reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 1 - General › Rule 15-3-2-1.1.1 - Legal Authority

Current through June 25, 2024
The Mississippi State Department of Health (Department)
						is assigned the responsibility for developing, implementing and managing the
						statewide STEMI System of Care (SOC). The Department shall be designated as the
						lead agency for STEMI SOC development, implementation and management. The
						Department shall develop and implement the Mississippi STEMI SOC Plan and STEMI
						SOC standards, which include but are not limited to those having to do with
						STEMI center designation, field triage of STEMI patients, inter-facility
						transfer of STEMI patients, STEMI care from initial medical contact through
						appropriate intervention, STEMI data collection, STEMI system evaluation and
						management of STEMI funding. The Department shall further promulgate specific
						regulations regarding the methods and procedures by which Mississippi-licensed
						acute care facilities shall participate in the statewide STEMI SOC. These
						specific regulations shall include mechanisms for determining the appropriate
						level of participation for each facility or class of facilities. The Department
						shall cause the implementation of professional and lay STEMI education programs
						including but not limited to STEMI education, CPR training and cardiac disease
						prevention programs.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 1 - General › Rule 15-3-2-1.1.2 - Mississippi STEMI SOC Advisory Committee: The Mississippi STEMI SOC

Current through June 25, 2024
Advisory Committee is created for the purpose of serving
						as an advisory body for statewide STEMI SOC development and shall provide
						support to the Department in all areas of STEMI SOC design, including the
						development and updating of SOC standards, SOC data collection and evaluation,
						SOC performance improvement, SOC funding, and evaluation of SOC programs.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 1 - General › Rule 15-3-2-1.1.3

Current through June 25, 2024
Members of the STEMI Advisory committee will be
						appointed by the State Health Officer for a term of three years and shall
						include representatives from the following entities (membership list may be
						updated as needed based on participation):
a. Cardiologist Chair
b. Cardiologist, Cardiac Surgeon, or
					 Emergency Medicine Vice-Chair
c.
					 Emergency Medicine Representatives from the Northern, Central and Southern
					 Regions
d. Emergency Nursing
					 Representatives from the Northern, Central and Southern Regions
e. Hospital Administration Representatives
					 from the Northern, Central and Southern Regions
f. Cardiology Representatives from the
					 Northern, Central and Southern Regions
g. STEMI Nursing Representatives from the
					 Northern, Central and Southern Regions
h. Registry Representatives from the
					 Northern, Central and Southern Regions
i. EMS Provider Representatives from the
					 Northern, Central and Southern Regions
j. EMS Administration Representatives from
					 the Northern, Central and Southern Regions
k. Non-transport EMS Representatives from the
					 Northern, Central and Southern Regions
l. Regional STEMI Coordinators from the
					 Northern, Central and Southern Regions
m. American Heart Association
					 Representative
n. Cardiac
					 Surgeon
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 1 - General › Rule 15-3-2-1.1.4

Current through June 25, 2024
The Mississippi STEMI SOC Advisory Committee shall meet
						at least quarterly.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.1 - Application for STEMI Center Designation

Current through June 25, 2024
a. The decision to
					 participate in the STEMI SOC is made jointly by the hospital administration and
					 the medical staff and must be documented in an official letter of application
					 for designation
b. The Letter of
					 Application should verify that the resolution to participate has been passed by
					 the appropriate quorum of the governing authority of the hospital and co-signed
					 by the director of the medical staff and contain the commitment to adhere to
					 state STEMI System of Care protocols
c. Each STEMI hospital must have an emergency
					 physician and cardiologist (co-directors) responsible for oversight of the
					 STEMI program
d. STEMI program
					 co-directors are responsible for developing and maintaining basic STEMI care
					 protocols for the hospital
e.
					 STEMI program co-directors also have oversight responsibility for the STEMI
					 component of the hospital PI program
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.2 - Application Process for Initial STEMI Center designation

