<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".17" citation="COMAR 30.08.17.17" title_num="30" subtitle_num="08" chapter_num="17" heading="Quality Management.">
  <paragraph num="A.">
    <text>In addition to the requirements of COMAR 30.08.11.14, the hospital shall incorporate into the hospital’s quality assurance process reports about:</text>
    <paragraph num="(1)">
      <text>Specific acute stroke treatment benchmarks; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Stroke treatment quality improvement goals.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The hospital shall establish a multidisciplinary institutional quality assurance/performance improvement committee that meets on a regular basis to:</text>
    <paragraph num="(1)">
      <text>Monitor quality benchmarks;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Review complications; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Review and modify practice patterns as appropriate.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>In cases where mechanical endovascular reperfusion therapy is appropriate, the hospital shall achieve door-to-device times (arrival to first pass of thrombectomy device) in 50 percent or more of eligible acute ischemic stroke patients within 120 minutes (for direct arriving patients) and within 60 minutes (for inter-facility transfer patients) treated with endovascular therapy.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The hospital shall demonstrate progress towards reducing door-to-device times in 50 percent or more of eligible acute ischemic stroke patients within 90 minutes for direct arriving patients.</text>
  </paragraph>
</regulation>