Acute Stroke-Ready Hospital Designation Criteria without National Certification

Section 515.5060  Acute Stroke-Ready Hospital Designation Criteria without National Certification 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.