Current through June 25, 2024
a.
					 The participation of acute care facilities in the STEMI SOC is voluntary;
					 however, participating hospitals must be appropriately designated according to
					 ability to care for STEMI patients - designation is a process of verifying that
					 appropriate staff and resources are available
b. To receive initial designation as a STEMI
					 center the applicant hospital shall submit a letter of application to the
					 Department
a. If currently designated as a
					 STEMI receiving center by the American Heart Association, or another nationally
					 recognized accrediting organization, and standards meet or exceed the
					 regulations of this chapter, reciprocity shall be granted
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.3 - Term of STEMI Center Designation

Current through June 25, 2024
a. The department
					 shall designate STEMI Centers for a period not to exceed three (3) years.
					 Designations shall remain active for three years provided no substantive
					 changes or variances have occurred. The Department (and may perform periodic
					 STEMI center audit/reviews. The State Health Officer (SHO) may extend STEMI
					 Center designations for one (1) year.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.4 - Continuing Designation

Current through June 25, 2024
Designated STEMI centers wishing to maintain current
						designation status shall submit a letter of intent to continue as currently
						designated no less than 30 days prior to the expiration of designation status.
a. Any designated hospital not
					 submitting a letter of intent to continue as currently designated will be
					 required to reapply through the initial application process
b. Any Designated STEMI center that loses,
					 either permanently or temporarily, patient care specialties required by this
					 regulation, shall report that loss to the Department
c. If the loss will result in the hospital's
					 inability to carry out the patient care activities associated with the current
					 level of designation for a period longer than 30 days, the facility must submit
					 a Corrective Action Plan (CAP) that addresses how and when the facility will
					 become compliant
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.5 - Suspension of STEMI Center Designation

Current through June 25, 2024
The State Health Officer may suspend the STEMI center
						designation of any hospital for:
a.
					 Documented conditions of serious threat or jeopardy to patients' health or
					 welfare
b. Failure to comply with
					 laws or regulations
c. Failure to
					 satisfactorily complete the minimum requirements as a STEMI center as defined
					 by the regulations for the designation level
d. Failure to complete a Corrective Action
					 Plan (CAP) within the timeframe specified by the Department
e. Hospitals having their Designation status
					 suspended may reapply for designation after resolution of all issues related to
					 the suspension, and completion and new application and designation survey visit
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 2 - Designation of STEMI Centers › Rule 15-3-2-1.2.6 - Change of STEMI Center Designation

Current through June 25, 2024
STEMI Centers will be permitted to change their
						designation if the following conditions are met in their entirety:
a. The STEMI Center has been appropriately
					 surveyed and designated by the Department, the designation is current, and the
					 STEMI Center is in full compliance with Department, regulations, policies,
					 procedures, and protocols
b. The
					 request to change designation has been approved by Mississippi STEMI Advisory
					 Council
c. The State Health
					 Officer (SHO) or designee issues the new designation
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 3 - Financial Support for the STEMI SOC › Rule 15-3-2-1.3.1

Current through June 25, 2024
The Mississippi State Department of Health is authorized
						to contract with the Mississippi Healthcare Alliance for services in the STEMI
						SOC. Services include but are not limited to cardiac disease education and
						prevention initiatives, public awareness initiatives designed for the purpose
						of making the public aware of the public health concern associated with cardiac
						disease, regional and STEMI center training in use of the STEMI registry,
						maintenance of the website providing lists and maps of currently designated
						STEMI centers, education activities of STEMI patient care providers, including
						EMS, ER and STEMI center personnel, CPR training and the dissemination of
						literature for use by STEMI providers. When funds are used in public awareness
						campaigns and STEMI programs, it should be noted that the Mississippi State
						Department of Health is the state agency assigned the responsibility for
						developing, implementing and managing the STEMI System of Care
						(SOC).
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 3 - Financial Support for the STEMI SOC › Rule 15-3-2-1.3.2 - STEMI Center Funding

Current through June 25, 2024
There are no assigned annual fund distributions for STEMI
						centers
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 4 - Mississippi State STEMI Registry › Rule 15-3-2-1.4.1 - STEMI Data Collection and Use

