R426-9-1100. Stroke Treatment and Stroke Receiving Facility Minimum Designation Requirements

  (1) A Primary or Comprehensive Stroke Treatment Center or an Acute Stroke Ready Hospital shall be accredited by the Joint Commission or other nationally recognized accrediting body.

  (2) A hospital designated as a Stroke Receiving Facility for receiving stroke patients via Emergency Medical Services shall meet the following requirements:

  (a) Be licensed as an acute care hospital in Utah;

  (b) Require physician response to the emergency department in less than thirty (30) minutes for treatment of stroke patients;

  (c) Maintain the ability of physician and nursing staff to utilize a standardized assessment tool for ischemic stroke patients;

  (d) Maintain and utilize approved thrombolytic medications for treatment of patients meeting criteria for administration of thrombolytic therapy;

  (e) Establish a standardized acute stroke protocol and authorize appropriate emergency department staff to implement the protocol when appropriate;

  (f) Have ancillary equipment and personnel available to diagnose and treat acute stroke patients in a timely manner;

  (g) Establish patient transport protocols with designated stroke treatment centers;

  (h) Have a performance improvement program for acute stroke care and report data as required by the Department; and

  (i) Submit to a site visit by representatives of the Department.

  (3) Upon designation, the Department may, in consultation with off line EMS medical direction and protocol, recommend direct transport of stroke patients to a Stroke Receiving Center or a Stroke Treatment Center by licensed ambulance provider.

  (4) All hospitals shall collect, and submit at least quarterly to the Department, Stroke Registry information necessary to maintain an inclusive stroke system. All hospitals shall provide such data in a standardized electronic format approved by the Department.

  (5) The stroke treatment and stroke receiving designation and re-designation shall be for a period of three years.