Missouri Code of State Regulations
Title 19 - DEPARTMENT OF HEALTH AND SENIOR SERVICES
Division 30 - Division of Regulation and Licensure
Chapter 40 - Comprehensive Emergency Medical Services Systems Regulations
Section 19 CSR 30-40.730 - Standards for Stroke Center Designation

A. A core team which provides administrative oversight and includes:

B. A stroke call roster that provides twenty-four (24) hours a day, seven (7) days a week neurology service coverage. The call roster identifies the physicians or qualified individuals on the schedule that are available to manage and coordinate emergent, urgent, and routine assessment, diagnosis, and treatment of stroke patients. A level I stroke center call roster shall include, but not be limited to, the emergency department physician, neuro-interventionalist, neurologist, and others as appropriate. A level II stroke center call roster shall include, but not be limited to, the emergency department physician, a physician with experience and expertise in diagnosing and treating patients with cerebrovascular disease, and others as appropriate. The level III stroke center call roster shall include, but not be limited to, the emergency department physician and others as appropriate. A level IV stroke center call roster shall include, but not be limited to, the emergency department physician and other qualified individuals as appropriate. (I-R, II-R, III-R, IV-R)

C. A clinical team appropriate to the center level designation that may include, but not be limited to, members of the stroke call roster, neurologists, physicians with expertise caring for stroke patients, neuro-interventionalists, neurosurgeons, anesthesiologists, intensivists, emergency department physicians, and other stroke center clinical staff as applicable. (I-R, II-R, III-R, IV-R)

A. A list of all stroke team members; (I-R, II-R, III-R, IV-R)

B. Position qualifications and completion of continuing education requirements by stroke team members as set forth in sections (1), (2), and (4) of this rule; (I-R, II-R, III-R, IV-R)

C. Management of sufficient numbers of stroke patients by the stroke team members in order to maintain their stroke skills; (I-R, II-R, III-R, IV-R)

D. Participation by the core team and members of the stroke call roster in at least half of the regular, ongoing stroke program peer review system meetings as shown in meeting attendance documents. The stroke medical director shall disseminate the information and findings from the peer review system meetings to the stroke call roster members and the core team and document such dissemination; (I-R, II-R, III-R, IV-R)

E. Participation by stroke team members in at least half of the regular, ongoing stroke program performance improvement and patient safety meetings and documentation of such attendance in the meeting minutes and/or meeting attendance documents. The stroke medical director shall disseminate the information and findings from the performance improvement and patient safety meetings to the stroke team members and document such dissemination. If a stroke team member is unable to attend a stroke program performance improvement and patient safety meeting, then the stroke team member shall send an appropriate representative in his/her place; (I-R, II-R, III-R, IV-R)

F. Maintenance of skill levels in the management of stroke patients by the stroke team members as required by the stroke center and the stroke medical director and documentation of such continued experience; (I-R, II-R, III-R, IV-R)

G. Review of regional outcome data on quality of patient care by the stroke team members as part of the stroke center's performance improvement and patient safety process; and (I-R, II-R, III-R, IV-R)

H. Evidence of a written agreement between a level III stroke center and a level I or II stroke center when a level III stroke center has a supervised relationship with a physician affiliated with a level I or II stroke center. A level III stroke center which provides lytic therapy to stroke patients may have an established plan for admitting and caring for stroke patients under a supervised relationship with a physician affiliated with a level I or II stroke center. This supervised relationship shall consist of a formally established and pre-planned relationship between the centers in which a physician from a level I or level II center supervises a physician in a level III center in the evaluation of a stroke patient for lytic therapy and the care of the patient postlytic therapy in certain circumstances where that level III center does not transfer the patient to a higher level stroke center. In this setting, management decisions, including, but not limited to, administration of lytic therapy, transfer or non-transfer of patient, and postlytic therapy shall be made jointly between the supervising and supervised physicians. Care protocols and pathways for patients that fall into this category shall be established by both parties at the outset of the establishment of the relationship. This supervised relationship shall be established by written agreement and detail the supervision of patient care. This written agreement may also include, but not be limited to, observation of patient care, review of level III stroke center's patient encounters, review of level III center's outcomes, evaluation of the level III center's process pertaining to stroke patients, and lytic therapy and guidance on methods to improve process, performance, and outcomes.

