NIH Stroke Scale International

Globally Harmonized, Standardized and Accredited Training and Certification Program

The International Network

The NIH Stroke Scale (NIHSS) International is an initiative by national and international government entities as well as private and scholastic organizations. These bodies are dedicated to promoting wellness and better patient care in the field of stroke.
It is our vision to provide all patients the best opportunity for survival. We believe the “Know Stroke” program gives healthcare providers the necessary tools to obtain this objective.

Mission       

To modernize the global healthcare and clinical research system using global standards of care so that no patient is left behind, no matter what race, religion, socio-economic status, political affiliation or geographical location.

Regulations and Privacy

Regulatory agencies, Ethical Review Committees and healthcare accreditation organizations now require that any healthcare professional, using the NIHSS as a patient diagnostic tool, must show continued competencies in the use of the tool in order to maximize inter-rater-reliability between diagnosticians and improve human subject protection and patient safety.

Approach to Human Subject Protection and Patient Safety

"The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. The NIHSS can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients. The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity. The NIHSS has been shown to be a predictor of both short and long term outcome of stroke patients. Additionally, the stroke scale serves as a data collection tool for planning patient care and provides a common language for information exchanges among healthcare providers. The scale is designed to be a simple, valid, and reliable tool that can be administered at the bedside consistently by physicians, nurses or therapists."
"The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained observer rates the patent’s ability to answer questions and perform activities. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. The single patient assessment requires less than 10 minutes to complete. The evaluation of stroke severity depends upon the ability of the observer to accurately and consistently assess the patient."



Modified Rankin Scale International

A consistent approach to scoring patient recovery is essential for healthcare and research purposes and is desirable for routine clinical application. This training program was prepared by Professor KR Lees in association with the Media Services Department of the University of Glasgow, with the assistance of an educational grant. The support and co-operation of staff in the Acute Stroke Unit Cerebrovascular Clinic of the Western Infirmary, Glasgow and of Drumchapel Hospital, Glasgow is gratefully acknowledged. Patients shown in the recordings gave consent to use of this material for teaching and research purposes. Unauthorised copying, sale or distribution of the material is prohibited. Patients shown in the recordings gave consent to use of this material for teaching and research purposes. Unauthorised copying, sale or distribution of the material is prohibited.

Barthel Index

This index measures the extent to which somebody can function independently and has mobility in their activities of daily living (ADL) i.e. feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation and stair climbing. The index also indicates the need for assistance in care. The Barthel Index (BI) is a widely used measure of functional disability. The index was developed for use in rehabilitation patients with stroke and other neuromuscular or musculoskeletal disorders, but may also be used for oncology patients.

Fugl-Meyer Assessment (FMA) (coming soon)

The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment index. It is designed to assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia (Fugl-Meyer, Jaasko, Leyman, Olsson, & Steglind, 1975; Gladstone, Danells, & Black, 2002). It is applied clinically and in research to determine disease severity, describe motor recovery, and to plan and assess treatment.

Columbia-Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is used extensively across primary care, clinical practice, surveillance, research, and institutional settings. It is available in over 100 country-specific languages, and is part of a national and international public health initiative involving the assessment of suicidality, including general medical and psychiatric emergency departments, hospital systems, managed care organizations, behavioral health organizations, medical homes, community mental health agencies, primary care, clergy, hospices, schools, college campuses, US Army, National Guard, VAs, Navy and Air Force settings, frontline responders (police, fire department, EMTs), substance abuse treatment centers, prisons, jails, juvenile justice systems, and judges to reduce unnecessary hospitalizations. Of note, the CDC adopted the Columbia definitions (referenced in CDC document) and there is a link to the C-SSRS in the new CDC surveillance document.

Beck Depression Inventory® (BDI)

