Figure: 25 TAC §157.133(a)(3)

Legend:   D = Desired
                E = Essential

Support (Level III) Stroke Facility Designation Criteria

Support (Level III) Stroke Facilities (SSFs) - Provides resuscitation, stabilization and assessment of the stroke victim and either provides the treatment or arranges for immediate transfer to a higher level of stroke care either a Comprehensive (Level I) Stroke Center or Primary (Level II) Stroke Center; provides ongoing educational opportunities in stroke related topics for health care professionals and the public; and implements stroke prevention programs.

A.  Stroke Program  
1. Identified Stroke Medical Director who:
      a.  Is actively credentialed by the hospital to provide stroke care
      b.  Is charged with overall management of the stroke care provided by the
      c.  Shall have the authority and responsibility of clinical oversight of the stroke
program.  This is accomplished through mechanisms that may include, but are not
limited to:  credentialing of staff that provide stroke care; providing stroke care;
development of treatment protocols; cooperating with nursing administration to
support the nursing needs of the stroke patient; coordinating the performance
improvement peer review; and correcting deficiencies in stroke care
           i.  There shall be a defined job description
           ii.  There shall be an organizational chart delineating the Stroke Medical
Director’s role and responsibility
           iii.  The Stroke Medical Director shall be credentialed by the hospital to
participate in the stabilization and treatment of stroke patients using criteria such
as board-certification/board eligibility; stroke continuing medical education;
compliance with stroke protocols, and participation in the Stroke Process
Improvement (PI) program
      d.  The Stroke Medical Director shall participate in a leadership role in the
hospital and community
2.  Identified Stroke Nurse Coordinator who:
       a.  Is a Registered Nurse
        b.  Has successfully completed and is current in Advanced Cardiac Life
        c.  Has successfully completed 8 hours of stroke continuing education in the
last 12 months and has successfully completed an approved National Institutes of
Health Stroke Scale (NIHSS) certification course
      d.  Has successfully completed an (NIHSS) certification course by an
approved certification program or a Department of State Health Services
approved equivalent
       e.  Has the authority and responsibility to monitor the stroke patient care from
Emergency Department (ED) admission through stabilization and transfer to a
higher level of care or admission
            i.  There shall be a defined job description
            ii.  There shall be an organizational chart delineating roles and
           iii.  The Stroke Nurse Coordinator shall receive education and training
designed for his/her role which provides essential information on the structure,
process, organization and administrative responsibilities of a PI program to
include stroke outcomes and performance improvement
3.  An identified Stroke Registrar who:
      a.  Has appropriate training in stroke chart abstraction
      b.  Has appropriate training in stroke registry data entry
      c.  Has the ability to provide stroke registry data to the PI program
4.  Written protocols, developed with approval by the hospital’s medical staff:
      a.  Stroke Team Activation
      b.  Identification of stroke team responsibilities during the stabilization of a
stroke patient
      c.  Triage, admission and transfer criteria of stroke patients
      d.  Protocols for the administration of thrombolytics and other approved stroke
      e.  Stabilization and treatment of stroke patients
      f.  Facility capability for stroke patients will be provided to the Regional
Advisory Council
1.  Emergency Medicine - this requirement may be fulfilled by a physician
credentialed by the hospital to provide emergency medical services
      a.  Any emergency physician who provides care to the stroke patient must be
credentialed by the Stroke Medical Director to participate in the stabilization and
treatment of stroke patients (i.e. current board certification/eligibility, compliance
with stroke protocols and participation in the stroke PI program)
      b.  An average of 8 hours per year of stroke related continuing medical
      c.  An Emergency Medicine Physician providing stroke coverage must be
current in Advanced Cardiac Life Support (ACLS)
      d.  The emergency physician representative to the multidisciplinary committee
that provides stroke coverage to the facility shall attend 50% or greater of
multidisciplinary and peer review stroke committee meetings
2.  Radiology - Capability to have computerized topography (CT) report read
within 45 minutes of patient arrival
3.  Primary Care Physician - the patient’s primary care physician should be
notified at an appropriate time
C.  NURSING SERVICES (all patient care areas)  
1.  All nurses caring for stroke patients throughout the continuum of care have
ongoing documented knowledge and skills in stroke nursing for patients of all
ages to include:
      a.  Stroke specific orientation
      b.  Annual competencies
      c.  Continuing annual education
2.  Written standards on nursing care for the stroke patients for
all units caring for stroke patients shall be implemented
3.  100% of nurses providing initial stabilization care for stroke patients shall be
competent in:
      a.  NIHSS (competency or certification)