A. The multidisciplinary team shall include a suitable representative from hospital units as appropriate for care of each stroke patient. The hospital units represented on the multidisciplinary team may include, but not be limited to: administration, emergency medical services, intensive care unit, radiology, pharmacy, laboratory, stroke unit, stroke rehabilitation, and discharge planning. (I-R, II-R, III-R, IV-R)

B. The multidisciplinary team members or their representatives shall attend at least half of the stroke program performance improvement and patient safety program meetings which shall be documented in the meeting minutes and/or meeting attendance documents. (I-R, II-R, III-R, IV-R)

A. Neuro-interventional specialist(s); and (I-R/PA)

B. Other clinical staff as deemed necessary. (I-R/PA)

A. Completion of a stroke fellowship; (I-R)

B. Participation (as an attendee or faculty) in one (1) national or international stroke course or conference each year or two (2) regional or state stroke courses or conferences each year; or (I-R)

C. Five (5) or more peer-reviewed publications on stroke. (I-R)

A. Completion of a stroke fellowship; (II-R)

B. Participation (as an attendee or faculty) in one (1) national or international stroke course or conference each year or two (2) regional or state stroke courses or conferences each year; or (II-R)

C. Five (5) or more peer-reviewed publications on stroke. (II-R)

A. Complete a minimum of four (4) hours of continuing medical education (CME) in the area of cerebrovascular disease every year; and (III-R)

B. Attend one (1) national, regional, or state meeting every three (3) years in cerebrovascular disease. Continuing medical education hours earned at these meetings can count toward the four (4) required continuing medical education hours for level III stroke medical directors. (III-R)

A. Meet continuing education requirements as set forth in section (4) of this rule; and (I-R, II-R, III-R, IV-R)

B. Participate in the performance improvement and patient safety program. (I-R, II-R, III-R, IV-R)

A. Neurosurgeon and back-up coverage on the call roster; (I-R/PA)

B. Neurosurgeon and back-up coverage on the call roster or available within two (2) hours by transfer agreement if not on staff; and (II-R/PA)

C. The neurosurgery staffing requirement may be fulfilled by a surgeon who has been approved by the chief of neurosurgery for care of stroke patients and shall be capable of initiating measures to stabilize the patient and perform diagnostic procedures; (I-R, II-R)

A. Anesthesiology staffing requirements may be fulfilled by anesthesiology residents, certified registered nurse anesthetists (CRNA), or anesthesia assistants capable of assessing emergent situations in stroke patients and of providing any indicated treatment including induction of anesthesia. When anesthesiology residents or CRNAs are used to fulfill availability requirements, the staff anesthesiologist on call will be advised and promptly available and present for all operative interventions and emergency airway conditions. The CRNA may proceed with life preserving therapy while the anesthesiologist is in route under the direction of the neurosurgeon, including induction of anesthesia. An anesthesiologist assistant shall practice only under the direct supervision of an anesthesiologist who is physically present or immediately available as this term is defined in section 334.400, RSMo. (I-R, II-R)

A. The emergency department in the stroke center shall provide immediate and appropriate care for the stroke patient; (I-R, II-R, III-R, IV-R)

B. A level I stroke center shall have a medical director of the emergency department who shall be board-certified or board-admissible in emergency medicine by the American Board of Medical Specialties, the American Osteopathic Association Board of Osteopathic Specialists, or the Royal College of Physicians and Surgeons of Canada; (I-R)

C. A level II stroke center shall have a medical director of the emergency department who shall be a board-certified or board-admissible physician; (II-R)

D. A level III and IV stroke center shall have a medical director of the emergency department who is recommended to be a board-certified or board-admissible physician; (III-R, IV-R)

