08 LC 33
2526
Senate
Bill 549
By:
Senator Thomas of the 54th
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Chapter 11 of Title 31 of the Official Code of Georgia Annotated, relating
to emergency medical services, so as to establish a three level system of stroke
centers; to provide for legislative findings; to provide for definitions; to
provide for the designation of primary, comprehensive, and support stroke
centers; to provide for requirements for primary, comprehensive, and support
stroke centers; to provide for a matching grant program; to provide for the
distribution of a list of designated stroke centers to emergency medical
services providers; to provide for the development of a model stroke triage
assessment tool; to provide for the establishment of protocols related to the
assessment, treatment, and transport of stroke patients by licensed emergency
medical services providers; to provide for annual reporting; to provide for
statutory construction; to provide that a hospital shall not advertise that it
is a primary, comprehensive, or support stroke center unless so designated; to
provide for rules and regulations; to provide for related matters; to repeal
conflicting laws; and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Chapter
11 of Title 31 of the Official Code of Georgia Annotated, relating to emergency
medical services, is amended by adding a new Article 6 to Chapter 11 to read as
follows:
"ARTICLE
6
31-11-110.
The
General Assembly finds and declares that:
(1)
The rapid identification, diagnosis, and treatment of stroke can save the lives
of stroke victims and in some cases can reverse neurological damage such as
paralysis and speech and language impairments, leaving stroke victims with few
or no neurological deficits;
(2)
Despite significant advances in diagnosis, treatment, and prevention, stroke is
the third leading cause of death and the biggest cause of disability in this
country; an estimated 700,000 to 750,000 new and recurrent strokes occur each
year in this country and with the aging of the population, the number of persons
who have strokes is projected to increase;
(3)
Although new treatments are available to improve the clinical outcomes of
stroke, many acute care hospitals lack the necessary staff and equipment to
optimally triage and treat stroke patients, including the provision of optimal,
safe, and effective emergency care for these patients;
(4)
An effective system to support stroke survival is needed in our communities in
order to treat stroke victims in a timely manner and to improve the overall
treatment of stroke victims in order to increase survival and a decrease the
disabilities associated with stroke. There is a public health need for acute
care hospitals in this state to establish stroke centers to ensure the rapid
triage, diagnostic evaluation, and treatment of patients suffering a
stroke;
(5)
Three levels of stroke centers should be established for the treatment of acute
stroke:
(A)
Primary stroke centers should be established in as many acute care hospitals as
possible to evaluate, stabilize, and provide emergency care to patients with
acute stroke and then, depending on the patient´s needs and the
center´s capabilities, either admit the patient and provide inpatient care
or transfer the patient to a comprehensive stroke center;
(B)
Comprehensive stroke centers should be established in hospitals to ensure
coverage for all patients throughout the state who require this level of care.
These centers would provide complete and specialized care to patients who
experience the most complex strokes, which require specialized testing, highly
technical procedures, and other interventions. Also, these centers would
provide education and guidance to affiliated primary and support stroke centers;
and
(C)
Support stroke centers should be established in rural areas served by critical
access hospitals to allow timely access to acute stroke care that would not
otherwise be available because transportation and access to care are limited.
These centers would, within the scope of their capability and in coordination
with a primary or comprehensive stroke center, evaluate, stabilize, and provide
emergency care to patients with acute stroke and then, depending on the
patient´s needs and the center´s capabilities, either admit the
patient and provide inpatient care or transfer the patient to a primary or
comprehensive stroke center. These centers would also utilize telemedicine
services as a 'spoke' within a hub and spoke network in collaboration with a
primary or comprehensive stroke center serving as a 'hub'; and
(6)
Therefore, it is in the best interest of the residents of this state to
establish a program to designate stroke centers throughout the state, to provide
specific patient care and support services criteria that stroke centers must
meet in order to ensure that stroke patients receive safe and effective care,
and to provide financial support to acute care hospitals to encourage them to
develop stroke centers in all areas of the state. Further, it is in the best
interest of the people of this state to modify the state´s emergency
medical response system to assure that stroke victims may be quickly identified
and transported to and treated in facilities that have specialized programs for
providing timely and effective treatment for stroke victims.
31-11-111.
As
used in this article, the term 'department' means the same state agency or state
board which regulates emergency medical services personnel and providers
pursuant to this chapter.
31-11-112.
(a)
The department shall designate hospitals that meet the criteria set forth in
this article as primary, comprehensive, or support stroke centers.
(b)
A hospital shall apply to the department for such designation and shall
demonstrate to the satisfaction of the department that the hospital meets the
applicable criteria set forth in Code Section 31-11-113 for a primary,
comprehensive, or support stroke center, respectively.