      b.  Dysphagia screening
      c.  Thrombolytic therapy administration
1.  The published physician on-call schedule must be available in the Emergency
Department (ED)
2.  A physician with special competence in the care of the stroke patient who is
on-call (if not in-house 24/7) shall be promptly available within 30 minutes of
request from outside the hospital and on patient arrival from inside the hospital
3.  The physician on duty or on-call to the ED shall be activated on EMS
communication with the ED or after a primary assessment of patients who arrive
to the ED by private vehicle or for patients who are exhibiting signs and symptoms
of an acute stroke
4.  A minimum of one and preferably two registered nurses who have stroke
training shall participate in the initial stabilization of the stroke patient. Nursing
staff required for initial stabilization is based on patient acuity and “last known well
5.  100% of the nursing staff have successfully completed and hold current
credentials and competencies in:
      a.  ACLS (certification)
      b.  NIHSS (competency or certification)
      c.  Dysphagia Screening (competency)
      d.  Thrombolytic therapy administration (competency)
6.  Nursing documentation for stroke patients is systematic and meets stroke
registry guidelines
7.  Two-way communication with all pre-hospital emergency medical services E
8.  Equipment and services for the evaluation and stabilization of, and to provide
life support for, critically ill stroke patients of all ages shall include, but not limited
      a.  Airway control and ventilation equipment
      b.  Continuous cardiac monitoring
      c.  Mechanical ventilator
      d.  Pulse oximetry
      e.  Suction devices
      f.  Electrocardiograph-oscilloscope-defibrillator
      g.  Supraglottic airway management device
      h.  All standard intravenous fluids and administration devices
      i.  Drugs and supplies necessary to provide thrombolytic therapy
1.  24-hour coverage by in-house technician D
2.  Computerized tomography E
1.  24-hour coverage by in-house lab technician D
2.  Drug and alcohol screening D
3.  Call-back process for stroke patients within 30 minutes
4.  Bedside glucose
5.  Standard analyses of blood, urine and other body fluids, including micro-
6.  Blood typing and cross-matching
7.  Coagulation studies
8.  Blood gases and pH determination
1.   A facility seeking initial designation must show at least 6 months worth of
audits for all qualifying stroke patients with evidence of "loop closure" on identified
2.   A designated stroke facility must have an ongoing PI program that includes at
a minimum:
      a. All stroke activations
      b. All stroke admissions
      c. All transfers out
      d. All readmissions
      e. All stroke deaths
3.   Performance improvement activities must be:
      a. continuous and ongoing throughout the designation period
      b. available for review on a rolling two year period and
      c. available for review at all times
4.   An organized Stroke PI program established by the hospital
      a.  Audit charts for appropriateness of stroke care
      b.  Documented evidence of identification of all deviations from standards of
stroke care
      c.  Documentation of actions taken to address identified issues
      d.  Documented evidence of participation by the Stroke Medical
      e.  Morbidity and mortality review including decisions by the Stroke Medical
Director as to whether or not standard of care was met
      f. Documented resolutions “loop closure” of all identified issues to prevent
future reoccurrences
      g. Special audit for all stroke deaths and other specified cases, including
      h. Multidisciplinary hospital Stroke PI Committee
5.  Multidisciplinary stroke conferences, continuing education and problem solving
to include documented nursing and pre-hospital participation
6.  Feedback regarding stroke patient transfers-out from the ED and in-patient
units shall be obtained from receiving facilities
7.  Stroke Registry - data shall be accumulated and downloaded to the receiving
8.  Participation with the regional advisory council’s (RAC) PI program, including
adherence to regional protocols, review of pre-hospital stroke care, submitting
data to the RAC as requested to include such things as summaries of transfer
denials and transfers to hospitals outside the RAC
9. Times of and reasons for diversion must be documented and reviewed by the
Stroke PI program
1.  Must participate in the regional stroke system development per RAC
2.  Participates in the development of RAC transport protocols for stroke patients,
including destination and facility capability
1.  A process to expedite the transfer of a stroke patient to include such things as
written transfer protocols, written/verbal transfer agreements, and a regional
stroke transfer plan for patients needing a higher level of care (Comprehensive or
Primary Stroke Center)
2.  A system for establishing an appropriate landing zone in close proximity to the
hospital (if rotor wing services are available)
1.  A public education program to address:
      a.  Signs and symptoms of a stroke
      b.  Activation of 911
      c.  Stroke risk factors
      d.  Stroke prevention
2.  Coordination and/or participation in community/RAC stroke prevention
1.  Formal programs in stroke continuing education provided by hospital for staff
based on needs identified from the Stroke PI program for:
      a.  Staff physicians
      b.  Nurses
      c.  Allied health personnel, including mid-level providers