Classification of emergency neurology services

(a) Level III. A Level III facility shall provide services with at least a licensed independent practitioner, registered nurse, licensed OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 211 September 13, 2019 practical nurse, or intermediate or paramedic level emergency medical technician on site twenty-four (24) hours a day. A hospital shall be classified at Level III for emergency neurology services if it meets the following requirements: (1) Clinical services and resources. No diagnostic, surgical, or medical specialty services are required. (2) Personnel. A physician, licensed independent practitioner, registered nurse, licensed practical nurse, or intermediate or paramedic level emergency medical technician shall be on site twenty- four (24) hours a day. In the absence of a physician, licensed independent practitioner, registered nurse, or paramedic level emergency medical technician, at least one of the practitioners on duty shall have received training in advanced life support techniques and be deemed competent to initiate treatment of the emergency patient. (A) If the facility is licensed as a General-Medical Surgical Hospital it shall also meet the personnel and staffing requirements at OAC 310:667-29-1 and any other applicable parts of this Chapter. (B) If the facility provides emergency medical services and is licensed as a Specialized Hospital: Psychiatric, it shall also meet the personnel and staffing requirements at OAC 310:667-33-2 and any other applicable parts of this Chapter. (C) If the facility provides emergency medical services and is licensed as a Specialized Hospital: Rehabilitation, it shall also meet the personnel and staffing requirements at OAC 310:667-35-3 and any other applicable parts of this Chapter. (D) If the facility provides emergency medical services and is licensed as a Critical Access Hospital, it shall also meet the personnel and staffing requirements at OAC 310:667-39-14 and any other applicable parts of this Chapter. (3) Supplies and equipment. In addition to the requirements at OAC 310:667-59-9(a)(3), the hospital shall have the following equipment and supplies on site, functional, and immediately available: (A) Seizure control agents; (B) Thiamine and glucose for intravenous administration; and (C) Antipyretics and procedures for reducing body temperature when necessary. (4) Agreements and policies on transfers. (A) The hospital shall have written policies defining the medical conditions and circumstances for those emergency patients which may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another facility. (B) The facility shall have a written agreement with a hospital, or board certified, board eligible, or residency trained neurologist, or group of neurologists to provide immediate consultative services for neurology patients twenty-four (24) hours a day. Such services shall include providing instructions for the initiation of appropriate therapy and/or patient transfer. (b) Level II. A Level II facility shall provide emergency medical services with an organized emergency department. A physician and nursing staff shall be on site twenty-four (24) hours a day. A hospital shall be classified at Level II for emergency neurology services if it meets OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 212 September 13, 2019 the following requirements: (1) Clinical services and resources. (A) Emergency services. A physician deemed competent in the care of the emergent neurology patient and credentialed by the hospital to provide emergency medical services and nursing personnel shall be on site twenty-four (24) hours a day. (i) For a hospital licensed as a general medical surgical hospital or specialty hospital, emergency services shall also comply with the requirements of OAC 310:667-29-1 through OAC 310:667-29-2. (ii) For a hospital licensed as a critical access hospital, emergency services shall also comply with OAC 310:667-39-14. (B) Diagnostic imaging. The hospital shall have diagnostic x-ray and computerized tomography services available twenty-four (24) hours a day. A radiologic technologist and computerized tomography technologist shall be on duty or on call and immediately available twenty-four (24) hours a day. A single technologist designated as qualified in both diagnostic x-ray and computerized tomography procedures by the radiologist may be used to meet this requirement if an on call schedule of additional diagnostic imaging personnel is maintained. The diagnostic imaging service shall provide at least the following services: (i) Ultrasonography; and (ii) Computed tomography. (iii) For a hospital licensed as a general medical surgical hospital or specialty hospital, diagnostic imaging services shall also comply with the applicable requirements in Subchapter 23 of this Chapter. (iv) For a hospital licensed as a critical access hospital, diagnostic imaging services shall also comply with the applicable requirements in Subchapter 39 of this Chapter. (C) Clinical laboratory service. The hospital shall have clinical laboratory services available twenty-four (24) hours a day. All or part of these services may be provided by arrangements with certified reference laboratories provided these services are available on an emergency basis twenty-four (24) hours a day. At least the following shall be available: (i) Standard analysis of blood, urine, and other body fluids to include routine chemistry and hematology testing; (ii) Cerebrospinal fluid, cell count, white blood cell differential, protein, glucose, Gram stain, and antigen testing when appropriate; (iii) Coagulation studies; (iv) Blood gas/pH analysis; (v) Drug and alcohol screening; and (vi) Comprehensive microbiology services or appropriate supplies for the collection, preservation, and transport of