Md. Code Regs. 30.08.18.13

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.08.18.13 - Policies, Protocols, Guidelines, and Agreements

The facility shall develop and implement:

A. A written policy which demonstrates that the facility has established the acute stroke ready center to:

(1) Monitor the care delivered to acute stroke patients;

(2) Improve the quality of care delivered to acute stroke patients;

(3) Move patients through the initial acute care phase of their hospital stay in a timely fashion; and

(4) Ensure that all stroke patients will receive medical care commensurate with the hospital designation as an acute stroke ready center;

B. Written procedures for rapidly activating the stroke team to care for potentially eligible fibrinolytic and endovascular candidates within 15 minutes of notification;

C. Written care protocols for the treatment of acute stroke which address:

(1) Evaluation of each patient by a member of the emergency department clinical staff within 10 minutes of the patient's arrival at the hospital emergency department;

(2) At least one member of the stroke team arriving at the acute stroke patient's bedside within 15 minutes of notification;

(3) Ischemic stroke;

(4) Hemorrhagic stroke;

(5) Stabilization of vital functions;

(6) Initial diagnostic tests;

(7) The use of medications including fibrinolytics;

(8) Care of the potential endovascular candidate; and

(9) Timely and safe patient transfer within 2 hours or less of emergency department arrival or when medically stable;

D. A current agreement with a transport service to meet the timeline in §C(9) of this regulation; and

E. A written protocol for transfer that includes communication and feedback from the receiving facility, which is:

(1) Updated at least annually; and

(2) Maintained up-to-date in:

(a) The emergency department; and

(b) All other locations where stroke care is provided.

Md. Code Regs. 30.08.18.13

Regulation .13 adopted 48:9 Md. R. 360, eff. 7/1/2021