# Title 23 — Health and Safety

## Chapter 23-43 — Stroke Centers and Care

### § 23-43-01. Stroke system.

The department of health and human services shall establish and maintain a
comprehensive stroke system for the state. The program must comply with this chapter; be
based on department-approved, nationally recognized guidelines and protocols; and provide
specific patient care and support services criteria stroke centers shall meet to ensure stroke
patients receive safe and effective care, and must modify the state's emergency medical
response system to assure stroke patients are quickly identified and transported to and treated
in facilities that have specialized programs for providing timely and effective treatment for stroke
patients. The stroke system must include standards for the following components:
1. A system plan.
2. Prehospital emergency medical services.
3. Hospitals, for which the standards must include:
a. Standards for designation, redesignation, and removal of designation.
b. Standards for evaluation and quality improvement programs for designated
facilities. The standards must require each facility to collect quality improvement
data and to provide specified portions to the department of health and human
services for use in state and regional stroke quality improvement programs.
4. A stroke registry. Data in the stroke registry is not subject to subpoena or discovery or
introduction into evidence in any civil action. A designated facility shall participate in
the stroke registry. A hospital not designated shall provide to the stroke registry a
minimum set of data elements for all stroke patients as determined by the stroke
system of care advisory task force.
5. A stroke quality improvement program to monitor the performance of the stroke
system. The proceedings and records of the stroke quality improvement program are
not subject to subpoena or discovery or introduction into evidence in any civil action
arising out of any matter that is the subject of consideration by the stroke quality
improvement program.
### § 23-43-02. Designation of comprehensive stroke center, primary stroke centers, and

acute stroke-ready hospitals.
1. The department of health and human services shall identify hospitals that meet the
criteria as a comprehensive stroke center, primary stroke center, or acute stroke-ready
hospital. In order to receive a designation under this section, a hospital shall apply to
the department of health and human services and shall demonstrate to the satisfaction
of the department the hospital meets the applicable criteria.
2. In order to qualify for designation as a comprehensive stroke center, an accredited
acute care hospital must be certified as a comprehensive stroke center by a
department-approved, nationally recognized guidelines-based organization, which
provides comprehensive stroke center hospital certification for stroke care. As a
condition of retaining designation as a comprehensive stroke center, an acute care
hospital shall maintain its certification.
3. In order to qualify for designation as a primary stroke center, an accredited acute care
hospital must be certified as a primary stroke center by a department-approved,
nationally recognized guidelines-based organization, which provides primary stroke
center certification for stroke care. As a condition of retaining designation as a primary
stroke center, an acute care hospital shall maintain its certification.
4. In order to qualify for designation as an acute stroke-ready hospital, an accredited
acute care hospital must be certified as an acute stroke-ready hospital by
department-approved, nationally recognized guidelines-based criteria. As a condition
of retaining designation as an acute stroke-ready hospital, an acute care hospital shall
maintain its certification.
5. Through agreement, a comprehensive stroke center and primary stroke center may
coordinate with an acute stroke-ready hospital to provide appropriate access to care

for acute stroke patients. The coordinating stroke care agreement must be in writing
and include, at a minimum:
a. The transfer agreement for the transport and acceptance of a stroke patient seen
by the acute stroke-ready hospital for stroke treatment therapies the stroke center
or primary care center is not capable of providing; and
b. Communication criteria and protocol with the acute stroke-ready hospital.
6. If the department determines the hospital is not in compliance with the requirements
set for designation level, after notice and a hearing, the department of health and
human services may suspend or revoke a hospital's state designation as a
comprehensive stroke center, primary stroke center, or acute stroke-ready hospital.
7. Any facility that is not designated, must have a predetermined plan for the triage of
acute stroke patients. The plan must be filed annually with the department of health
and human services, division of emergency medical services and trauma.
### § 23-43-03. Emergency medical services operations - Assessment and transportation of