The Beck Depression Inventory (BDI) is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression (Beck, et al., 1961). The BDI has been developed in different forms, including several computerized forms, a card form (May, Urquhart, Tarran, 1969, cited in Groth-Marnat, 1990), the 13-item short form and the more recent BDI-11 by Beck, Steer & Brown, 1996. (See Steer, Rissmiller & Beck , 2000 for information on the clinical utility of the BDI-11.) The BDI takes approximately 10 minutes to complete, although clients require a fifth – sixth grade reading level to adequately understand the questions (Groth-Marnat, 1990). Internal consistency for the BDI ranges from .73 to .92 with a mean of .86. (Beck, Steer, & Garbin, 1988). Similar reliabilities have been found for the 13-item short form (Groth-Marnat, 1990). The BDI demonstrates high internal consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric populations respectively (Beck et al., 1988). References Beck, A.T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Beck, A. T., Steer, R.A., & Garbin, M.G. (1988) Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77-100. Groth-Marnat G. (1990). The handbook of psychological assessment (2nd ed.). New York: John Wiley & Sons. Hojat, M., Shapurian, R., Mehrya, A.H., (1986). Psychometric properties of a Persian version of the short form of the Beck Depression Inventory for Iranian college students, Psychological Reports, 59(1), 331-338. Steer, R. A., Rissmiller, D. J.& Beck, A.T., (2000) Use of the Beck Depression Inventory with depressed geriatric patients. Behaviour Research and Therapy, 38(3), 311-318.

Important Quotes from Industry Leaders

“Working closely with global industry leaders– including major universities, governments, private and not-for profit organizations–we have proven that we can ultimately create globally accepted standards without boundaries, moving our industry to become more efficient by breaking down the silos and non-collaborative models,” said Al O. Pacino, President, HealthCarePoint. “Our collaborative approach eliminates redundant burdens at the investigator site level, saving industry stakeholders billions, as regulatory agencies continue to require increased proof of competencies and professional compliance.”

When NINDS produced a full and accurate, high quality program for the NIH Stroke Scale in 2002, we knew it was something the research community badly needed. But I don’t think we could have ever dreamed that the program would reach this many people. We are impressed by the fact that this important medical tool has been made available globally, and to so many disciplines,” said Walter J. Koroshetz, M.D., Deputy Director of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health.

“As the most successful training and certification program, the NIHSS International illustrates how other programs can achieve global acceptance. By combining programs like the NIHSS into global healthcare and clinical research, we could ultimately improve outcomes as all healthcare providers learn to diagnose patients the same way–in a standardized fashion.”–Patrick Lyden, MD, FAAN, FAHA, Chairman, Department of Neurology Carmen and Louis Warschaw Chairin Neurology Cedars-SinaiMedical Center.

“The Portuguese language is spoken by 244 million people worldwide. The NIHSS certification has become a vastly important initiative, allowing healthcare providers to transnationally use the instrument as a standard of care, ultimately leading to better outcomes for stroke patients.”–Elsa Azevedo, MD, PhD, São João Hospital Center, University of Porto, Portugal; Pedro Castro, MD, São João Hospital Center, University of Porto.

"The NIHSS is used widely In the Netherlands during trials. Now we have the opportunity to promote its use in routine care by certified ER personnel, stroke nurses and neurologists, and I am convinced that this will improve the care and clinical outcomes of our stroke patients.”–Diederik W J Dippel, MD, Prof, Erasmus MC University Medical Center.

“Spanish is spoken by nearly 406 million people in 31 countries. Not only has the Spanish-NIHSS become widely used across most of the Spanish-speaking world, it has also become a unifying tool for research, stroke registers, quality control and every day clinical work. We are very proud of being a part of this global effort.”–Arnold Hoppe, MD, Director Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiagode Chile.

“When the Italian-NIHSS became public, we thought we would be helping Italian stroke physicians and nurses to improve their ability to use the scale in the proper way. Over the years, we came to realize that NIHSS is not only a scale, it now belongs to a new vision of modern stroke care!”–Francesca Romana Pezzella, MD, PhD, MSc Stroke Unit, DEM, AOS St Camillo Forlanini, Roma.

“Stroke is a major health concern in Malaysia due to the steady increase in the prevalence of vascular risk factors and a growing number of elderly. Thrombolysis for stroke is in its early days in Malaysia. Because access to the standardized program is free, it should become more wide spread among healthcare providers, just as it has in other countries, and hopefully will lead to a reduction in assessment delays and improved patient care.”–Ramesh Sahathevan, MD, Ph. D, MRCP, M. Med, University Kebangsaan, Malaysia Medical Centre.

“Sharing our BlueCloud Delivery, Distribution, Implementation and Tracking (DDIT) sustainable innovations, intellectual property, including our delivery vehicles and our proprietary database methodologies, has proven to be a successful collaborative model to help modernize the world of healthcare and clinical research. With the help of champion collaborators, programs like the NIHSS can be delivered to healthcare providers around using our DDIT innovations the world without added financial burdens to the ecosystem because ☆ NO PATIENT SHOULD BE LEFT BEHIND ☆. Our goal is to continue our collaborative efforts so that all organizations and their patients can have an equal opportunity to participate in our global healthcare and clinical research ecosystem, learn best practices and ultimately offer the best possible standards of care, with a common global mission to modernize the healthcare and clinical research system so that no patient is left behind no matter what race, religion, socio-economic status, political affiliation or geographical area by empowering and incentivizing people and businesses to share their information for business and compliance.”–Al O. Pacino, President, HealthCarePoint.