E. There shall be an emergency department physician credentialed for stroke care by the stroke center covering the emergency department twenty-four (24) hours a day, seven (7) days a week; (I-R/IH, II-R/IH, III-R/IH, IV-R/IA)

F. The emergency department physician who provides coverage shall be current in continuing medical education in the area of cerebrovascular disease; (I-R)

G. There shall be a written policy defining the relationship of the emergency department physicians to other physician members of the stroke team; (I-R, II-R, III-R, IV-R)

H. Registered nurses in the emergency department shall be current in continuing education requirements as set forth in section (4) of this rule; (I-R)

I. All registered nurses assigned to the emergency department shall be determined to be credentialed in the care of the stroke patient by the stroke center within one (1) year of assignment and remain current in continuing education requirements as set forth in section (4) of this rule; and (I-R, II-R, III-R, IV-R)

J. The emergency department in stroke centers shall have written care protocols for identification, triage, and treatment of acute stroke patients that are available to emergency department personnel, reviewed annually, and revised as needed. (I-R, II-R, III-R, IV-R)

A. Airway control and ventilation equipment including:

B. Suction devices; (I-R, II-R, III-R, IV-R)

C. Electrocardiograph (ECG), cardiac monitor, and defibrillator; (I-R, II-R, III-R, IV-R)

D. Central line insertion equipment; (I-R, II-R, III-R)

E. All standard intravenous fluids and administration devices including intravenous catheters and intraosseous devices; (I-R, II-R, III-R, IV-R)

F. Drugs and supplies necessary for emergency care; (I-R, II-R, III-R, IV-R)

G. Two- (2-) way communication link with emergency medical service (EMS) vehicles; (I-R, II-R, III-R, IV-R)

H. End-tidal carbon dioxide monitor; and (I-R, II-R, III-R, IV-R)

I. Temperature control devices for patient and resuscitation fluids. (I-R, II-R, III-R IV-R)

A. The stroke center intensive care unit shall have a designated intensive care unit medical director who has twenty-four (24) hours a day, seven (7) days a week access to a physician knowledgeable in stroke care and who meets the stroke call roster continuing medical education requirements as set forth in section (4) of this rule. (I-R, II-R)

B. The stroke center intensive care unit shall have a physician on duty or available twenty-four (24) hours a day, seven (7) days a week who is not the emergency department physician. This physician shall have access to a physician on the stroke call roster. (I-R/IA, II-R/IA)

C. The stroke center intensive care unit shall have a one to one (1:1) or one to two (1:2) registered nurse/patient ratio used for critically ill patients requiring intensive care unit level care. (I-R, II-R)

D. The stroke center intensive care unit shall have registered nurses in the intensive care unit who are current in continuing education requirements as set forth in section (4) of this rule. (I-R, II-R)

E. The stroke center intensive care unit shall have registered nurses in the intensive care unit who meet at least the following core credentials for care of stroke patients on a yearly basis:

A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes, bag-mask resuscitator, and a mechanical ventilator; (I-R, II-R)

B. Oxygen source with concentration controls; (I-R, II-R)

C. Cardiac emergency cart, including medications; (I-R, II-R)

D. Telemetry, ECG capability, cardiac monitor, and defibrillator; (I-R, II-R)

E. Electronic pressure monitoring and pulse oximetry; (I-R, II-R)

F. End-tidal carbon dioxide monitor; (I-R, II-R)

G. Patient weighing devices; (I-R, II-R)

H. Drugs, intravenous fluids, and supplies; and (I-R, II-R)

I. Intracranial pressure monitoring devices. (I-R, II-R)

A. Airway control and ventilation equipment including:

B. Telemetry, electrocardiograph, cardiac monitor, and defibrillator; (I-R, II-R, III-R)

C. All standard intravenous fluids and administration devices and intravenous catheters; and (I-R, II-R, III-R)

D. Drugs and supplies necessary for emergency care. (I-R, II-R, III-R)

A. Angiography with interventional capability available twenty-four (24) hours a day, seven (7) days a week; (I-R/PA)

B. Cerebroangiography technologist on call and available within thirty (30) minutes for emergent procedures, and on call and available within sixty (60) minutes for routine procedures, and available twenty-four (24) hours a day, seven (7) days a week; (I-R)