(c)
The department shall designate as many hospitals as primary stroke centers as
apply for the designation, provided that each applicant meets the criteria set
forth in subsection (a) of Code Section 31-11-113.
(d)
The department shall designate as many hospitals as comprehensive stroke centers
as apply for the designation, provided that each applicant meets the criteria
set forth in subsection (b) of Code Section 31-11-113.
(e)
The department shall designate as many critical access hospitals serving rural
areas of this state as support stroke centers as apply for the designation,
provided that each applicant meets the criteria set forth in subsection (c) of
Code Section 31-11-113.
(f)
The department may suspend or revoke a hospital´s designation as a stroke
center, after notice and hearing, if the department determines that the hospital
is not in compliance with the requirements of this article.
31-11-113.
(a)
A hospital designated as a primary stroke center shall be certified as such by
the Joint Commission on Accreditation of Healthcare Organizations or, at a
minimum, meet the following criteria:
(1)
With respect to patient care, the hospital shall:
(A)
Maintain acute stroke team availability to see an emergency department patient
within 15 minutes of arrival at the emergency department, 24 hours a day, seven
days a week;
(B)
Maintain written care protocols and standing orders for emergency care of stroke
patients;
(C)
Maintain neurology and emergency department personnel trained in the diagnosis
and treatment of acute stroke;
(D)
Maintain telemetry or critical care beds staffed by physicians and nurses who
are trained and experienced in caring for acute stroke patients;
(E)
Provide for neurosurgical services, including operating room availability either
at the hospital or through an agreement with a comprehensive stroke center,
within two hours, 24 hours a day, seven days a week;
(F)
Provide acute care rehabilitation services;
(G)
Enter into and maintain a written transfer agreement with a comprehensive stroke
center so that patients with complex strokes may be transported to the
comprehensive center for care when clinically warranted; and
(H)
Enter into and maintain written transfer agreements with support stroke centers
to accept transfer of patients with strokes when within the capabilities of the
primary stroke center and clinically warranted; and
(2)
With respect to support services, the hospital shall:
(A)
Demonstrate an institutional commitment to and support of a stroke center,
including having a designated physician stroke center director with special
training and experience in caring for patients with stroke;
(B)
Maintain neuroimaging services capability which shall include computerized
tomography scanning or magnetic resonance imaging and interpretation of the
image that is available 24 hours a day, seven days a week, within 25 minutes of
order entry;
(C)
Maintain laboratory services capability, which shall include blood testing,
electrocardiography, and X-ray services that are available 24 hours a day, seven
days a week, within 45 minutes of order entry;
(D)
Develop and maintain outcome and quality improvement activities, which include a
data base or registry to track patient outcomes. These data shall include, at a
minimum:
(i)
The number of patients evaluated;
(ii)
The number of patients receiving acute interventional therapy;
(iii)
The amount of time from patient presentation to delivery of acute interventional
therapy;
(iv)
Patient length of stay;
(v)
Patient functional outcome; and
(vi)
Patient morbidity;
(E)
Provide annual continuing education on stroke to support staff and emergency
services personnel regarding stroke diagnosis and treatment, which shall be the
responsibility of the stroke center director;
(F)
Require the stroke center director and designated stroke team staff to obtain a
minimum of eight hours of continuing education on stroke each year;
and
(G)
Demonstrate a continuing commitment to ongoing education to the general public
about stroke, which includes conducting at least two programs annually for the
general public on the prevention, recognition, diagnosis, and treatment of
stroke.
(b)
A hospital designated as a comprehensive stroke center shall use proven
state-of-the-art technology and medical techniques and, at a minimum, meet the
following criteria:
(1)
The hospital shall meet all of the criteria required for a primary stroke center
pursuant to subsection (a) of this Code section;
(2)
With respect to patient care, the hospital shall:
(A)
Maintain a neurosurgical team that is capable of assessing and treating complex
stroke and stroke-like syndromes;
(B)
Maintain on staff a neuroradiologist with a Certificate of Added Qualifications
and a physician with neuro-interventional angiographic training and
skills;
(C)
Provide comprehensive rehabilitation services either on site or by transfer
agreement with another health care facility; and
(D)
Enter into and maintain written transfer agreements with primary and support
stroke centers to accept transfer of patients with complex strokes when
clinically warranted; and
(3)
With respect to support services, the hospital shall:
(A)
Have magnetic resonance imaging and computed tomography angiography
capabilities;
(B)
Have digital subtraction angiography and a suite equipped for
neuro-interventional procedures;
(C)
Develop and maintain sophisticated outcomes assessment and performance
improvement capability that incorporates data from affiliated primary stroke
centers and integrates regional, state, and national data;
(D)
Provide guidance and continuing medical education to primary stroke
centers;
(E)
Provide graduate medical education in stroke; and
(F)
Conduct research on stroke related topics.
