Request for Acute Stroke-Ready Hospital Designation without National Certification

Section 515.5070  Request for Acute Stroke-Ready Hospital Designation without National Certification a)         Any hospital seeking designation as an Acute Stroke-Ready Hospital shall apply for and receive ASRH designation from the Department, provided that the hospital attests, on a form developed by the Department in consultation with the State Stroke Advisory Subcommittee, that the hospital meets, and will continue to meet, the criteria for ASRH designation (see Section 515.5060) and pays an annual fee. (Section 3.117(b)(2) of the Act) The Department will post and maintain ASRH designation instructions, including an application available on the Department's Division of EMS website. b)         The application available through the Department shall include a statement that the hospital meets each requirement in Section 3.117 of the Act, including the designation criteria in Section 3.117(b)(3) of the Act and Section 515.5060 of this Part. The hospital shall provide the following: 1)         Hospital name and address; 2)         Hospital chief executive officer/administrator typed name and signature; 3)         Chief medical officer (or designee) typed name and signature; 4)         Hospital stroke director typed name, clinical credentials and signature; and 5)         Contact person typed name, e-mail address and phone number. c)         The hospital shall indicate on the application whether it is applying for an initial ASRH designation or a renewal. d)         The hospital shall provide the Department with supporting documentation indicating compliance with each designation criterion in Section 3.117(b)(3) of the Act and Section 515.5060 with the initial ASRH application, as follows: 1)         A copy of the hospital's stroke policies, procedures or protocols related to the provision of emergent stroke care ; 2)         A copy of the hospital's transfer agreement with one or more hospitals that have board certified or board eligible neurosurgical expertise , and policies, procedures or protocols related to the transfer; 3)         The hospital stroke director's name, contact information and curriculum vitae or resume to demonstrate that the Director is a clinical member of the hospital staff or a clinical designee of the hospital administrator; 4)         A copy of the hospital's policies, procedures or protocols related to the administration of thrombolytic therapy, or subsequently developed medical therapies that meet nationally recognized evidence-based stroke protocols or guidelines ; 5)         A letter from the stroke director or hospital administrator indicating how the hospital conducts and interprets brain image tests at all times that consider and reflect nationally recognized evidence-based stroke protocols or guidelines; 6)         Documentation of laboratory accreditation by a nationally recognized accrediting body; 7)         A sample stroke log or verification of use of a nationally recognized stroke data registry that meets the minimum requirements (see Section 515.5090) (Section 3.117(b)(3) of the Act) 8)         Each ASRH shall submit a description of its comprehensive ongoing quality improvement plan, including, but not limited to, all of the quality measurements in subsection (e). The description shall include the steps an ASRH would use to implement performance improvement processes. e)         For re-designation, the hospital shall provide the Department with updated supporting documentation, including quality outcomes, indicating compliance with ASRH criteria in Section 515.5060.  Hospitals shall submit a full application every three years. f)         Quality outcomes data shall include a summary of the following quality outcomes, as indicated by the stroke log: 1)         Results time for door-to-blood coagulation study; 2)         Completed time for door-to-brain imaging; 3)         Results time for door-to-brain imaging; 4)         Time for door-to-thrombolytic therapy, if applicable; 5)         Time for door-to-transfer from emergency department, if applicable; and 6)         Non-emergency department patients transferred out of the hospital for stroke diagnosis. g)         Each ASRH shall submit a copy of its comprehensive quality assessment, including, but not limited to, all of the quality measurements in subsection (e) that do not meet nationally recognized evidenced-based stroke guidelines. For each outcome not meeting national guidelines, the ASRH shall implement a written quality improvement plan. h)         After receipt of a completed application that meets the requirements of this Section, the Department will designate a hospital as an ASRH no more than 30 business days after receipt of the form.  The Department will notify the hospital, in writing, of the designation. i)          A hospital designated as an ASRH shall pay an annual fee of $250.