The hospital shall develop and implement:

1. A. A written policy which demonstrates that the hospital has established the stroke center to:

   1. (1) Monitor the care delivered to acute stroke patients;
   2. (2) Improve the quality of care delivered to acute stroke patients;
   3. (3) Move patients through the initial acute care phase of their hospital stay in a timely fashion; and
   4. (4) Ensure that all stroke patients will receive medical care commensurate with the hospital's designation as a primary stroke center;
2. B. Written procedures for rapidly activating the stroke team to care for potentially eligible fibrinolytic and endovascular candidates within 15 minutes of notification; and

3. C. Written care protocols for the treatment of acute stroke which:

   1. (1) Address:

      1. (a) Evaluation of each patient by a member of the emergency department clinical staff within 10 minutes of the patient's arrival at the hospital emergency department;
      2. (b) At least one member of the stroke team arriving at the acute stroke patient's bedside within 15 minutes of notification;
      3. (c) Ischemic stroke;
      4. (d) Hemorrhagic stroke;
      5. (e) Stabilization of vital functions;
      6. (f) Initial diagnostic tests;
      7. (g) The use of medications including fibrinolytics;
      8. (h) Care of the potential endovascular candidate;
      9. (i) Timely and safe patient transfer; and
      10. (j) The hospital's plan for updating the protocols at least annually;

   2. (2) Are maintained up-to-date in:

      1. (a) The emergency department;
      2. (b) The stroke unit;
      3. (c) The intensive care unit; and
      4. (d) All other locations where stroke care is provided.

Authority: Education Article, §13-509, Annotated Code of Maryland

Effective date: June 5, 2006 (33:11 Md. R. 952)

Regulation .06B amended effective June 4, 2007 (34:11 Md. R. 973)

Chapter revised effective July 1, 2021 (48:9 Md. R. 360)

Regulation .01B amended effective July 21, 2025 (52:14 Md. R. 714)

Regulation .15 repealed effective October 18, 2021 (48:21 Md. R. 892)