catalyst is not available
Preferred mentor
Preferred peer group / Journal club / Forum
Preferred local conference
Preferred Regional or International congress
For internal use only. Subject to local medical and legal approval.
Stroke Team
Stroke Team
Stroke Specialist
Emergency Medical Service
Companies serving hospital
EMS Call Centres
Emergency Physician
Emergency Department Nurse
Triage Nurse / Physician
Clinical laboratory services
Radiologist
Hospital Administrator
Hospital Marketing Department
Stroke Unit Consultant
Stroke Unit Nurses
Neurosurgeon
Neuroradiologist (if available)
For internal use only. Subject to local medical and legal approval.
Stroke Team Arrangements
Stroke team special arrangements
Please provide details of the special arrangements regarding treatments of stroke patients, if they
currently exist.
Emergency medical services
Call Centre
Diagnosis of stroke
Dispatch of Ambulance services
Training requirements
Emergency Medical Services
Diagnosis of stroke
Treating stroke as an emergency
Pre-notification of the hospital
Protocols to be followed while
transporting patients
Handover procedure
Training requirements
Quality monitoring KPI's
For internal use only. Subject to local medical and legal approval.
Stroke Team Arrangements
Emergency Ward
Diagnosis & Triage of stroke patients
Code stroke activation procedure
Registered Nurse protocol
Emergency Physician protocol
Target time in which evaluations
have to be completed
Authority to order tests
Handover procedure
Training requirements
Quality monitoring KPI's
Clinical laboratory
Availability
For internal use only. Subject to local medical and legal approval.
Pre-notification / Code stroke
procedure
Standard tests
Point of Care tests (INR / Glucose)
Stroke Team Arrangements
Priority labelling
Report procedure (paper/ phone/
computer)
Which test the stroke physician will
wait for before treatment
Training requirements
Quality monitoring KPI's
Radiology department
Availability
Standard test
Protocol
Reporting procedure
Reporting person
For internal use only. Subject to local medical and legal approval.
Back-up plan if not available
Priority access for stroke patients
Pre-notification / Code stroke
procedure
Training requirements
Stroke Team Agreements
Quality monitoring KPI's
Stroke physician
Availability
Back-up plan if not available
Protocol
Code stroke activation procedure
Training requirements
KPI's
Stroke unit
Availability of beds for stroke patients
For internal use only. Subject to local medical and legal approval.
Handover procedure
Protocols
Integration and coordination of rehab
services
Training requirements
KPI's
atment Protocols / Standing orders
Stroke Treatment Protocols / Standing orders
Exist
Implemented
Emergency medical services
Emergency ward - Registered nurse
Emergency ward - Physician
Radiology
Stroke physician
rt-PA Administration
Post lysis
Day 2 - 3 post lysis
For internal use only. Subject to local medical and legal approval.
Quality
monitored
Managing complications post lysis
General stroke protocol (Excl. lysis)
General stroke complications
Stroke units Nursing Care
Intracranial Haemorrhage
Rehabilitation
Discharge
Stroke Team Education
Education
Please provide details of what training is provided for:
The Stroke Network
Emergency response call centres
Emergency medical response
services
Emergency department staff
Clinical laboratory
For internal use only. Subject to local medical and legal approval.
Radiology department
Stroke specialist
Stroke unit staff
Referring doctors
Patient education / awareness
campaigns
Described tools used
Frequency of training
Last training session
Quality Monitoring
Quality Monitoring
Please provide details of Quality monitoring process at the hospital. What is measured, how and how
often?
Does the hospital submit data to any registry or national audit?
Is quality monitoring built into day-to-day tasks or is it additional work?
For internal use only. Subject to local medical and legal approval.
Last audit
Stroke Team Motivation
Door to
Needle
time
% of pts.
with
DTN time
<60mins
Symptom
Door
Results of last audit
Motivation
Please provide details of strategies to keep Stroke Team members motivated
Does the Stroke Team have regular meetings?
ke Activation Procedure
Code Stroke
Does a Code Stroke activation procedure exist?
Who is activated?
Which tools are used? (Bleeper / Pager / SMS / Phone call / Telemedicine/ Other)
For internal use only. Subject to local medical and legal approval.
Symptom
Treatment
Who can activate a Code Stroke?
What are the agreed response times & is this quality controlled?
Is this currently implemented for all stroke suspicions?
For internal use only. Subject to local medical and legal approval.