References

 • 
Ghandehari K. Challenging comparison of stroke scales. J Res Med Sci. 2013 Oct;18(10):906-10.
 •  Seven-day NIHSS is a sensitive outcome measure for exploratory clinical trials in acute stroke: evidence from the Virtual International Stroke Trials Archive. Kerr DM1, Fulton RL, Lees KR; VISTA Collaborators. Stroke. 2012 May;43(5):1401-3. doi: 10.1161/STROKEAHA.111.644484. Epub 2012 Feb 2.
 •  Cumbler E et al. Quality of care for in-hospital stroke: analysis of a statewide registry. Stroke. 2011 Jan;42(1):207-10. doi: 10.1161/STROKEAHA.110.590265. Epub 2010 Dec 2.
 • 
Hills NK1, Josephson SA, Lyden PD, Johnston SC. Is the NIHSS certification process too lenient? Cerebrovasc Dis. 2009;27(5):426-32. doi: 10.1159/000209237. Epub 2009 Mar 19.
 •  Gocan S, Fisher A. Neurological assessment by nurses using the National Institutes of Health Stroke Scale: implementation of best practice guidelines. Can J Neurosci Nurs. 2008;30(3):31-42.
 •  Adams HP, et al. Guidelines for the Early Management of Adults With Ischemic Stroke. A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655-1711.
 •  Lindsell CJ, et al. Validity of a Retrospective National Institutes of Health Stroke Scale Scoring Methodology in Patients With Severe Stroke. J Stroke Cardiovasc Diseas. 2005;14(6):281-283.
 •  Lindsay MP, et al. Research to practice: nursing stroke assessment guidelines link to clinical performance indicators. Axone. 2005 Jun;26(4):22-7.
 •  Connors, III JJ, et al. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention. A Joint Statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology* Neurology. 2005;64:190-198.
 •  Alberts MJ, Easton JD. Stroke Best Practices: a team approach to evidence-based care. J Natl Med Assoc. 2004 Apr;96(4 Suppl):5S-20S.
 •  Leyden P (video). NIH Stroke Scale. NIHSS-English Instructions and Training Only – V3. 2004.

Important Quotes from Industry Leaders

“Sharing our BlueCloud Delivery, Distribution, Implementation and Tracking (DDIT) sustainable innovations, intellectual property, including our delivery vehicles and our proprietary database methodologies, has proven to be a successful collaborative model to help modernize the world of healthcare and clinical research. With the help of champion collaborators, programs like the NIHSS can be delivered to healthcare providers around using our DDIT innovations the world without added financial burdens to the ecosystem because ☆ NO PATIENT SHOULD BE LEFT BEHIND ☆. Our goal is to continue our collaborative efforts so that all organizations and their patients can have an equal opportunity to participate in our global healthcare and clinical research ecosystem, learn best practices and ultimately offer the best possible standards of care, with a common global mission to modernize the healthcare and clinical research system so that no patient is left behind no matter what race, religion, socio-economic status, political affiliation or geographical area by empowering and incentivizing people and businesses to share their information for business and compliance.”–Al O. Pacino, President, HealthCarePoint.


NIHSS CLINICAL TRIALS DISCLOSURE / DISCLAIMER for CRO, Sponsors and Regulatory Agencies

Sponsors and institutions using this program to document rater competency, inter-rater reliability and educational compliance for studies, programs and clinical trials: You may need additional documentation beyond a completion certificate (WHICH HAVE BEEN KNOWN TO BE USED IN FRAUD AND ABUSE CASES IN HEALTHCARE AND CLINICAL RESEARCH) to fulfill requirements of regulatory agencies. Certificate records should be checked against centralized repositories / databases in order to verify their authenticity. Neither HealthCarePoint.com nor any BlueCloud network member is responsible for any liabilities resulting from the improper use or improper documentation required to properly document competency, inter-rater reliability or evidence based education for clinical trial programs. Please call our program administrator if you require additional information.

Method of Participation

THIS PROGRAM IS FREE OF CHARGE TO ALL HEALTHCARE PROFESSIONALS!