stroke patients to a comprehensive stroke center, primary stroke center, or acute
stroke-ready hospital.
1. Before June first of each year the department of health and human services shall send
the list of comprehensive stroke centers, primary stroke centers, and acute
stroke-ready hospitals to the medical director of each licensed emergency medical
services operation in this state. The department of health and human services shall
maintain a copy of the list and shall post a list of comprehensive stroke centers,
primary stroke centers, and acute stroke-ready hospitals to the department of health
and human services' website.
2. The department of health and human services shall adopt and distribute a nationally
recognized, standardized stroke triage assessment tool. The department shall post this
stroke triage assessment tool on the department's website and provide a copy of the
assessment tool to each licensed emergency medical services operation. Each
licensed emergency medical services operation shall use a stroke triage assessment
tool that is substantially similar to the sample stroke triage assessment tool provided
by the department of health and human services.
3. Each emergency medical services operation in the state shall establish prehospital
care protocols related to the assessment, treatment, and transport of a stroke patient
by a licensed emergency medical services operation. Such protocols must include
plans for the triage and transport of an acute stroke patient to the closest
comprehensive or primary stroke center or when appropriate to an acute stroke-ready
hospital, within a specified time frame of onset of symptoms.
4. As part of current training requirements, each emergency medical services operation
in the state shall establish protocols to assure licensed emergency medical services
providers and 911 dispatch personnel receive regular training on the assessment and
treatment of stroke patients.
5. An emergency medical services operation shall comply with this chapter.
6. All data reported under this chapter must be made available to the department of
health and human services and to all other government agencies, or contractors of
government agencies, which have responsibility for the management and
administration of emergency medical services throughout the state.
7. This chapter may not be construed to require disclosure of any confidential information
or other data in violation of the federal Health Insurance Portability and Accountability
Act of 1996 [Pub. L. 104-191; 110 Stat. 1936; 29 U.S.C. 1181 et seq.].
### § 23-43-04. Continuous improvement of quality of care for individuals with stroke -

Recommendations - Report to legislative management.
1. The department of health and human services shall establish and implement a plan for
achieving continuous quality improvement in the quality of care provided under the
state comprehensive stroke system for stroke response and treatment. In
implementing this plan, the department of health and human services shall:

a. Maintain a statewide stroke database that compiles information and statistics on
stroke care which align with nationally recognized stroke consensus metrics. The
department of health and human services shall utilize a nationally recognized
data set platform with confidentiality standards no less secure than the stroke
registry data platform. The department of health and human services shall
coordinate with national voluntary health organizations involved in stroke quality
improvement to avoid duplication and redundancy.
b. Require comprehensive stroke centers and primary stroke centers and
encourage acute stroke-ready hospitals and emergency medical services
operations to report data consistent with nationally recognized guidelines on the
treatment of individuals with confirmed stroke within the state.
c. Encourage sharing of information and data among health care providers on ways
to improve the quality of care of stroke patients in this state.
d. Facilitate the communication and analysis of health information and data among
the health care professionals providing care for individuals with stroke.
e. Require the application of evidence-based treatment guidelines regarding the
transitioning of patients to community-based followup care in hospital outpatient,
physician office, and ambulatory clinic settings for ongoing care after hospital
discharge following acute treatment for stroke.
2. The department of health and human services shall establish a data oversight process
and implement a plan for achieving continuous quality improvement in the quality of
care provided under the state comprehensive stroke system for stroke response and
treatment which must:
a. Analyze data generated by the stroke registry on stroke response and treatment;
b. Identify potential interventions to improve stroke care in geographic areas or
regions of the state; and
c. Provide recommendations to the department of health and human services,
emergency medical services advisory council, and legislative assembly for the
improvement of stroke care and delivery in the state.
3. Data reported under this section must be made available to the department of health
and human services and to other government agencies, or contractors of government
agencies, which have responsibility for the management and administration of
emergency medical services throughout the state.
4. Before June first of each even-numbered year, the department of health and human
services shall provide a report to the legislative management regarding progress made
toward the recommendations provided in this chapter and any recommendations for
future legislation.
### § 23-43-05. Stroke system of care task force.

1. The department of health and human services shall establish a stroke system of care
task force to address matters of triage, treatment, and transport of possible acute
stroke patients. The stroke system of care task force must include representation from
the department of health and human services, the emergency medical services
advisory council, the university of North Dakota's center for rural health, the American
stroke association or similar entity, comprehensive stroke centers, primary stroke
centers, rural hospitals, physicians, and emergency medical services operations.
2. The task force shall implement the regulations necessary to establish an effective
stroke system of care in the state, with a focus on serving rural areas. The regulations
must include protocols for the assessment, stabilization, and appropriate routing of
stroke patients by emergency medical services operations, and for coordination and
communication between hospitals, comprehensive stroke centers, primary stroke
centers, and other support services necessary to assure all residents have access to
effective and efficient stroke care.
3. The stroke system of care task force shall make recommendations to the department
of health and human services. Upon receiving such recommendations, the department
of health and human services may adopt rules implementing the recommendations.

4. As used in this subsection, "telemedicine services" means the use of interactive audio,
video, and other electronic media used for the purpose of diagnosis, consultation, or
treatment of acute stroke. The stroke system of care task force shall recommend
eligible essential health care services for acute stroke care provided through
telemedicine services.
### § 23-43-06. General provisions.

1. This chapter is not a medical practice guideline and may not be used to restrict the
authority of a hospital to provide services for which the hospital received a license
under state law. Patients must be treated individually based on the needs and
circumstances of each patient.
2. A person may not advertise to the public, by way of any medium, that a hospital is a
comprehensive stroke center, primary stroke center, or acute stroke ready hospital
unless the hospital is designated as such by the department of health and human
services.
3. The department of health and human services may adopt rules to implement this
chapter.
