TITLE 7               HEALTH


PART 13               CERTIFICATION OF STROKE CENTERS               ISSUING AGENCY:  New Mexico Department of Health, Epidemiology and Response Division, Emergency Medical Systems Bureau.

[ NMAC - N, 8/15/14]               SCOPE:  These rules apply to New Mexico acute care hospitals that seek to be accredited or become accredited as an acute stroke capable center, primary stroke center, or comprehensive stroke center by the joint commission.

[ NMAC - N, 8/15/14]               STATUTORY AUTHORITY:  These rules are promulgated pursuant to the following statutory authorities: 1) the New Mexico Department of Health Act, Subsection E of Section 9-7-6 NMSA 1978, which authorizes the secretary of the department of health to “make and adopt such reasonable and procedural rules and regulations as may be necessary to carry out the duties of the department and its divisions,” and; 2) the Public Health Act, Section 24-1-34 NMSA 1978 (“Primary stroke centers; comprehensive stroke centers; acute stroke capable centers; department certification; rulemaking”).

[ NMAC - N, 8/15/14]               DURATION:  Permanent.

[ NMAC - N, 8/15/14]               EFFECTIVE DATE:  August 15, 2014, unless a later date is cited at the end of a section.

[ NMAC - N, 8/15/14]               OBJECTIVE:  These rules are intended to establish the requirements necessary for acute care hospitals to be certified by the department as an acute stroke capable center, primary stroke center, or comprehensive stroke center.  Additionally, the rule intends to identify incentives for participation in a stroke registry, as well as assist and encourage stroke centers to enter into coordinated care agreements with other health care facilities throughout the state to provide appropriate access to care for stroke patients.

[ NMAC - N, 8/15/14]               DEFINITIONS:  Unless a different meaning is plainly required by the context, the following words and phrases used in these regulations shall have the meanings indicated.

                A.            “Accredited” means a process of validation by the joint commission recognized by the department.

                B.            “Acute care hospital” means a facility with an emergency department and physicians(s) available, licensed under state statute, or a comparable facility operated by the federal government or located and licensed by another state.

                C.            “Bureau” means the EMS bureau of the epidemiology and response division of the department of health.

                D.            “Certified” means a formal determination by the department that an acute care facility has met the standards necessary for joint commission accreditation, including functioning in a stroke care system, and capable of providing special resources and care as an acute stroke capable, primary, or comprehensive center.

                E.            “Department” means the New Mexico department of health.

                F.            “Joint commission” means an independent, not-for-profit group in the United States that administers accreditation programs that address crucial elements of operations, such as patient care, for hospitals and other healthcare-related organizations

                G.            “Recognized” means written acknowledgement by the bureau.

                H.            “Registry” means a bureau approved database which documents and integrates medical and system information related to the provision of stroke care by acute care hospital facilities.

                I.             “Stroke” is a term that broadly describes the death of central nervous system cells and tissues attributed to an insufficient supply of blood to the central nervous system.  It includes conditions caused by ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage.

                J.             “Stroke center” means an acute care hospital with a group of medical caregivers that have specific education and resources to diagnose and treat stroke; three levels of stroke centers - acute stroke capable, primary, and comprehensive - are accredited by the joint commission based on the capability of stroke care by the acute care hospital.

[ NMAC - N, 8/15/14]               STROKE REGISTRY:

                A.            Funding for data submission:

                    (1)     The department shall, depending on availability of funds and based on guidelines approved by the department and administered by the bureau, provide limited financial assistance to acute care hospitals providing stroke data to the approved registry data platform, and allowing department access to that data.   This funding is provided to defray licensing costs associated with the submission of data to the approved data platform.  Participation in data submission to the registry is required to be eligible for funds.

                    (2)     Acute care hospitals designated or seeking designation as acute stroke capable, primary, or comprehensive centers must report data to the department approved data platform that is consistent with nationally recognized guidelines on the treatment of individuals with confirmed stroke.

                B.            Data platform:  The department of health shall approve a single data platform, to which data is submitted by each hospital, and maintain a statewide stroke database that compiles information and statistics on stroke care through this data platform.

[ NMAC - N, 8/15/14]               ACUTE STROKE CAPABLE, PRIMARY, OR COMPREHENSIVE STROKE CENTER CERTIFICATION:  The department shall certify an acute care hospital as a primary stroke center, comprehensive stroke center, or acute stroke capable center if that hospital has been accredited as an acute stroke capable center, primary stroke center, or comprehensive stroke center. The department shall post information regarding certification on the department's web site. If a hospital loses its national accreditation as a stroke center, the secretary shall revoke the hospital's certification.

[ NMAC - N, 8/15/14]             STROKE SYSTEM DEVELOPMENT AND IMPROVEMENT:  To every extent possible, the department of health will:

                A.            Facilitate the communication and analysis of information and data between the department, acute care hospitals, emergency medical services, and other care providers regarding ways to improve the quality of care for stroke patients.

                B.            Establish a stroke data oversight process, and implement a plan for continuous quality improvement in the quality of care provided to stroke patients statewide based on stroke and other data sources.  This will include:

                    (1)     analyzing data generated by the registry on stroke response and treatment;

                    (2)     identifying potential interventions to improve stroke care in the prehospital and acute care hospital settings throughout the state, and based on guidelines approved by the department and administered by the bureau, provide limited financial assistance depending on availability of funds;

                    (3)     assuring that data reported under section NMAC shall be made available to requesting entities that have responsibility for the management and administration of services that provide prehospital and acute hospital care of stroke patients.

[ NMAC - N, 8/15/14]