NIH Stroke Scale Training & Certification

Estimated time to complete: 3.0 hours

Target Audience
This activity has been designed to meet the educational needs of physicians and nursing professionals.
Other healthcare providers may also participate.

Learning Objectives
After participating in the activity, learners should be better able to:
• Consistently apply appropriate scores for neurological deficits in stroke patients
• Use the scale to assess changes in neurological deficits in stroke patients over time.

Provided by

Accreditation and Credit Designation

In support of improving patient care, American Academy of CME, Inc. is Jointly
accredited by the Accreditation Council for Continuing Medical Education (ACCME),
the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses
Credentialing Center (ANCC), to provide continuing education for the healthcare
team.
Physicians
American Academy of CME designates this enduring material for a maximum of 3.0 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensurate with the extent of their participation in
the activity.

Nurses
American Academy of CME, Inc. designates this educational activity for 3.0 contact hours.
California
Provider approved by the California Board of Registered Nursing, Provider Number CEP16993 for 3.0
contact hours.

Additional Healthcare Professionals will receive a certificate of completion.

FREE NIHSS TRAINING AND EDUCATION PROGRAM:

There are no fees for participating in this activity. After reviewing the Program Orientation, please
proceed with completing ONLY ONE (1) of the program test Group A, B, C, D and so on... If this is your
first time using this program, please begin with test Group A -- Additional modules, B, C, D, E,.... are used
to re-certify on an annual basis.

To Obtain a Completion and CME/CE Certificate (FREE)

The successful completion of the Program Orientation and one test group is sufficient to receive a
certificate of completion. To receive CME/CE Credit you must also complete the activity evaluation. A
CME/CE certificate is issued by the system immediately upon your successful completion of the Test
Group and completion of the activity evaluation. You must achieve a passing score of at least 84 out of
90. You are able to retake the Test Group if this score is not achieved. Your completion certificate history
can be viewed and/or printed from “My Activities” at any time. Each certificate of completion is valid for
a maximum of 1 year from the date of successful completion.

IMPORTANT: The successful completion of one test group is sufficient to receive a certificate of
completion. You may apply for a maximum of one completed test group. You may complete additional
Test Groups to recertify per guidelines. Consult your supervisor to determine the requirements of your
organization. You may only apply for CME/CE credit for completing the program orientation and one
test group per 12-month period. You may apply for credit for future test groups based on the
certification periods specified.

Release date: July 1, 2011

Reviewed: May 5, 2014
Reviewed: May 5, 2017
Reviewed: May 5, 2020
Reviewed: May 5, 2023
Expiration date: May 4, 2026

NIHSS -Advisory Working Group and their affiliations at the time this online training was developed.
Patrick Lyden, MD
Neurologist, Chief of Stroke Clinic • Veteran's Affairs Medical Center • Chairman, Department of
Neurology • Sinai Hospital • Professor of Neuroscience • UCSD School of Medicine • San Diego, CA
Walter J. Koroshetz, MD
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. 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. All relevant financial relationships listed for these individuals have been
mitigated.
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) reported the following relationships at the time the training
was developed. 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) reported the
following relationships at the time the training was developed. Advisor and grant support: Pfizer;
Lecture grant (migraine and stroke): GlaxoSmithKline

Planners:
John JD Juchniewicz, MCIS, CHCP, Natalie Kirkwood, RN, BS, JD, Sondra Moylan, MS, RN, Tina Posey -
have no relevant financial relationships to disclose.

Implicit Bias
Implicit bias refers to unconscious attitudes and stereotypes that influence our thoughts, judgements,
decisions, and actions without our awareness. Everyone is susceptible to implicit bias, even clinicians. In
healthcare, implicit biases can have a significant impact on the quality of care an individual receives.
These biases can be both favorable and unfavorable, and are activated involuntarily without an
individual’s awareness or intentional control.

It is important for healthcare professionals to recognize that their clinical decision-making may be
impacted by their own implicit biases. Considering one might have unconscious biases and exploring
them may be uncomfortable because the very idea that they exist may conflict with how clinicians
perceive themselves. It is only by becoming aware of one’s unconscious biases, however, that members
of the healthcare team can take steps to mitigate them to ensure all patients receive quality healthcare.

As related to NIHSS and this test, it’s important to be aware of implicit biases as related to scoring.
Research shows that implicit bias can lead to underestimation of stroke severity among those medical
professionals using the NIHSS.1-3 For example, studies as cited below found that there were significant
differences in NIHSS scores between African American and Caucasian patients, even after adjusting for
stroke severity and other clinical factors. African American patients were more likely to receive lower
NIHSS scores, suggesting that their strokes were less severe than Caucasian patients with similar clinical
characteristics.

As you go through the training modules for this course, we encourage you to challenge yourself to look
for possible implicit bias that could be unconsciously affecting how you score patients of different
gender, racial or ethnic backgrounds. Whether this is the first time you are becoming certified or you
have been retraining and recertifying in the NIHSS for years, this course should help maintain accuracy
and reliability in making NIHSS assessments.

1. Albright KC, Boehme AK, Matherne-Meyer DE, et al. Underestimation of stroke severity using the National
Institutes of Health Stroke Scale in patients with intracerebral hemorrhage. Stroke. 2017;48(4):931-933.
doi:10.1161/STROKEAHA.116.016586
2. Kleimaker M, Laumeier I, Niederstadt C, et al. The influence of implicit bias on stroke severity scoring. PLoS
One. 2021;16(4):e0249565. doi:10.1371/journal.pone.0249565
3. Cruz-Flores S, Rabinstein A, Biller J, et al. Racial-ethnic disparities in stroke care: the American experience: a
statement for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2011;42(7):2091-2116. doi:10.1161/STR.0b013e3182213e24

Hardware/Software Requirements:
Windows Requirements: • Operating system: Windows 7 or later • Browser: Internet Explorer (10 or
later), Chrome, Mozilla Firefox • Internet connection: Broadband or other high-speed connection •
Flash: Adobe Flash Player 12 or later

Apple/Mac Requirements: •Operating system: Mac OS X v10.3 or later • Browser: Mozilla Firefox •
Internet connection: Broadband internet connection • Flash: Adobe Flash Player 12 or later

Contact
For technical support or replacement certificates, please contact: 512-302-3113 For any questions about
this activity, please contact: [email protected]

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