Current through June 25, 2024
a. Participants in
					 the statewide STEMI SOC will utilize a department approved national registry
					 platform to collect data on STEMI patients and identify system issues, such as
					 over and under triage
b. All
					 designated STEMI centers shall enter data on all STEMI patients
c. Data collection will begin with systems
					 and field data and continue through patient discharge/autopsy
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 5 - STEMI Receiving Center Standards › Rule 15-3-2-1.5.1

Current through June 25, 2024
During the Initial Application for Designation Process
						and for re-designation STEMI Receiving Centers shall verify the following
						resources:
a. Hospital Organization
i. STEMI service line or equivalent
ii. STEMI Care Coordinator or
					 Service Line Director
iii.
					 Departments/Sections
* Interventional/Non-Interventional Cardiology
* Cardiac Catheterization Laboratory
* Emergency Department
* Coronary Care Unit
* Cardiovascular Surgery on-site or transfer protocols in
						place
iv. STEMI Treatment
					 Protocols
* Protocols for triage, diagnosis (ECG < 10 minutes),
						and Cardiac Catheterization Laboratory activation
* A single activation telephone call should alert the
						STEMI team
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 5 - STEMI Receiving Center Standards › Rule 15-3-2-1.5.2

Current through June 25, 2024
During the Initial Application for Designation Process
						and for re-designation STEMI non-PCI Centers shall verify the following
						resources
a.
Hospital
					 Organization
i. Departments/Sections
* Emergency Department
* STEMI treatment protocols
* Each ED should maintain a standardized reperfusion
						STEMI care pathway that designates primary PCI as the preferred strategy if
						transfer to a primary PCI Center can be achieved within ACC/AHA guidelines
* Each ED should maintain a standardized STEMI care
						pathway that designates fibrinolysis in the ED (for eligible patients) when
						transfer to a primary PCI Center within ACC/AHA guidelines cannot be achieved
* If reperfusion strategy is for transfer to a primary
						PCI Center, patients should be transported to the most appropriate PCI Center
						where the first door-to-balloon time is < 120 minutes
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 6 - Pre-hospital Component and Field Triage › Rule 15-3-2-1.6.1

Current through June 25, 2024
The STEMI triage and transfer guidelines are based on the
						concept of getting the right patient to the right hospital in the shortest
						period of time. In order to do this some hospitals may be completely bypassed
						in favor of a more distant but more medically capable hospital. This rule
						provides a sample EMS Field Destination Guideline [see Appendix
						A].
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 6 - Pre-hospital Component and Field Triage › Rule 15-3-2-1.6.2

Current through June 25, 2024
EMS providers shall utilize the same 10 minute
						recommendation for acquiring the 12-lead ECG and transmit the ECG prior to
						arrival at the STEMI Center
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 6 - Pre-hospital Component and Field Triage › Rule 15-3-2-1.6.3

Current through June 25, 2024
If first medical contact to device can be anticipated by
						EMS to be achieved in 90 minutes or less, patient should be transferred
						directly to the STEMI Receiving Center, by-passing facilities not capable of
						providing PCI.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 7 - Inter-facility Transfers of STEMI Patients › Rule 15-3-2-1.7.1 - Inter-facility Transfers

Current through June 25, 2024
1. Patients may be
					 transferred from STEMI Referral Center to a STEMI Receiving Center and/or
					 specialty referral centers provided that any such transfer is medically
					 prudent, as determined by the transferring STEMI Center physician of record,
					 and is conducted by the appropriate level of emergency medical service provider
2. STEMI Referral Center shall
					 develop written criteria for consultation and transfer of patients needing a
					 higher/specialty level of care
3.
					 STEMI Receiving Center shall provide written feedback to the STEMI Referral
					 Center and shall participate in the state performance improvement process.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-2-1.8.1

