The facility shall:

1. A. 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;
2. B. Have participated in the stroke registry and maintained a stroke log for a minimum of 6 months prior to time of requesting an application;
3. C. Demonstrate ongoing participation in the stroke registry;
4. D. Authorize the stroke registry to provide the hospital data to MIEMSS for health oversight activities in a manner approved by the EMS Board;

5. E. Establish at least two outcome objectives that:

   1. (1) Are time-specific;
   2. (2) Are measurable;
   3. (3) Reflect tracking and trending of performance measures and indicators; and
   4. (4) Are reviewed in annual comparison studies;

6. F. Maintain a stroke log which includes at a minimum the following information for each entry:

   1. (1) The number of times the stroke team was activated;
   2. (2) The stroke team’s response time to the acute stroke patient;
   3. (3) The on-call neurologist’s response time for consultation to the acute stroke patient;
   4. (4) The type or types of diagnostic tests and acute treatment utilized;
   5. (5) The patient’s diagnosis;
   6. (6) Door to IV fibrinolytic time;
   7. (7) Patient complications;
   8. (8) Arrival and departure/transfer times; and
   9. (9) Disposition of the patient;
7. G. Monitor its IV fibrinolytic complications, which includes symptomatic intracerebral hemorrhage and serious life-threatening systemic bleeding;

8. H. 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:

   1. (1) Meets;
   2. (2) Reviews practice patterns; and
   3. (3) Modifies practice patterns as appropriate;

9. I. In cases where the administration of fibrinolytics is appropriate:

   1. (1) Administer the fibrinolytic within 60 minutes from the time the patient arrives at the emergency department for greater than or equal to 50 percent of eligible patients;
   2. (2) 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; and
   3. (3) Demonstrate progress towards reducing time of administration of fibrinolytics to 45 minutes for greater than or equal to 50 percent of eligible patients;

10. J. Incorporate into their quality assurance process progress reports about:

    1. (1) Specific acute stroke treatment benchmarks;
    2. (2) Outcomes data on patients transferred for a higher level of care; and
    3. (3) Stroke treatment quality improvement goals; and

11. K. Provide MIEMSS with documentation of quality management of the stroke program for review, including, if appropriate:

    1. (1) Problem identification;
    2. (2) Problem analysis;
    3. (3) An action plan;
    4. (4) Implementation of the plan; and
    5. (5) Re-evaluation of the plan.

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)