Md. Code Regs. 30.08.18.14

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

Section 30.08.18.14 - Quality Management

The facility shall:

A. Participate, in a manner approved by the EMS Board, in a stroke registry that includes the data elements tracked by the Centers for Medicare and Medicaid Services and the American Heart/American Stroke Get With the Guidelines®-Stroke Registry;

B. Have participated in the stroke registry and maintained a stroke log for a minimum of 6 months prior to time of requesting an application;

C. Demonstrate ongoing participation in the stroke registry;

D. Authorize the stroke registry to provide the hospital data to MIEMSS for health oversight activities in a manner approved by the EMS Board;

E. Establish at least two outcome objectives that:

(1) Are time-specific;

(2) Are measurable;

(3) Reflect tracking and trending of performance measures and indicators; and

(4) Are reviewed in annual comparison studies;

F. Maintain a stroke log which includes at a minimum the following information for each entry:

(1) The number of times the stroke team was activated;

(2) The stroke team's response time to the acute stroke patient;

(3) The on-call neurologist's response time for consultation to the acute stroke patient;

(4) The type or types of diagnostic tests and acute treatment utilized;

(5) The patient's diagnosis;

(6) Door to IV fibrinolytic time;

(7) Patient complications;

(8) Arrival and departure/transfer times; and

(9) Disposition of the patient;

G. Monitor its IV fibrinolytic complications, which includes symptomatic intracerebral hemorrhage and serious life-threatening systemic bleeding;

H. Establish at least one stroke center quality assurance medical review committee which shall be a medical review committee under Health Occupations Article, § 1-401, Annotated Code of Maryland, as a committee established in the Maryland Institute for Emergency Medical Services Systems which, at least three times a year:

(1) Meets;

(2) Reviews practice patterns; and

(3) Modifies practice patterns as appropriate;

I. In cases where the administration of fibrinolytics is appropriate:

(1) Administer the fibrinolytic within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 50 percent of eligible patients;

(2) Demonstrate progress towards administering fibrinolytics within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 75 percent of eligible patients; and

(3) Demonstrate progress towards reducing time of administration of fibrinolytics to 45 minutes for greater than or equal to 50 percent of eligible patients;

J. Incorporate into their quality assurance process progress reports about:

(1) Specific acute stroke treatment benchmarks;

(2) Outcomes data on patients transferred for a higher level of care; and

(3) Stroke treatment quality improvement goals; and

K. Provide MIEMSS with documentation of quality management of the stroke program for review, including, if appropriate:

(1) Problem identification;

(2) Problem analysis;

(3) An action plan;

(4) Implementation of the plan; and

(5) Re-evaluation of the plan.

Md. Code Regs. 30.08.18.14

Regulation .14 adopted 48:9 Md. R. 360, eff. 7/1/2021