# COMAR Title 30 — Maryland Institute for Emergency Medical Services Systems (MIEMSS)

## Subtitle 08 — Designation of Trauma and Specialty Referral Centers

### Chapter 18 — Designated Acute Stroke Ready Center

#### Regulation .13 Policies, Protocols, Guidelines, and Agreements.

*COMAR 30.08.18.13*

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.