C. In-house computerized tomography; (I-R/IA, II-R/IA, III-R/IA)

D. Computerized tomography perfusion; (I-R/IA)

E. Computerized tomography angiography; (I-R/IA)

F. Computerized tomography technologist; (I-R/IH, II-R/IH, III-R/IA)

G. Magnetic resonance imaging; (I-R, II-R)

H. Magnetic resonance angiogram/magnetic resonance venography; (I-R, II-R)

I. Magnetic resonance imaging technologist on call and available within sixty (60) minutes, twenty-four (24) hours a day, seven (7) days a week; (I-R, II-R)

J. Extracranial ultrasound; (I-R, II-R)

K. Equipment and clinical staff to evaluate for vasospasm available within thirty (30) minutes for emergent evaluation, and available within sixty (60) minutes for routine evaluation, and available twenty-four (24) hours a day, seven (7) days a week; (I-R)

L. Transthoracic echo; (I-R, II-R)

M. Transesophageal echo; and (I-R, II-R)

N. Resuscitation equipment available to the radiology department. (I-R, II-R, III-R)

A. Operating microscope; (I-R, II-R)

B. Thermal control equipment for patient and resuscitation fluids; (I-R, II-R)

C. X-ray capability; (I-R, II-R)

D. Instruments necessary to perform an open craniotomy; (I-R, II-R)

E. Monitoring equipment; and (I-R, II-R)

F. Resuscitation equipment available to the operating room. (I-R, II-R)

A. Airway control and ventilation equipment including laryngoscopes, endotracheal tubes of all sizes, bag-mask resuscitator, sources of oxygen, and mechanical ventilator; (I-R, II-R)

B. Suction devices; (I-R, II-R)

C. Telemetry, ECG capability, cardiac monitor, and defibrillator; (I-R, II-R)

D. All standard intravenous fluids and administration devices, including intravenous catheters; and (I-R, II-R)

E. Drugs and supplies necessary for emergency care; and (I-R, II-R)

A. Complete a minimum of eight (8) hours of continuing education every year in cerebrovascular disease. This continuing education shall be reviewed by the stroke medical director for appropriateness to the stroke program manager/coordinator's level of responsibility; and (I-R)

B. Attend one (1) national, regional, or state meeting every two (2) years focused on the area of cerebrovascular disease. If the national or regional meeting provides continuing education, then that continuing education may count toward the annual requirement; (I-R)

A. Complete a minimum average of eight (8) hours of continuing education every year in cerebrovascular disease. This continuing education shall be reviewed for appropriateness by the stroke medical director to the stroke program manager/coordinator's level of responsibility; and (II-R)

B. Attend one (1) national, regional, or state meeting every three (3) years focused on the area of cerebrovascular disease. If the national, regional, or state meeting provides continuing education, then that continuing education may count toward the annual requirement; and (II-R)

A. Level I emergency department physicians providing stroke coverage shall complete a minimum of two (2) hours of continuing medical education in cerebrovascular disease every year, except for physicians who are emergency medicine board certified or board eligible through the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) and who are practicing in the emergency department; (I-R)

A. Level I registered nurses shall complete a minimum of two (2) hours of cerebrovascular disease continuing education every year; and (I-R)

B. Registered nurses shall maintain core competencies in the care of the stroke patient annually as determined by the stroke center. Training to maintain these competencies may count toward continuing education requirements. (I-R, II-R, III-R, IV-R)

A. Door-to-needle time; (I-R, II-R, III-R)

B. Number of patients presenting within the treatment window; and (I-R, II-R, III-R)

C. Number of eligible patients treated with thrombolytics. (I-R, II-R, III-R)