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P003: Epidemiology and Response Division (FY17-FY19 Strategic Plan)

P003: Percent of NM hospitals certified for stroke care

Current Value


FY 2017


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Story Behind the Curve

  • In the US and NM, stroke is the fifth leading cause of death and a leading cause of adult disability. There are three levels of stroke center certification. Six out of 43 acute care hospitals (14%) in NM are certified for stroke care, and four of the six submit their data to the American Heart Association (AHA) Get with the Guidelines (GWTG) Stroke Registry.
  • Patients receiving care at primary stroke centers have a higher rate of survival and recovery than those treated in hospitals without this type of specialized care.  
  • A benefit to communities is for patients to be directed in a timely manner to the nearest certified stroke care hospital. Stroke care center designation cannot be awarded until stroke data is submitted to a national registry, enabling facilities to analyze and improve healthcare outcomes.
  • In Q2 of FY17, two new hospitals from the southern and northwest parts of the state began submitting data. There is a benchmarking group for stroke data for the six hospitals now submitting data to GWTG-Stroke Registry who can now review blinded data from the American Heart Association for process improvement in stroke care.
  • The New Mexico Department of Health (NMDOH) Emergency Medical Systems (EMS) Bureau Stroke Program assisted these two hospitals by initiating their data registry registration for their national accreditation process.
  • Continued outreach to rural facilities will occur statewide.


  • NM Environment Department Air Quality Bureau    
  • Acute care hospitals
  • EMS agencies
  • American Heart Association
  • American College of Cardiology

What Works

  • The incentive from a hospital obtaining stroke center accreditation and certification has many benefits for the community, including assurance that the hospital adheres to stroke prevention and treatment measures that have been agreed upon by the American Heart and Stroke Associations, the U.S. Centers for Disease Control and Prevention, and national accrediting bodies. 
  • Adherence to stroke prevention and treatment measures reduces disability and death associated with stroke.  
  • Accreditation and certification will help assure that the hospitals are appropriately reimbursed by Medicare, Medicaid, and third-party payers for the improved care delivered to stroke patients.


  • Continue reporting on the number of hospitals that are nationally accredited and achieve NMDOH certification as stroke centers.
  • Collect data on stroke patients in accordance with national guidelines.
  • Once data is being submitted, NMDOH will work with the hospitals in achieving other aspects required for stroke center designation.
  • NMDOH will then, in accordance with NMDOH rules, certify an acute care hospital as a:
    • Primary Stroke Center
    • Comprehensive Stroke Center
    • Acute Stroke Hospital

Action Plan

The EMS Bureau will increase the percentage of NM hospitals certified in stroke care by achieving the following quarterly milestones:

  • Q1: Assist two hospitals in the southern and central regions with national data registry and participation in stroke system of care activities. Completed.
  • Q2: Assist at least two new hospitals in the southern or central region not reporting to Get with the Guidelines (GWTG) to begin reporting their data directly to the EMS Bureau for quality improvement and benchmarking. Completed.
  • Q3: Identify at least one hospital capable of becoming acute stroke ready by working with UNM Telemedicine. Completed.
  • Q4: Continue outreach at quarterly meetings and document success stories to disseminate to hospitals for their use. Completed.

FY17 Annual Progress Summary

During FY17, the stroke coordinator worked with statewide partners to improve the quality of stroke care in NM. There are seven hospitals entering data into the data registry approved by NMDOH, and the Department will be able to access these data soon. The participating hospitals, as well as hospitals interested in participating in the system of care, are dedicated to improved care. Participation in the system of care includes not only data submission, but also quarterly meetings with local and state partners, as well as increased education and awareness for hospital and EMS caregivers. At the end of FY17, there were six hospitals certified as Primary Stroke Centers by NMDOH. Additionally, a seventh hospital received their national accreditation as an Acute Stroke Ready Stroke Hospital, and will be certified by NMDOH soon. Rehoboth McKinley Christian Healthcare Services will be the first facility certified at the Acute Stroke Ready Hospital level in New Mexico.

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