Regulation .13 Policies, Protocols, Guidelines, and Agreements.
Regulation .13 Policies, Protocols, Guidelines, and Agreements.LinkCopy Citation
The hospital shall develop and implement:
A.
A written policy which demonstrates that the hospital has established the stroke 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's designation as a primary stroke center;
B.
Written procedures for rapidly activating the stroke team to care for potentially eligible fibrinolytic and endovascular candidates within 15 minutes of notification; and
C.
Written care protocols for the treatment of acute stroke which:
(1)
Address:
(a)
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;
(b)
At least one member of the stroke team arriving at the acute stroke patient's bedside within 15 minutes of notification;
(c)
Ischemic stroke;
(d)
Hemorrhagic stroke;
(e)
Stabilization of vital functions;
(f)
Initial diagnostic tests;
(g)
The use of medications including fibrinolytics;
(h)
Care of the potential endovascular candidate;
(i)
Timely and safe patient transfer; and
(j)
The hospital's plan for updating the protocols at least annually;
(2)
Are maintained up-to-date in:
(a)
The emergency department;
(b)
The stroke unit;
(c)
The intensive care unit; and
(d)
All other locations where stroke care is provided.