Current through June 25, 2024
Performance Improvement shall be an essential part of the
						STEMI SOC. It shall be used to analyze proper functioning of the system and
						implement improvements in system operation. The PI program will be system wide.
						Every designated STEMI center is required to participate in the system PI
						process. The appropriateness and quantity of all activities of the STEMI system
						must be continuously evaluated.
a. The
					 STEMI PI committee of shall be responsible for the PI oversight of the STEMI
					 System. Members of the STEMI PI committee will be appointed by the State Health
					 Officer for a term of three years and shall include representatives from the
					 following entities (membership list may be updated as needed based on
					 participation):
i. One Interventional
					 Cardiologist practicing PCI from each of the three regions
ii. One Emergency Medicine physician
					 practicing at a STEMI Receiving Center from each of the three regions
iii. The State EMS Medical Director or his
					 physician designee
The STEMI PI will be chaired by a cardiology physician
						and a vice-chair cardiologist or emergency medicine physician.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-2-1.8.2 - Specific audit filters will be established by the STEMI PI committee

Current through June 25, 2024
a. In general, the following performance
					 improvement processes should be performed by each STEMI center. The results of
					 these reviews shall be reported to the STEMI PI committee.
i. Each STEMI center assigns a PI person to
					 oversee the process
ii. Standards
					 established
iii. Determine audit
					 filters
iv. Collect data
v. Evaluate data
vi. Determine PI issues present
vii. Develop corrective action plan (CAP)
viii. Re-evaluate to document
					 results/effectiveness of CAP
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-2-1.8.3

Current through June 25, 2024
Data will be reviewed and analyzed at no less than two
						separate levels. Primary patient care data will be reviewed at each facility by
						its Multidisciplinary Committee. These committees will utilize nationally
						accepted patient review criteria and will also review the pre-hospital care of
						STEMI patients. The final level of data review will take place at the state
						level. Statewide data will be used for the review of statewide criteria and
						epidemiological purposes. The Statewide Education/Prevention program will be
						based on this data.
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Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 2 - STEMI System of Care › Chapter 1 - Mississippi STEMI System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-2-1.8.4

Current through June 25, 2024
Members appointed to the STEMI Advisory Committee and
						STEMI Performance Improvement Committee will be required to attend at least 75%
						of all regularly scheduled meetings. Any respective member who does not meet
						this minimum meeting attendance requirement may be removed from the membership
						list and replaced by another appointee by the State Health
						Officer.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 1 - General › Rule 15-3-3-1.1.1 - Legal Authority

Current through June 25, 2024
The Mississippi State Department of Health (Department)
						is assigned the responsibility for developing, implementing and managing the
						statewide Stroke System of Care (SOC). The Department shall be designated as
						the lead agency for Stroke SOC development, implementation and management. The
						Department shall develop and implement the Mississippi Stroke SOC Plan and
						Stroke SOC standards, which include but are not limited to those having to do
						with stroke center designation, field triage of stroke patients, drip and ship
						transfer of stroke patients, stroke care from initial medical contact through
						appropriate intervention, stroke data collection, stroke system evaluation and
						management of stroke funding. The Department shall further promulgate specific
						regulations regarding the methods and procedures by which Mississippi-licensed
						acute care facilities shall participate in the statewide Stroke SOC. These
						specific regulations shall include mechanisms for determining the appropriate
						level of participation for each facility or class of facilities. The Department
						shall cause the implementation of professional and lay stroke education
						programs including but not limited to stroke education, stroke prevention
						programs.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 1 - General › Rule 15-3-3-1.1.2 - Mississippi Stroke SOC Advisory Committee

Current through June 25, 2024
The Mississippi Stroke SOC Advisory Committee is created
						for the purpose of serving as an advisory body for statewide Stroke SOC
						development and shall provide support to the Department in all areas of Stroke
						SOC design, including the development and updating of SOC standards, SOC data
						collection and evaluation, SOC performance improvement, SOC funding, and
						evaluation of SOC programs.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 1 - General › Rule 15-3-3-1.1.3

