Chapter 17. Comprehensive Stroke Center Standards

Be designated by MIEMSS as a primary stroke center at the time of application for designation as a comprehensive stroke center;

Continue to meet the primary stroke center requirements in COMAR 30.08.11 to the extent such requirements are consistent with designation as a comprehensive stroke center;

Act as a resource center for other facilities in its region or state;

Annually care for at least 20 Subarachnoid Hemorrhage by aneurysm patients per year;

Annually perform a combined total of 15 endovascular coiling and surgical clippings per year for aneurysm;

Annually administer fibrinolytics to 25 eligible patients per year or 50 eligible patients over 2 years:

Satisfy the MIEMSS requirements for designation as a comprehensive stroke center by MIEMSS; and

Meet the requirements for a site review in COMAR 30.08.02.06, which may be satisfied by completing either:

Has designated beds for the care of acute stroke patients;

Has 24/7 on-site practitioners with neurovascular training, including, for example, APNs, PAs, neuro-intensivists, fellows, or residents;

Provides care to acute stroke patients through qualified clinical staff who meet the requirements in Regulations .12—.15 of this chapter;

Follows standardized processes derived from evidence-based practice clinical practice guidelines to facilitate clinical care;

Incorporates individualized plans of care that are based on the patient’s assessed needs and reflect coordination of care with other programs, as determined by patient comorbidities;

Has a process to assess the abilities and resources of family members to be involved in post-acute care; and

Maintains written documentation delineating the function of the neuroscience intensive care unit, including:

Have sufficient personnel available to respond to health care personnel at other hospitals to provide them with guidance and recommendations about the diagnosis and treatment of stroke and referral to an appropriate facility if transfer is required or requested;

Have written policies or procedures to direct the organized, safe, intra-hospital and inter-hospital transport of stroke patients;

Have priority bed availability for stroke patients with appropriately trained registered nurses in sufficient numbers based on patient acuity; and

Have a written plan for triaging patients from the neuroscience intensive care unit and/or the dedicated this unit to make beds available for other stroke patients when necessary or for provision of alternate critical care beds for stroke patients with appropriately trained registered nurse staff.

In addition to meeting the requirement of COMAR 30.08.11.05, the hospital shall:

The acute stroke team shall include at a minimum:

If a physician otherwise satisfies §B(1) of this regulation but is not Board-certified or Board-eligible in neurology, a Board-certified or Board-eligible neurologist shall be available within 15 minutes for consultation under the terms of a written agreement by:

An attending board certified/board eligible neurosurgeon on call with a 45-minute arrival time to the hospital;

Written procedures demonstrating the ability to care for two complex neurosurgical stroke patients at one time using appropriate clinical staff; and

Written documentation demonstrating on-call and back-up on-call schedules for physicians and staff for 24/7 coverage.

Interventional services promptly available 24 hours a day with appropriately trained support staff and equipment, including:

A neurointerventionalist who may be a board-certified/board-eligible neuroradiologist, neurologist, or neurosurgeon on call with a 45-minute arrival time to the hospital;

An on-call schedule for primary and back-up neurointerventionalists or neuroradiologists;

A written protocol to accept the inter-facility transfer of acute ischemic stroke patients requiring endovascular therapy that includes communication and feedback to the sending facility; and

A written protocol to accept the inter-facility transfer of acute stroke patients requiring a higher level of care.

Carotid duplex ultrasound;

Transcranial ultrasonography; and

Transesophageal or transthorasic echocardiogram.

Director.

Neurologists, Neurosurgeons, NeurInterventionalists, NeuroRadiologisst, NeuroIntensivists, and Vascular Surgeons. Qualifications for neurologists, neurosurgeons, neurointerventionalists, neuroradiologists, vascular surgeons and neurointensivists shall include:

Emergency Physicians. The qualifications of emergency physicians who care for stroke patients shall include:

Nurse Practitioners. Nurse Practitioners who care for stroke patients shall:

Physician Assistants. Physician assistants who care for stroke patients shall:

Clinical nurses, nurse practitioners, and physician assistants providing care to stroke patients in the neuroscience intensive care unit shall be trained in assessment of neurological function and management and treatment of all aspects of neurocritical care, including:

Continuing education requirements for nurses, nurse practitioners, and physician assistants who care for the acute stroke patients in the neuroscience intensive care unit shall include at least 5 hours of stroke-specific education annually.

Emergency department nurses, nurse practitioners, and physician assistants who triage patients in the emergency department or care for acute stroke patients shall be trained in:

Continuing education requirements for nurses, nurse practitioners, and physician assistants who care for the acute stroke patients in the emergency department shall include at least 5 hours of stroke-specific education annually.

Have written policies ensuring that:

Have written care protocols for advanced treatment of complex stroke patients, including, but not limited to, acute ischemic stroke patients, acute intra-arterial therapeutic interventions, management of intracranial hemorrhage, and management of subarachnoid hemorrhage;

Have written procedures demonstrating the ability of neurosurgery and interventional radiology to care for two complex stroke patients at one time with appropriate clinicians;

Maintain up-to-date written care protocols for the treatment of acute stroke in:

Have established mechanisms to serve and act as a resource center for other facilities in their region or state, which shall include:

Have written policies and or protocols delineating the scope of practice and the roles and responsibilities of nurse practitioners and physician assistants providing care to the acute stroke patient in the neuroscience intensive care unit, the emergency department, and the stroke unit.

In addition to the requirements of COMAR 30.08.11.14, the hospital shall incorporate into the hospital’s quality assurance process reports about:

The hospital shall establish a multidisciplinary institutional quality assurance/performance improvement committee that meets on a regular basis to:

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.

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.

Have an acute stroke research program and acute stroke research plan; and

Demonstrate participation in clinical research trials in acute stroke care.