Md. Code Regs. 30.08.11.14

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.08.11.14 - Quality Management

A. The hospital shall 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. The hospital shall authorize the stroke registry to provide the hospital's data to MIEMSS for health oversight activities in a manner approved by the EMS Board.

C. Outcome Objectives.

(1) The hospital shall establish at least 2 outcome objectives that are:

(a) Time-specific;

(b) Measurable;

(c) Reflective of tracking and trending of performance measures and indicators; and

(d) Reviewed in annual comparison studies.

(2) The hospital shall monitor IV fibrinolytic complications, which include symptomatic intracerebral hemorrhage and serious life-threatening systemic bleeding.

(3) The hospital shall monitor and demonstrate tracking and trending of modified Rankin Scores (mRS) at discharge and at 90 days post-discharge on patients with acute ischemic stroke.

(4) The hospital shall 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:

(a) Meets;

(b) Reviews practice patterns; and

(c) Modifies practice patterns as appropriate.

(5) In cases where the administration of fibrinolytics is appropriate, the hospital shall administer fibrinolytics within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 50 percent of eligible patients. The hospital shall 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.

(6) The hospital shall demonstrate progress towards reducing time of administration of fibrinolytics to 45 minutes for greater than or equal to 50 percent of eligible patients.

D. The hospital shall incorporate into the hospital's quality assurance process progress reports about:

(1) Specific acute stroke treatment benchmarks;

(2) Outcomes data on patients transferred for higher level of care; and

(3) Stroke treatment quality improvement goals.

E. The hospital shall 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) Reevaluation of the plan.

Md. Code Regs. 30.08.11.14

Regulation .14 amended effective 48:9 Md. R. 360, eff. 7/1/2021