Current through June 25, 2024
Members of the Stroke Advisory committee will be
						appointed by the State Health Officer for a term of three years and shall
						include representatives from the following entities:
a. Emergency Medicine Physician
b. Emergency Nursing
c. Hospital Administration
d. Neurology
e. Interventional
					 Neurology/Radiology/Neurosurgery
f. Stroke Program Coordinators
g. Stroke Registry Personnel
h. AHA Representative
i. EMS Provider (ALS)
j. EMS Administration
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 1 - General › Rule 15-3-3-1.1.4

Current through June 25, 2024
The Mississippi Stroke SOC Advisory Committee shall meet
						at least quarterly.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.1 - Application for Stroke Center Designation

Current through June 25, 2024
a. Hospitals may
					 participate in the Stroke SOC on a voluntary basis, but must meet the standards
					 defined in Appendix A of the Stroke SOC. Each hospital would determine whether
					 they are available to receive patients or on critical care diversion
b. The decision to participate in the Stroke
					 SOC is made jointly by the hospital administration and the medical staff
c. A written commitment in the
					 form of a resolution passed by the appropriate quorum of the governing
					 authority of the hospital, and co-signed by the director of the medical staff,
					 signifies the facility's desire to participate in the system
d. Level 1 and Level 2 Stroke Centers must
					 have a neurologist director responsible for oversight of the Stroke Program
					 (developing and maintaining basic stroke care protocols and stroke component of
					 hospital performance improvement)
e. Level 3 Stroke Ready Hospitals must have a
					 physician director for oversight of the Stroke Program (developing and
					 maintaining basic stroke care protocols)
f. Stroke Centers and Stroke Ready Hospitals
					 must participate in the approved national registry platform.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.2 - Application Process for Initial Stroke Center Designation

Current through June 25, 2024
a.
					 The participation of acute care facilities in the Stroke SOC is voluntary;
					 however, participating hospitals must be appropriately designated according to
					 ability to care for stroke patients - designation is a process of verifying
					 that appropriate staff and resources are available
b. To receive initial designation as a Stroke
					 Center the applicant hospital shall submit a letter of application to the
					 Department
a. If currently
					 designated as a Stroke Center by The Joint Commission or another nationally
					 accrediting organization, and standards meet or exceed the regulations of this
					 chapter, reciprocity shall be granted
c. Within 60 days of receipt of the letter of
					 application, the Department shall:
a. acknowledges receipt of the letter
					 application
b. provides the status
					 of the application (accepted or rejected)
d. If the application is accepted, the
					 Department shall:
a. work with the
					 hospital staff to schedule the date for the designation survey visit
b. provides materials to hospital staff for
					 preparing for the designation survey visit
e. If the application is rejected, the
					 Department shall:
a. provides
					 reasons for rejection
b. requires
					 documentation of corrective actions before accepting subsequent letters of
					 application for designation from the applicant hospital
f. The Department shall provide results of
					 the designation survey and any proposed CAP to the Mississippi Stroke SOC
					 Advisory Committee
g. The
					 Mississippi Stroke SOC Advisory Committee will make a recommendation for
					 designation to the State Health Officer
h. The Department shall inform the applicant
					 hospital of the status of the application within 30 days of the Advisory
					 Committee meeting
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.3 - Term of Stroke Center Designations

Current through June 25, 2024
a. The Department
					 shall designate Stroke Centers for a period not to exceed three (3) years.
					 Designations shall remain active for three years provided no substantive
					 changes or variances have occurred. The Department may perform periodic Stroke
					 Center audits/reviews. The State Health Officer may extend Stroke Center
					 designations for one (1) year. In cases of reciprocity the term of designation
					 expires concurrently with the designation granted by the organization through
					 which reciprocity was granted
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.4 - Continuing Designation

Current through June 25, 2024
a. Any Designated
					 Stroke Center that loses, either permanently or temporarily, patient care
					 specialties required by this regulation, shall report that loss to the
					 Department
b. If the loss will
					 result in the hospital's inability to carry out the patient care activities
					 associated with the current level of designation for a period longer than 30
					 days, the facility must submit a Corrective Action Plan that addresses how and
					 when the facility will become compliant
c. Subsequent designations for Stroke Centers
					 designated based on reciprocity must be applied for through the same process
					 followed for their initial designation and as prescribed in this document
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.5 - Suspension of Stroke Center Designation

