The Primary Stroke Service protocols referenced in 105 CMR 130.1405 shall be reviewed and revised as necessary and at least annually by a committee designated by the governing body of the hospital and including the Stroke Service Director or Coordinator. The committee's review must incorporate at a minimum the number of stroke patients, types of stroke evaluated, nature of any complications of thrombolytic therapy, and compliance with 105 CMR 130.1404 through 130.1413, including adherence to the time targets.
105 CMR, § 130.1413