The International Network

When assessing outcome after stroke, the main issue that concerns patients or the regulatory authorities that license drugs or devices, is the degree of disability that the patient is left with.  The degree of disability is usually assessed by an independent observer and can be scored according to a standardised scale.
The modified Rankin scale is a 6 point disability scale with possible scores for function ranging from 0 up to 5.  A separate category (of 6) is usually added to classify patients who die before the assessment window.  The modified Rankin scale has been used widely in both secondary prevention and acute stroke trials, including most of the thrombolysis trials and all of the thrombectomy trials; and is becoming standard for rehabilitation research alongside tailored scales.
Rankin training and certification has been in use since the beginning of the 21st century and almost every stroke clinician with a research or audit interest will hold certification.  Although variations in Rankin scoring systems have been proposed from time to time - including focussed assessments, automated scoring etc - these may place unwarranted reliance on the skills of elderly, disabled patients in understanding the principles behind scoring and cannot replace the skilled judgement of an alert, trained clinician in matching functional ability to the mRS scoring rules.
In order to detect a treatment effect or to demonstrate clinical improvement, it is important that patients are rated in a consistent manner, minimising variability.  This becomes especially important if patients are enrolled across multiple sites, if trial results need to be combined through meta-analysis, or if registries are used to judge outcomes from healthcare strategies or services. Use of a common ‘language’ to describe patient outcome is critical. The modified Rankin Scale has clearly defined thresholds for each level of function but both patients and clinicians inevitably perceive these in diverse ways, introducing inter-rater variation in scoring. This cannot be completely eradicated but can be minimised through working to a common protocol.  The modified Rankin training program seeks to standardise the approach to scoring of mRS and the certification tools confirm that raters have understood and can apply these in practice, so that their scores fall within the same range as 90% of their peers for similar patients.


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.

Approach to Human Subject Protection and Patient Safety

Regulatory agencies, Ethical Review Committees and healthcare accreditation organizations now require that any healthcare professional, using the Rankin mRS 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.

Clinical Trials - Global Standardization Methodology – mRS Rankin

Investigators required to certify in use of the modified Rankin Scale often participate in several trials, running across institutions and countries. These trials may each have a different sponsor. It is important that the arrangements for certification remain consistent between trials and among investigators within trials. Investigators who hold a certificate from a source other than the BlueCloud Network cannot transfer their certificate to a new trial without undertaking full training and certification de novo. This ensures that certificates in existence were based on a common, validated and harmonized approach in order to have consistent inter-rater-reliability during clinical trials. The training and certification material on this network are constantly monitored and updated as necessary to ensure maintain validity.

NIH Stroke Scale

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.

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.

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