Current Copy of Joint Commission Certification. Copy of Certification Y N An acute Stroke team available within 15 minutes On-call schedules for 3 months. On-call policy and procedure Y N In person or telemedicine Written policies and procedures for Stroke services Copy of policies, procedures Y N Include protocols and standardized orders Data-reporting mechanism Copy of agreement with AHA Y N AHA Get with the Guidelines-Stroke Neuro-imaging capability 24/7/365 Policies/protocols supporting operations Y N CT or MRI One of the following: Qualified Radiologist, Qualified Neurologist, Or Qualified Neurosurgeon Copy of appropriate board certification On-call schedules for 3 months Y N If using telemedicine, hospital must document this standard Laboratory services 24/7 Copy of policies/procedures/ protocols for lab services Y N Blood testing, EKG, and x-ray services Immediate, telemetry or critical care beds Immediate: ____ Telemetry: _____ Critical Care: ______ Y N Neurosurgical services including operating room Number of operating rooms ___ on license Y N May be under agreement with another PSC or CSC If no neurosurgical services available: Plan to transfer within 2 hours Supporting policies and procedures Y N Required if no Neurosurgery In-patient acute care rehabilitation Policies/procedures for in-patient rehabilitation Y N Designated Telephone Number Actual Number on File Y N Written transfer guidelines for higher level of service Transfer policies/procedures Copy of agreement Y N Copy of Designation Agreement Between Hospital and County Copy of Contract Y N
Continuing Education Provider Copy of Approval Letter with CE provider Number Y N Stroke contingency plans 1. Personnel 2. Imaging equipment Pertinent policy and procedures to minimize disruption Y N Expectation of NO DIVERSION STAFFING Acute Stroke Care Team: One of the following: Neurologist Neurosurgeon Interventional- neuroradiologist Emergency physician Copy of appropriate board certification On-call schedule for 3 months Copy of job description Y N Board certified or Board eligible in neurology, neurosurgery, endovascular neurosurgical radiology, with experience and expertise in dealing with cerebral vascular disease One of the following: Registered nurse Physician assistant Nurse practitioner Copy of license Copy of job description Y N Demonstrated competency in caring for acute Stroke patients COMPREHENSIVE All of the above PLUS Written policies and procedures for comprehensive Stroke services Copies of policies/ procedures/ protocols for activation of Stroke care Y N Reviewed every two years and revised as needed Data driven CQI Including collection and monitoring of standardized Comprehensive Stroke Center performance measures Copies of data collection procedures Copies of internal CQI process Y N Transfer agreements with primary Stroke Centers to accept transfer of patients with complex Strokes Copies of transfer agreements Y N
Policies/ procedures/ protocols in place to accept patients Provide guidance and continuing education to hospitals designated as Primary Stroke Centers with which they have agreements Copies of policies/ procedures/ guidelines to provide CME Copies of agreements Y N SATELLITE STROKE CENTERS Current License to provide Basic Emergency Services in Kern County or Standby Services Copy of License Y N Current Designation to operate as a Paramedic Base Station in Kern County Copy of contract Y N Standby ER’s Excluded Acute Stroke care team Copies of policies/ procedures/ protocols On call schedule Y N May be via telemedicine Emergency Department policies and procedures Copies of ED policies/ procedures/ protocols/ standard orders for Stroke care Y N
Data driven CQI Collection and monitoring of performance measures CQI polices/ procedures/ guidelines/ standards Y N Neuro-imaging capability 24/7/365 Policies/protocols supporting operations Y N CT or MRI, as well as interpretation Physician with appropriate expertise: Radiologist Neurologist Neurosurgeon Residents Copy of Board certificates Y N Telemedicine may be used for interpretation All staff qualification requirements shall be documented by the hospital Laboratory Services 24/7/365 Policies/protocols supporting operations Y N Minimum include blood testing, ECG, and services Neurosurgical services, including OR availability, within 3 hours of admission Supporting policies and procedures Number of operating rooms ___ on license Y N OR may be under agreement with PSC or CSC Transfer arrangements with PSC or CSC Copies of agreements Y N Director: Physician or Advanced Practice Nurse Copy of license Documentation of training Copy of job description Y N Maintains 6 hours per year education in cerebrovascular disease Acute Stroke Care Team: At a minimum- Registered Nurse and Physician Copy of Licenses Documentation of Training Y N Some training and expertise in acute Stroke care