(c)
A hospital designated as a support stroke facility shall provide timely access
to a limited number of stroke care services as well as access to and
collaboration with primary and comprehensive stroke centers. Support stroke
facilities shall:
(1)
Create, implement, and document a stroke triage and treatment plan which can be
accomplished within the capabilities of the facility;
(2)
Clearly designate and specify the availability of neurosurgical and
interventional neuroradiology/endovascular services; and
(3)
Enter into a collaborative support agreement with a primary or comprehensive
stroke center that agrees to collaborate with the support stroke facility in
order to provide access to the supplemental resources needed to meet the
criteria of a primary stroke center included in subsection (a) of this Code
section. In order to do so, each support stroke facility shall
provide:
(A)
Access, 24 hours per day, seven days a week, to a qualified medical
professional, as described in department rules;
(B)
An agreement with a primary or comprehensive stroke center providing for the
transfer and acceptance of all stroke patients seen by the support stroke
facility for stroke treatment therapies which the stroke support facility is not
capable of providing, and providing for an on-call neurologist at the
collaborating primary or comprehensive stroke center who can diagnose and
recommend treatment with a two-way consultation using a web browser and webcam
when transport cannot be accomplished in accordance with critical time
frames;
(C)
Transport or communication criteria with the collaborating primary stroke center
or comprehensive stroke center which include a protocol for identifying and
specifying any times or circumstances in which the support stroke facility
cannot provide appropriate treatment;
(D)
Protocols for administering thrombolytics and other approved acute stroke
treatment therapies; and
(E)
Protocols for the transport of patients to the collaborating primary or
comprehensive stroke center in the event of unavailable neurosurgical services
within 90 minutes of identified need;
(4)
Provide computer equipment and portable stations that allow a physician of the
support stroke facility to see and interact with a remote neurologist at the
collaborating primary or comprehensive stroke center;
(5)
Implement and document training in stroke for all emergency department
personnel; and
(6)
Designate a specific physician as stroke director.
(d)
If the department determines that a new drug, device, technique, or technology
has become available for the treatment of stroke that provides a diagnostic or
therapeutic advantage over existing elements included in the criteria
established in this Code section, the department may, by regulation, revise or
update the criteria accordingly.
31-11-114.
(a)
In order to encourage and ensure the establishment of stroke centers throughout
the state, the department shall award matching grants, subject to appropriations
from the General Assembly, to hospitals that seek designation as stroke centers
and demonstrate a need for financial assistance to develop the necessary
infrastructure, including personnel and equipment, in order to satisfy the
criteria for designation of such stroke centers provided pursuant to Code
Section 31-11-113. The matching grants shall not exceed $250,000.00 or 50
percent of the hospital´s cost for developing the necessary infrastructure,
whichever is less.
(b)
A hospital seeking designation as a stroke center pursuant to this article may
apply to the department for a matching grant, in a manner and on a form required
by the department, and provide such information as the department deems
necessary to determine if the hospital is eligible for a grant.
(c)
The department may provide matching grants to as many hospitals as it deems
appropriate, subject to appropriations, except that:
(1)
Matching grant awards shall be made to at least two applicant hospitals in each
region of the state, provided that the applicant hospitals receiving the awards
must be eligible to serve as primary, comprehensive, or support stroke centers
under this article; and
(2)
No more than 20 percent of the funds disbursed pursuant to this Code section
shall be allocated to hospitals that seek designation as comprehensive stroke
centers.
(d)
The department shall, not later than July 1, 2009, prepare and submit to the
Governor, the President of the Senate, and the Speaker of the House of
Representatives a report indicating, as of June 30, 2009, the total number of
hospitals that have applied for grants pursuant to this Code section, the number
of applicants that have been determined by the department to be eligible for
such grants, the total number of grants awarded, the name and address of each
grantee hospital, and the amount of the award to each grantee, and the amount of
each award that has been disbursed to the grantee.
31-11-115.
(a)
By June 1 of each year, the department shall send the list of primary,
comprehensive, and support stroke centers designated pursuant to Code Section
31-11-113 to the medical director of each licensed emergency medical services
provider in this state and shall post such list on the department´s
website.
(b)
The department shall develop a model stroke triage assessment tool. The
department shall post the model stroke triage assessment tool on its website and
shall distribute a copy of such assessment tool to each licensed emergency
medical services provider in this state no later than December 31, 2008. Each
licensed emergency medical services provider shall use a stroke triage
assessment tool that is substantially similar to the model stroke triage
assessment tool provided by the department.