Current through June 25, 2024
The State Health Officer may suspend the Stroke Center
						designation of any hospital for:
a.
					 Documented conditions of serious threat or jeopardy to patients' health or
					 welfare
b. Failure to comply with
					 laws or regulations
c. Failure to
					 satisfactorily complete the minimum requirements as a Stroke Center as defined
					 by the regulations for the designation level
d. Failure to complete a Corrective Action
					 Plan within the timeframe specified by the Department
e. Hospitals having their Designation status
					 suspended may reapply for designation after resolution of all issues related to
					 the suspension, and completion and new application and designation survey visit
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 2 - Designation of Stroke Centers › Rule 15-3-3-1.2.6 - Change of Stroke Center Designation

Current through June 25, 2024
Stroke Centers will be permitted to change their
						designation if the following conditions are met in their entirety:
a. The Stroke Center has been appropriately
					 surveyed and designated by an accredited organization and/or the Department,
					 the designation is current, and the Stroke Center is in full compliance with
					 Department, regulations, policies, procedures, and protocols
b. The request to change designation has been
					 approved by Mississippi Stroke Advisory Council
c. The State Health Officer or designee
					 issues the new designation
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 3 - Financial Support for the Stroke SOC › Rule 15-3-3-1.3.1

Current through June 25, 2024
The Mississippi State Department of Health is authorized
						to contract with the Mississippi Healthcare Alliance for services in the Stroke
						SOC. Services include but are not limited to stroke education and prevention
						initiatives, public awareness initiatives designed for the purpose of making
						the public aware of the public health concern associated with stroke training
						in use of the Stroke Registry, maintenance of the website providing lists and
						maps of currently designated Stroke Centers, education activities of stroke
						patient care providers, including EMS, ED and Stroke Center personnel, CPR
						training and the dissemination of literature for use by stroke providers. When
						funds are used in public awareness campaigns and stroke programs, it should be
						noted that the Mississippi State Department of Health is the state agency
						assigned the responsibility for developing, implementing and managing the
						Stroke System of Care.
Miss. Code Ann.
						§
												41-3-15
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 3 - Financial Support for the Stroke SOC › Rule 15-3-3-1.3.2

Current through June 25, 2024
Stroke Center Funding There are no assigned annual fund
						distributions for Stroke Centers.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 4 - Mississippi State Stroke Registry › Rule 15-3-3-1.4.1 - Stroke Data Collection and Use

Current through June 25, 2024
a. Participants in
					 the statewide Stroke SOC will utilize a Department approved national registry
					 platform to collect data on Stroke patients and identify system issues, such as
					 over and under triage
b. All
					 designated Stroke Centers shall enter data on all stroke patients
c. Data collection will begin with systems
					 and field data and continue through patient discharge.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 5 - Stroke Center Standards › Rule 15-3-3-1.5.1 - During the Initial Application for Designation Process - Level 1 Stroke Centers shall verify the following resources

Current through June 25, 2024
a. Hospital
					 Organization
i. Core team of personnel,
					 infrastructure, and expertise to diagnose and treat stroke patients who require
					 intensive medical, surgical, and interventional vascular care. The team
					 consists of a neurologist, neurosurgeon, and endovascular specialists
ii. Fully equipped Emergency
					 Department (ED) for rapid diagnosis and treatment using standard CT imaging
					 within 20 minutes and the ability to have results reported within 45 minutes of
					 arrival
iii. Departments/Sections
1. Emergency Department
2. Interventional/Vascular Suite
3. Laboratory
4. Radiology
5. Stroke Unit or Designated Beds
6. Operating Room
iv. Stroke Treatment Protocols
1. Protocols and care plans are available in
					 the Emergency Department, acute care areas and stroke units for the acute
					 assessment and treatment of patients with ischemic or hemorrhagic stroke
2. Utilizes an evidenced based
					 bedside dysphagia screen protocol approved by the organization
3. Protocol for IV thrombolytics
4. A single activation should alert the
					 stroke team
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 5 - Stroke Center Standards › Rule 15-3-3-1.5.2 - During the Initial Application for Designation Process - Level 2 Stroke Centers shall verify the following resources

