Sec. 30.08.11.13. Policies, Protocols, Guidelines, and Agreements

The hospital shall develop and implement:

A. A written policy which demonstrates that the hospital has established the stroke 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's designation as a primary stroke center;

B. Written procedures for rapidly activating the stroke team to care for potentially eligible fibrinolytic candidates within 15 minutes of notification; and

C. Written care protocols for the treatment of acute stroke which:

(1) Address:

(a) 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;

(b) At least one member of the stroke team arriving at the acute stroke patient's bedside within 15 minutes of notification;

(c) Ischemic stroke;

(d) Hemorrhagic stroke;

(e) Stabilization of vital functions;

(f) Initial diagnostic tests;

(g) The use of medications including fibrinolytics;

(h) Timely and safe patient transfer; and

(i) The hospital's plan for updating the protocols at least annually;

(2) Are maintained up-to-date in:

(a) The emergency department;

(b) The stroke unit;

(c) The intensive care unit; and

(d) All other locations where stroke care is provided.