clinical specimens for aerobic and anaerobic bacterial, mycobacterial, and fungus cultures; and (vii) For a hospital licensed as a general medical surgical hospital or specialty hospital, clinical laboratory services shall also comply with the applicable requirements in Subchapter 23 of this Chapter. OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 213 September 13, 2019 (viii) For a hospital licensed as a critical access hospital, clinical laboratory services shall also comply with the applicable requirements in Subchapter 39 of this Chapter. (2) Personnel. (A) Emergency services director. The medical staff shall designate a physician credentialed to provide emergency medical care as emergency services director. (B) Neurologist. A physician board certified, board eligible, or residency trained in neurology shall be available for consultation on site or immediately available by telephone or other electronic means twenty-four (24) hours a day. (3) Supplies and equipment. In addition to the requirements at OAC 310:667-59-9(a)(3), the hospital shall have the following equipment and supplies on site, functional, and immediately available: (A) Equipment to perform electroencephalographic (EEG) testing; (B) Seizure control agents; (C) Thiamine and glucose for intravenous administration; (D) Antipyretics and procedures for reducing body temperature when necessary; (E) Sterile procedure trays for: (i) Lumbar puncture and measurement of intracranial pressure; and (ii) Gastric lavage and administration of activated charcoal. (F) Agents to manage increased intracranial pressure including: (i) Osmotic diuretics such as mannitol; (ii) Loop diuretics such as furosemide; and (iii) Corticosteriods when appropriate. (G) Drugs to manage migraine headache such as sumatriptin, ergotic agents, antinauseants, narcotic analgesics, etc.; and (H) Thrombolytic agents for treatment of acute nonhemorrhagic stroke. (4) Agreements and policies on transfers. (A) The hospital shall have written policies defining the medical conditions and circumstances for those emergency patients which may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another facility. (B) The facility shall have a written agreement with a hospital, or board certified, board eligible, or residency trained neurologist, or group of neurologists to provide immediate consultative services for neurology patients twenty-four (24) hours a day. Such services shall include providing instructions for the initiation of appropriate therapy and/or patient transfer. (c) Level I. A Level I facility shall provide emergency medical services with organized emergency, neurology, and neurosurgery departments. A physician and nursing staff with special capability in neurologic care shall be on site twenty-four (24) hours a day. The facility shall have the capability to provide immediate diagnostic imaging and neurosurgical intervention twenty-four (24) hours a day. A hospital shall be classified at Level I for emergency neurology services if it meets the following requirements: (1) Clinical services and resources. (A) Emergency services. A physician deemed competent in the care of the emergent neurology patient and credentialed by the hospital OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 214 September 13, 2019 to provide emergency medical services and nursing personnel with special capability in neurologic care shall be on site twenty-four (24) hours a day. For a hospital licensed as a general medical surgical hospital or specialty hospital, emergency services shall also comply with the requirements of OAC 310:667-29-1 through OAC 310:667-29-2. (B) Neurology. The facility shall have organized neurology service with appropriately credentialed physicians experienced in neurologic procedures immediately available twenty-four (24) hours a day. Physician members of the neurology services shall be board certified, board eligible, or residency trained in neurology. On call physicians shall respond as required by the hospital's policy. (C) Neurosurgery. The facility shall have organized neurosurgery service with appropriately credentialed physicians experienced in neurosurgical procedures immediately available twenty-four (24) hours a day. Physician members of the neurosurgery service shall be board certified, board eligible, or residency trained in neurosurgery. On call physicians shall respond as required by the hospital's policy. (D) Anesthesia. A board certified, board eligible, or residency trained anesthesiologist shall be on site or on call twenty-four (24) hours a day and promptly available. All anesthesia shall be administered as required in OAC 310:667-25-2. (E) Operating suite. An operating suite with adequate staff and equipment shall be immediately available twenty-four (24) hours a day. The hospital shall define and document in writing the minimum staffing requirements for the operating suite. An on call schedule for emergency replacement staff shall be maintained. (F) Post-anesthesia recovery unit. The hospital shall have a post-anesthesia recovery room or intensive care unit in compliance with OAC 310:667-15-7 with nursing personnel and anesthesia services remaining in the unit until the patient is discharged from post-anesthesia care. (G) Intensive care unit. The hospital shall have an intensive care unit in compliance with OAC 310:667-15-7 with a registered nurse on duty in the intensive care unit whenever the unit has a patient(s). A registered nurse shall be on call and immediately available when no patients are in the unit. The hospital shall define and document in writing the minimum staffing requirements for the intensive care unit and shall monitor compliance with these requirements through the quality improvement program. (H) Diagnostic Imaging. The hospital shall have diagnostic x-ray and computed tomography services