My Activities Page
This page is where you will find your program for your to 'Enroll' according to your hospital requirements. Once enrolled, the system will dynamically place the chosen activity under your 'Assigned' activities where you can begin the chosen program.

Program Guidelines and Timelines
The program consists of a self-paced Instruction-Demonstration module and the certification modules. The NIH Stroke Scale International (NIHSSI) Test contains 6 sections, each containing a single patient interview. You must score all 6 patients at >84 out of 90 items correct to achieve certification. As of June 19, 2018 – certification is VALID FOR UP TO ONE -1- YEAR FROM THE DATE OF COMPLETION when used in clinical research or, more than one year, time line controlled by the local SOP requirements of your organization - recommended 2 years when used for healthcare purposes only.


NIHSS - Advisory Working Group
Patrick Lyden, M.D.

Neurologist, Chief of Stroke Clinic • Veteran's Affairs Medical Center • Chairman, Department of Neurology • Siani Hospital • Professor of Neuroscience • UCSD School of Medicine • San Diego, CA

Walter J. Koroshetz, M.D.

Vice Chair, Neurology Service • Medical Director, Neurointensive Care Unit • Massachusetts General Hospital • Boston, MA

John R. Marler, MD

Medical Officer (former) • National Institute of Neurological Disorders and Stroke • National Institutes of Health • Bethesda, MD

Marian Emr

Director, Office of Communications and Public Liaison • National Institute of Neurological Disorders and Stroke • National Institutes of Health • Bethesda, MD

Margo Warren

Chief Public Liaison Section, Office of Communications and Public Liaison • National Institute of Neurological Disorders and Stroke • National Institutes of Health • Bethesda, MD

NIHSS Disclosures

According to the disclosure policy of the Academy, planning committee members, editors, managers, and other individuals who are in a position to control content are required to disclose any relevant relationships with any commercial interests related to this activity. The existence of these interests or relationships is not viewed as implying bias or decreasing the value of the presentation. All educational materials are reviewed for fair balance, scientific objectivity, and levels of evidence.

This educational activity does not include discussion of drugs or devices or uses of drugs and devices that have not been approved by the FDA. The opinions expressed in this educational activity are those of the faculty, and do not represent those of the Academy, or American Nurses Credentialing Council’s Commission on Accreditation. This activity is intended as a supplement to existing knowledge, published information, and practice guidelines. Learners should appraise the information presented critically, and draw conclusions only after careful consideration of all available scientific information.

Advisory Working Group Members:

Marian Emr, Walter J. Koroshetz, Patrick Lyden, John Marler, Margo Warren – reported no relevant financial relationships to disclose at the time this online training was developed.

Examiners:

Yu D. Cheng, MD, PhD (University of California at San Diego Stroke Center), Kama Z. Goluma, MD (University of California at San Diego); Judith A. Hinchey, MD (New England Medical Center); Mary A. Kalafut, MD (Scripps Clinic); Brett C. Meyer, MD (University of California at San Diego); Karen S. Rapp, RN, BSN, CCRC (University of California at San Diego Stroke Center); Sandi G. Shaw, RN, BSN (University of Texas Medical School at Houston); Sidney Starkman (University of California at Los Angeles) reported they had no relevant financial relationships at the time the training was developed.

Expert Commentators:

Thomas G. Brott, MD (Mayo Medical School—Jacksonville); Larry B. Goldstein, MD (Duke University Medical Center): James C. Grotta, MD (University of Texas Medical School at Houston); Christopher A. Lewandowski, MD (Henry Ford Hospital); Judith A. Spilker, RN (University of Cincinnati)-reported they had no relevant financial relationships to disclose at the time the training was developed.

Harold P. Adams, Jr, MD (University of Iowa): Consultant: Merck (adjudicate end points) and Medtronic (safety board)

Joseph P. Broderick, MD (University of Cincinnati): Consultant: Ono Pharmaceuticals (chair, Data Safety Monitoring Committee), Novo Nordisk (steering committee); Grant support: AstraZeneca, EKOS Corporation (PI), Genentech; Honoraria for speaking: Boehringer Ingelheim; Scientific Advisor: Genentech;

K. Michael Welch, MD (Finch University of Health Sciences--The Chicago Medical School) Advisor and grant support: Pfizer; Lecture grant (migraine and stroke): GlaxoSmithKline

Academy Planners:

American Academy of CME: John JD Juchniewicz, MCIS, CCMEP, Natalie Kirkwood, RN, BS, JD (lead nurse planner), Sondra Moylan, MS, RN - have no relevant financial relationships to disclose.



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