Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 130.000 - Hospital Licensure
Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES
Section 130.1405 - Written Care Protocols

Universal Citation: 105 CMR 130.000 MA Code of Regs 130.1405

Current through Register 1531, September 27, 2024

(A) The hospital shall develop and implement written care protocols for acute stroke. Such protocols shall include both the emergency and post-admission care of acute stroke patients by a multidisciplinary team. The hospital shall treat eligible patients according to its written care protocols consistent with time targets acceptable to the Department. These protocols shall address issues such as stabilization of vital functions, initial diagnostic tests, and use of medications (including but not limited to intravenous tissue-type plasminogen activator (t-PA) treatment), as applicable. These protocols shall be based on previously published guidelines or developed by a multidisciplinary team organized by the Stroke Service.

(B) Emergency Department (ED) Stroke Protocols. The hospital shall develop and implement written protocols, including, but not limited to:

(1) triage and treatment of patients presenting with symptoms of acute stroke in the Emergency Department (e.g., use of thrombolytic therapy, management of increased intracranial pressure and blood pressure and post-thrombolysis management plan, as applicable).

(2) communicating effectively with Emergency Medical Service (EMS) personnel in the pre-hospital setting during transportation of a patient with symptoms of acute stroke. The ED must be able to efficiently prepare for the arrival, to receive, and to triage patients with symptoms of acute stroke arriving via EMS transportation.

(3) a specific, well-organized system for promptly notifying and activating the Acute Stroke Team to evaluate patients presenting with symptoms of acute stroke.

(C) Post-admission Care Protocols. The hospital shall develop and implement written protocols for the post-admission care of acute stroke patients.

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