(c)
The department shall establish protocols related to the assessment, treatment,
and transport of stroke patients by licensed emergency medical services
providers in this state. Such protocols shall include regional transport plans
for the triage and transport of adult stroke patients to hospitals which are
best able to care for them including the bypass of health care facilities not
designated as primary, comprehensive, or support stroke centers when it is safe
to do so and shall also provide for the following:
(1)
When a stroke patient requires initial transportation to a hospital by an
ambulance provider, the patient shall be transported by such ambulance provider
to the hospital of his or her choice provided:
(A)
The hospital chosen is capable of meeting the patient´s immediate
needs;
(B)
The hospital chosen is within reasonable distance as determined by the ambulance
attendant´s assessment in collaboration with the ambulance service medical
director so as not to further jeopardize the patient´s health or compromise
the ability of the emergency medical services system to function in a normal
manner; and
(C)
The hospital chosen is within a usual and customary patient transport or
referral area as determined by the ambulance service medical
director;
(2)
If the patient´s choice of hospital is not appropriate with respect to the
protocols or if the patient does not, can not, or will not express a choice, the
ambulance provider shall transport the patient to the nearest hospital believed
capable of meeting the patient´s immediate medical needs without regard to
other factors, such as patient´s ability to pay, hospital charges, or
county or city limits, in accordance with the pre-established guidelines within
the protocols. If for any reason the pre-established guidelines are unclear or
not applicable to the specific case, then the ambulance service medical director
shall be consulted for a definitive decision; and
(3)
If the patient continues to insist on being transported to a hospital which is
inappropriate for his or her needs, then the patient shall be transported to
that hospital after the ambulance attendant notifies the ambulance service
medical director of the patient´s decision.
The
department shall provide for training on such protocols for emergency medical
services personnel.
(d)
On and after January 1, 2009, each emergency medical services provider shall
comply with the provisions of this Code section.
31-11-116.
(a)
In order to assure that the patients are receiving the appropriate level of care
and treatment at each primary, comprehensive, and support stroke center in the
state, each hospital designated as a primary, comprehensive, or support stroke
center shall annually report the following information to the
department:
(1)
The number of patients evaluated;
(2)
The number of patients receiving acute interventional therapy;
(3)
The amount of time from patient presentation to delivery of acute interventional
therapy;
(4)
Patient length of stay;
(5)
Patient functional outcome;
(6)
Patient morbidity;
(7)
Deep vein thrombosis prophylaxis given;
(8)
Number of patients discharged on antiplatelet or antithrombotics
medication;
(9)
Number of patients with atrial fibrillation receiving anticoagulation
therapy;
(10)
Patients on which the administration of tissue plasminogen activator was
considered;
(11)
Antithrombolic medication given within 48 hours of hospitalization;
(12)
Number of lipid profiles ordered during hospitalization;
(13)
Number of screens for dysphagia performed;
(14)
Stroke education provided;
(15)
Number of smoking cessation programs provided or discussed;
(16)
The number of patients assessed for rehabilitation and whether a plan for
rehabilitation was considered;
(17)
The number of emergency medical services stroke patients who were transported to
the facility;
(18)
The number of emergency medical services stroke patients who were admitted to
the facility;
(19)
The number and percentage of stroke cases treated with intravenous or
intra-arterial tissue plasminogen activator; and
(20)
The number of patients discharged on cholesterol-reducing
medication.
(b)
The department shall collect the information reported pursuant to subsection (a)
of this Code section and shall post such information in the form of a report
card annually on the department´s website. The report shall be submitted
to the Governor, the President of the Senate, and the Speaker of the House of
Representatives. The results of the report may be used by the department to
conduct training with the designated facilities regarding best practices in the
treatment of stroke.
(c)
In no way shall this article be construed to require disclosure of any health
care information or other data in violation of the federal Health Insurance
Portability and Accountability Act of 1996, P.L. 104-191.
31-11-117
This
article shall not be construed to be a medical practice guideline and shall not
be used to restrict the authority of a hospital to provide services for which it
has received a license under state law. The General Assembly intends that all
patients be treated individually based on each patient´s needs and
circumstances.
31-11-118
A
person may not advertise to the public, by way of any medium whatsoever, that a
hospital is a primary, comprehensive, or support stroke center unless the
hospital has been designated as such by the department pursuant to this
article.
31-11-119.
The
department shall be authorized to promulgate rules and regulations to carry out
the purposes of this article."
SECTION
2.
All
laws and parts of laws in conflict with this Act are repealed.