Regulation .14 Quality Management.
Regulation .14 Quality Management.LinkCopy Citation
The facility shall:
A.
Participate, in a manner approved by the EMS Board, in a stroke registry that includes the data elements tracked by the Centers for Medicare and Medicaid Services and the American Heart/American Stroke Get With the Guidelines®-Stroke Registry;
B.
Have participated in the stroke registry and maintained a stroke log for a minimum of 6 months prior to time of requesting an application;
C.
Demonstrate ongoing participation in the stroke registry;
D.
Authorize the stroke registry to provide the hospital data to MIEMSS for health oversight activities in a manner approved by the EMS Board;
E.
Establish at least two outcome objectives that:
(1)
Are time-specific;
(2)
Are measurable;
(3)
Reflect tracking and trending of performance measures and indicators; and
(4)
Are reviewed in annual comparison studies;
F.
Maintain a stroke log which includes at a minimum the following information for each entry:
(1)
The number of times the stroke team was activated;
(2)
The stroke team’s response time to the acute stroke patient;
(3)
The on-call neurologist’s response time for consultation to the acute stroke patient;
(4)
The type or types of diagnostic tests and acute treatment utilized;
(5)
The patient’s diagnosis;
(6)
Door to IV fibrinolytic time;
(7)
Patient complications;
(8)
Arrival and departure/transfer times; and
(9)
Disposition of the patient;
G.
Monitor its IV fibrinolytic complications, which includes symptomatic intracerebral hemorrhage and serious life-threatening systemic bleeding;
H.
Establish at least one stroke center quality assurance medical review committee which shall be a medical review committee under Health Occupations Article, §1-401, Annotated Code of Maryland, as a committee established in the Maryland Institute for Emergency Medical Services Systems which, at least three times a year:
(1)
Meets;
(2)
Reviews practice patterns; and
(3)
Modifies practice patterns as appropriate;
I.
In cases where the administration of fibrinolytics is appropriate:
(1)
Administer the fibrinolytic within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 50 percent of eligible patients;
(2)
Demonstrate progress towards administering fibrinolytics within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 75 percent of eligible patients; and
(3)
Demonstrate progress towards reducing time of administration of fibrinolytics to 45 minutes for greater than or equal to 50 percent of eligible patients;
J.
Incorporate into their quality assurance process progress reports about:
(1)
Specific acute stroke treatment benchmarks;
(2)
Outcomes data on patients transferred for a higher level of care; and
(3)
Stroke treatment quality improvement goals; and
K.
Provide MIEMSS with documentation of quality management of the stroke program for review, including, if appropriate:
(1)
Problem identification;
(2)
Problem analysis;
(3)
An action plan;
(4)
Implementation of the plan; and
(5)
Re-evaluation of the plan.