R426-2-710. Stroke Treatment and Stroke Receiving Center Designation Requirements

A hospital desiring to be a Stroke Treatment Center (Primary or Comprehensive) must be accredited as such by the Joint Commission on Accreditation of healthcare Organizations (JACHO) or other nationally recognized accrediting body. A hospital desiring to be designated as a Stroke Receiving Center for receiving stroke patients via Emergency Medical Services shall meet the following requirements:

(1) Be licensed as an acute care hospital in Utah.

(2) Have an emergency department staffed by a Registered Nurse at all time.

(3) Require physician response to the emergency department in less that thirty (30) minutes for treatment of stroke patients.

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

(5) Maintain, have readily available and utilize approved thrombolytic medications for treatment of patients meeting criteria for administration of thrombolytic therapy.

(6) Have a standardized acute stroke protocol in place and provide authority of appropriate emergency department staff to implement the protocol when appropriate.

(7) Maintain availability of ancillary equipment and personnel to diagnose and treat acute stroke patients in a timely manner.

(8) Have in place patient transport protocols with designated stroke treatment centers.

(9) Have an active and functioning performance improvement program for acute stroke care and report required data to the Utah Department of Health as required by the Department.

(10) Submit to a formal survey by representatives of the Department

(11) Upon successful 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 an EMS agency.