Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart K - COMPREHENSIVE STROKE CENTERS, PRIMARY STROKE CENTERS AND ACUTE STROKE-READY HOSPITALS › Section 515.5060 - Acute Stroke-Ready Hospital Designation Criteria without National Certification

Current through Register Vol. 48, No. 28, July 12, 2024
a)
Hospitals seeking Acute Stroke-Ready Hospital designation that do not
				have
national
certification shall develop policies and
				procedures that are consistent with nationally recognized, evidence-based
				protocols for the provision of emergent stroke care.
(Section
				3.117(b)(3) of the Act)
b)
Hospital policies,
procedures or protocols
relating to
				emergent stroke care and stroke patient outcome shall be reviewed at least
				annually, or more often as needed, by a hospital committee that oversees
				quality improvement. Adjustments shall be made as necessary to advance the
				quality of stroke care delivered.
(Section 3.117(b)(3) of the
				Act)
c)
Criteria for ASRH
				designation of hospitals shall be limited to the ability of the hospital
				to:
1)
Create written acute
				care
policies, procedures, or
protocols related to emergent
				stroke care,
including transfer criteria (Section 3.117(b)(3)(A) of
				the Act);
2)
Participate in
				the data collection system provided in Section 3.118
of the
				Act
, if available
(Section 3.117(b)(3)(A-5) of the
				Act);
3)
Maintain a written
				transfer agreement with one or more hospitals that have neurosurgical
				expertise
(Section 3.117(b)(3)(B) of the Act);
4)
Designate a Clinical Director of
				Stroke Care who shall be a clinical member of the hospital staff with training
				or experience, as defined by the facility, in the care of patients with
				cerebrovascular disease. This training or experience may include, but is not
				limited to, completion of a fellowship or other specialized training in the
				area of cerebrovascular disease, attendance at national courses, or prior
				experience in neuroscience intensive care units. The Clinical Director of
				Stroke Care may be a neurologist, neurosurgeon, emergency medicine physician,
				internist, radiologist, advanced practice nurse, or physician
				assistant.
(Section 3.117(b)(3)(C) of the
				Act)
;
5)
Provide rapid access to an acute stroke team, as defined by the
				facility, that considers and reflects nationally recognized, evidenced-based
				protocols or guidelines
(Section 3.117(b)(3)(C-5) of the
				Act);
6)
Administer
				thrombolytic therapy, or subsequently developed medical therapies that meet
				nationally recognized, evidence-based stroke
protocols or
guidelines
(Section 3.117(b)(3)(D) of the Act);
7)
Conduct brain image tests at all
				times
(Section 3.117(b)(3)(E) of the Act), which shall consider and
				reflect current nationally recognized evidence-based protocols or
				guidelines;
8)
Conduct
				blood coagulation studies at all times
(Section 3.117(b)(3)(F) of the
				Act, which shall consider and reflect current nationally recognized
				evidence-based protocols or guidelines;
9)
Maintain a log of stroke patients,
				which shall be available for review upon request by the Department or any
				hospital that has a written transfer agreement with the ASRH.
(Section
				3.117(b)(3)(G) of the Act) The stroke patient log shall be available to be used
				for internal hospital quality improvement purposes. Hospitals may alternatively
				participate in a nationally recognized stroke data registry. Hospitals shall
				submit data from their stroke patient log or nationally recognized stroke data
				registry to the Department upon request. The hospital may share unidentified
				patient data with its EMS Region, EMS System, or other stroke network partners
				for quality improvement purposes. Hospitals shall review and analyze the data
				elements listed in this subsection (c)(9) quarterly, at a minimum, and submit a
				summary to the Department with the annual written attestation. The stroke
				patient log shall contain, at a minimum:
A)
				The patient's medical record number;
B) Date of emergency visit;
C) Mode of patient arrival;
D) Time presented in the emergency
				department;
E) Last time patient
				was observed to be free of current symptoms (i.e., time of last known well), if
				known;
F) Baseline initial stroke
				severity score upon arrival at the hospital (i.e., National Institutes of
				Health (NIH) Stroke Scale);
G) Time
				of blood coagulation results available;
H) Time of brain imaging;
I) Time of brain imaging results
				available;
J) Time and type of
				thrombolytic therapy or nationally recognized evidence-based exclusion
				criteria;
K) Time of transfer from
				the emergency department;
L) Time
				of transfer if from another location in the hospital; and
M) Transfer/discharge diagnosis and
				destination;
10)
Admit stroke patients to a unit that can provide appropriate care that
				considers and reflects nationally recognized, evidence-based protocols or
				guidelines or transfer stroke patients to an ASRH, PSC, or CSC, or another
				facility that can provide the appropriate care that considers and reflects
				nationally recognized, evidence-based protocols or guidelines
(Section
				3.117(b)(3)(H) of the Act);
11) At
				a minimum,
demonstrate compliance with nationally recognized quality
				indicators
(Section 3.117(b)(3)(I) of the Act) referenced in
				subsection (c)(9); and
12) Comply
				with nationally accepted guidelines regarding stoke awareness community
				education, hospital education and EMS education provided by the hospital
				regarding stroke treatment.