Current through June 25, 2024
a. Hospital
					 Organization
i. Core team of personnel,
					 infrastructure, and expertise to diagnose and treat stroke patients who require
					 intensive medical and surgical care. The team consists of a diagnostic
					 radiologist, neurologist, and neurosurgeon
ii. Fully equipped Emergency Department for
					 rapid diagnosis and treatment using standard CT imaging as defined in the
					 AHA/ASA CPGs
iii.
					 Departments/Sections
1. Emergency Department
2. Laboratory
3. Radiology
4. Stroke unit or designated beds
5. Operating Room
iv. Stroke Treatment Protocols
1. Protocols and care plans are available in
					 the Emergency Department, acute care areas and stroke units for the acute
					 assessment and treatment of patients with ischemic or hemorrhagic stroke
2. Utilizes an evidenced based
					 bedside dysphagia screen protocol approved by the organization.
3. Protocol for IV thrombolytics
4. A single activation should alert the
					 stroke team
5. Evaluation protocol
					 to assess for large vessel occlusion that may benefit from intervention
6. Transfer protocol to Level 1
					 Stroke Center for large vessel occlusion
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 5 - Stroke Center Standards › Rule 15-3-3-1.5.3

Current through June 25, 2024
During the Initial Application for Designation Process -
						Level 3 Stroke Ready Hospital shall verify the following resources
a. Hospital Organization
i. ED Physician, other qualified physician,
					 or physician extender available 24/7 to diagnose and initiate appropriate
					 treatment including patient transfer to a Level 1 or Level 2 facility
ii. Rapid diagnosis and treatment
					 using standard CT imaging as defined in the AHA/ASA CPGs
iii. Departments/Sections
1. Emergency Department
2. Laboratory
3. Radiology
iv. Stroke Treatment Protocols
1. Protocols and care plans are available in
					 the Emergency Department for the acute assessment and treatment of patients
					 with ischemic or hemorrhagic stroke
2. Utilizes an evidenced based bedside
					 dysphagia screen protocol approved by the organization
3. Protocol for IV thrombolytics
4. A single activation should alert the
					 stroke team
5. Evaluation protocol
					 to assess for large vessel occlusion that may benefit from intervention
6. Transfer protocol to Level 1
					 Stroke Center for large vessel occlusion
a.
					 Consider rapid transfer to Level 1 Stroke Center for the following:
i. Patients, who were previously functionally
					 independent, with signs of large vessel occlusion (examples include aphasia,
					 neglect, eye deviation, hemiplegia, intubated, NIHSS -6); consider transfer at
					 the discretion of the accepting physician
ii. Patients with large strokes with cerebral
					 edema for consideration of surgical decompression
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 5 - Stroke Center Standards › Rule 15-3-3-1.5.4 - During the Initial Application for Designation Process - Level 4 Non Stroke Hospital shall verify the following resources

Current through June 25, 2024
a. Hospital
					 Organization
i. Facility is able to access
					 and evaluate for possible stroke, but lacks essential components to treat
					 patients with IV thrombolytics
ii.
					 Transition plans must be established to facilitate rapid evaluation and
					 transfer of patients to Level 1 or Level 2 Stroke Centers.
iii. May be bypassed in accordance with this
					 plan or an EMS Medical Control Plan.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 6 - Pre-hospital Component and Field Triage › Rule 15-3-3-1.6.1

Current through June 25, 2024
The Stroke triage and transfer guidelines are based on
						the concept of getting the right patient to the right hospital in the shortest
						period of time. In order to do this some hospitals may be completely bypassed,
						based on EMS guidelines or protocols, in favor of a more distant but more
						medically capable hospital.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 7 - Inter-facility Transfers of Stroke Patients › Rule 15-3-3-1.7.1 - Drip and Ship Transfer Protocol

