The facility shall develop and implement:

1. A. A written policy which demonstrates that the facility has established the acute stroke ready 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 designation as an acute stroke ready 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;

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

   1. (1) 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. (2) At least one member of the stroke team arriving at the acute stroke patient’s bedside within 15 minutes of notification;
   3. (3) Ischemic stroke;
   4. (4) Hemorrhagic stroke;
   5. (5) Stabilization of vital functions;
   6. (6) Initial diagnostic tests;
   7. (7) The use of medications including fibrinolytics;
   8. (8) Care of the potential endovascular candidate; and
   9. (9) Timely and safe patient transfer within 2 hours or less of emergency department arrival or when medically stable;
4. D. A current agreement with a transport service to meet the timeline in §C(9) of this regulation; and

5. E. A written protocol for transfer that includes communication and feedback from the receiving facility, which is:

   1. (1) Updated at least annually; and

   2. (2) Maintained up-to-date in:

      1. (a) The emergency department; and
      2. (b) All other locations where stroke care is provided.

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

Effective date: July 1, 2021 (48:9 Md. R. 360)

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