Regulation .13 Policies, Protocols, Guidelines, and Agreements.
Regulation .13 Policies, Protocols, Guidelines, and Agreements.LinkCopy Citation
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.