# 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 .14 Quality Management.

*COMAR 30.08.18.14*

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.