Current through June 25, 2024
1. Patients may be
					 transferred from Level 2, 3, or 4 center to a Level 1 or 2 center provided that
					 any such transfer is medically prudent, after implementation of time sensitive
					 therapy, as determined by the transferring Stroke Center physician of record,
					 and is conducted by the appropriate level of emergency medical service provider
2. Level 2, 3 and 4 centers shall
					 develop written criteria for consultation and transfer of patients needing a
					 higher/specialty level of care
3.
					 Level 1 and 2 centers shall provide feedback as requested to the Level 2, 3 or
					 4 center and shall participate in the state performance improvement process
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-3-1.8.1

Current through June 25, 2024
Performance Improvement shall be an essential part of the
						Stroke SOC. It shall be used to analyze proper functioning of the system and
						implement improvements in system operation. The PI program will be system-wide.
						Every designated Stroke Center is required to participate in the system PI
						process and input the required statewide minimal dataset. The appropriateness
						and quantity of all activities of the Stroke system must be continuously
						evaluated.
a. The Stroke PI committee
					 shall be a subcommittee of the Stroke Advisory Committee responsible for the PI
					 oversight of the Stroke System. Members of the Stroke PI committee shall
					 include:
i. Chairperson - Neurologist
					 participating in the Stroke System
ii. Each Level 1 and 2 Stroke Center will be
					 authorized an administrative and/or clinical representative
iii. Level 3 hospitals may participate. The
					 number of representatives will be determined by the permanent members of the
					 subcommittee
iv. Three EMS
					 organizations - one from a hospital-based EMS provider, a private EMS provider,
					 and a public/government EMS provider
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-3-1.8.2 - Specific audit filters will be established by the Stroke PI committee

Current through June 25, 2024
a. In general, the following performance
					 improvement processes should be performed by each Stroke Center. The results of
					 these reviews shall be reported to the Stroke PI committee.
i. Each Stroke Center assigns a PI person to
					 oversee the process
ii. Standards
					 established
iii. Determine audit
					 filters
iv. Collect data
v. Evaluate data
vi. Determine PI issues present
vii. Develop corrective action plan
viii. Re-evaluate to document
					 results/effectiveness of CAP
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 3 - Stroke System of Care › Chapter 1 - Mississippi Stroke System of Care › Subchapter 8 - Performance Improvement and System Evaluation › Rule 15-3-3-1.8.3

Current through June 25, 2024
Data will be reviewed and analyzed at no less than two
						separate levels. Primary patient care data will be reviewed at each facility by
						its Multidisciplinary Committee. These committees will utilize nationally
						accepted patient review criteria and will also review the pre-hospital care of
						stroke patients. The final level of data review will take place at the state
						level. Statewide data will be used for the review of statewide criteria and
						epidemiological purposes. The Statewide Education/Prevention program will be
						based on this data. Stroke registry personnel should be included on the PI
						Committee.
Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 3 - Bureau of Acute Care Systems › Subpart 5 - Mississippi Hospital Sustainability Program › Chapter 1 - Mississippi Hospital Sustainability Grant Program Regulations › Subchapter 1 - General › Rule 15-3-5-1.1.3 - Eligible Beneficiaries

Current through June 25, 2024
Eligible Beneficiaries are those specifically outlined in
						SB 2372, Section 1 (iii) (a-f) as eligible to apply for funding under this
						program for an amount UP TO the amount outlined in the applicable portion of SB
						2372, Section 1 (iii) (a-f).
In order to be considered for funding under this Program,
						an entity must (1) be defined as eligible to apply in SB 2372, Section 1 (iii)
						(a-f); (2) submit an application for funding with all required information and
						documentation within the initial application window; and (3) demonstrate
						through its application and supporting documentation that it experienced a
						financial harm as a result of the COVID-19 pandemic.
The Program will maintain Frequently Asked Questions on
						the Department website
https://msdh.ms.gov/sustainabilitygrant
.
Senate
						Bill 2372, 2023 Regular Legislative Session