Current through Register Vol. 48, No. 12, March 22, 2024
a)
Hospitals seeking Acute Stroke-Ready Hospital designation that do not
have national certification shall develop policies and
procedures that are consistent with nationally recognized, evidence-based
protocols for the provision of emergent stroke care. (Section
3.117(b)(3) of the Act)
b)
Hospital policies, procedures or protocols relating to
emergent stroke care and stroke patient outcome shall be reviewed at least
annually, or more often as needed, by a hospital committee that oversees
quality improvement. Adjustments shall be made as necessary to advance the
quality of stroke care delivered. (Section 3.117(b)(3) of the
Act)
c)
Criteria for ASRH
designation of hospitals shall be limited to the ability of the hospital
to:
1)
Create written acute
care policies, procedures, or protocols related to emergent
stroke care, including transfer criteria (Section 3.117(b)(3)(A) of
the Act);
2)
Participate in
the data collection system provided in Section 3.118 of the
Act, if available (Section 3.117(b)(3)(A-5) of the
Act);
3)
Maintain a written
transfer agreement with one or more hospitals that have neurosurgical
expertise (Section 3.117(b)(3)(B) of the Act);
4)
Designate a Clinical Director of
Stroke Care who shall be a clinical member of the hospital staff with training
or experience, as defined by the facility, in the care of patients with
cerebrovascular disease. This training or experience may include, but is not
limited to, completion of a fellowship or other specialized training in the
area of cerebrovascular disease, attendance at national courses, or prior
experience in neuroscience intensive care units. The Clinical Director of
Stroke Care may be a neurologist, neurosurgeon, emergency medicine physician,
internist, radiologist, advanced practice nurse, or physician
assistant. (Section 3.117(b)(3)(C) of the
Act);
5)
Provide rapid access to an acute stroke team, as defined by the
facility, that considers and reflects nationally recognized, evidenced-based
protocols or guidelines (Section 3.117(b)(3)(C-5) of the
Act);
6)
Administer
thrombolytic therapy, or subsequently developed medical therapies that meet
nationally recognized, evidence-based stroke protocols or
guidelines (Section 3.117(b)(3)(D) of the Act);
7)
Conduct brain image tests at all
times (Section 3.117(b)(3)(E) of the Act), which shall consider and
reflect current nationally recognized evidence-based protocols or
guidelines;
8)
Conduct
blood coagulation studies at all times (Section 3.117(b)(3)(F) of the
Act, which shall consider and reflect current nationally recognized
evidence-based protocols or guidelines;
9)
Maintain a log of stroke patients,
which shall be available for review upon request by the Department or any
hospital that has a written transfer agreement with the ASRH. (Section
3.117(b)(3)(G) of the Act) The stroke patient log shall be available to be used
for internal hospital quality improvement purposes. Hospitals may alternatively
participate in a nationally recognized stroke data registry. Hospitals shall
submit data from their stroke patient log or nationally recognized stroke data
registry to the Department upon request. The hospital may share unidentified
patient data with its EMS Region, EMS System, or other stroke network partners
for quality improvement purposes. Hospitals shall review and analyze the data
elements listed in this subsection (c)(9) quarterly, at a minimum, and submit a
summary to the Department with the annual written attestation. The stroke
patient log shall contain, at a minimum:
A)
The patient's medical record number;
B) Date of emergency visit;
C) Mode of patient arrival;
D) Time presented in the emergency
department;
E) Last time patient
was observed to be free of current symptoms (i.e., time of last known well), if
known;
F) Baseline initial stroke
severity score upon arrival at the hospital (i.e., National Institutes of
Health (NIH) Stroke Scale);
G) Time
of blood coagulation results available;
H) Time of brain imaging;
I) Time of brain imaging results
available;
J) Time and type of
thrombolytic therapy or nationally recognized evidence-based exclusion
criteria;
K) Time of transfer from
the emergency department;
L) Time
of transfer if from another location in the hospital; and
M) Transfer/discharge diagnosis and
destination;
10)
Admit stroke patients to a unit that can provide appropriate care that
considers and reflects nationally recognized, evidence-based protocols or
guidelines or transfer stroke patients to an ASRH, PSC, or CSC, or another
facility that can provide the appropriate care that considers and reflects
nationally recognized, evidence-based protocols or guidelines (Section
3.117(b)(3)(H) of the Act);
11) At
a minimum, demonstrate compliance with nationally recognized quality
indicators (Section 3.117(b)(3)(I) of the Act) referenced in
subsection (c)(9); and
12) Comply
with nationally accepted guidelines regarding stoke awareness community
education, hospital education and EMS education provided by the hospital
regarding stroke treatment.