available twenty-four (24) hours a day. A radiologic technologist and computerized tomography technologist shall be on duty or on call and immediately available twenty-four (24) hours a day. A single technologist designated as qualified in both diagnostic x-ray and computerized tomography procedures by the radiologist may be used to meet this requirement if an on call schedule of additional diagnostic imaging personnel is maintained. The diagnostic imaging service shall provide at least the following services: (i) Cerebral angiography; OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 215 September 13, 2019 (ii) Myelography; (iii) Ultrasonography; (iv) Computed tomography; (v) Magnetic resonance imaging; and (vi) Neuroradiology. (vii) For a hospital licensed as a general medical surgical hospital or specialty hospital, diagnostic imaging services shall also comply with the applicable requirements in Subchapter 23 of this Chapter. (I) Electrophysiologic Testing. The hospital shall have electrophysiologic testing services including electroecephalography (EEG), electrocardiography (ECG), and electromyography (EMG) services available as needed. (J) Clinical laboratory service. The hospital shall have clinical laboratory services available twenty-four (24) hours a day. All or part of these services may be provided by arrangements with certified reference laboratories provided these services are available on an emergency basis twenty-four (24) hours a day. At least the following shall be available: (i) Comprehensive immunohematology services including blood typing and compatibility testing. A supply of blood and blood products shall be on hand and adequate to meet expected patient needs. All blood and blood products shall be properly stored. The hospital shall have access to services provided by a community central blood bank; (ii) Standard analysis of blood, urine, and other body fluids to include routine chemistry and hematology testing; (iii) Cerebrospinal fluid, cell count, white blood cell differential, protein, glucose, gram stain, and antigen testing when appropriate; (iv) Coagulation studies; (v) Blood gas/pH analysis; and (vi) Comprehensive microbiology services or at least appropriate supplies for the collection, preservation, and transport of clinical specimens for aerobic and anaerobic bacterial, mycobacterial, and fungus cultures. (vii) For a hospital licensed as a general medical surgical hospital or specialty hospital, clinical laboratory services shall also comply with the applicable requirements in Subchapter 23 of this Chapter. (K) Social services. Social services shall be available and provided as required in Subchapter 31 of this Chapter. (L) Respiratory therapy. Routine respiratory therapy procedures and mechanical ventilators shall be available twenty-four (24) hours a day. Respiratory therapy services shall comply with OAC 310:667-23-6. (M) Rehabilitation services. (i) The hospital shall provide rehabilitation services in a rehabilitation center with a staff of personnel trained in rehabilitation care and equipped properly for acute care of the critically ill patient; or (ii) If the hospital does not meet the requirements at OAC 310:667-59-21(c)(1)(M)(i) it shall have a written transfer OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 216 September 13, 2019 agreement with a hospital which meets the requirements of Subchapter 35 of this Chapter and is capable of providing rehabilitation services in a rehabilitation center with a staff of personnel trained in rehabilitation care and equipped properly for acute care of the critically ill patient. (2) Personnel. (A) Emergency services director. The medical staff shall designate a physician credentialed to provide emergency medical care as emergency services director. (B) Neurology services director. The medical staff shall designate a physician credentialed to provide neurologic and/or neurosurgical care as neurology services director. (C) Physician qualifications. (i) Physician members of the neurology service shall be board certified, board eligible, or residency trained in neurology. (ii) Physician members of the neurosurgical service shall be board certified, board eligible, or residency trained in neurosurgery. (3) Supplies and equipment. (A) Emergency department. In addition to the requirements at OAC 310:667-59-19(d)(3), the hospital shall have the following equipment and supplies on site, functional, and immediately available: (i) Equipment to perform electroencephalographic (EEG) testing; (ii) Seizure control agents; (iii) Thiamine and glucose for intravenous administration; (iv) Antipyretics and procedures for reducing body temperature when necessary; (v) Sterile procedure trays for: (I) Lumbar puncture and measurement of intracranial pressure; (II) Gastric lavage and administration of activated charcoal; and (III) Emergency burr hole. (vi) Agents to manage increased intracranial pressure including: (I) Osmotic diuretics such as mannitol; (II) Loop diuretics such as furosemide; and (III) Corticosteriods when appropriate. (vii) Drugs to manage migraine headache such as sumatriptin, ergotic agents, antinauseants, narcotic analgesics, etc.; (viii) Thrombolytic agents for treatment of acute nonhemorrhagic stroke; and (ix) Equipment to monitor intracranial pressure. (B) Operating suite. The operating suite shall have the following supplies and equipment on site, functional and available for use: (i) Cardiopulmonary bypass capability; (ii) Operating microscope; (iii) Thermal control equipment for patients and infusion of blood, blood products, and other fluids; (iv) X-ray capability including c-arm intensifier; OAC 310:667 OKLAHOMA STATE DEPARTMENT OF HEALTH 217 September 13, 2019 (v) Endoscopes; (vi) Craniotomy instruments; and (vii) Equipment for the continuous monitoring of intracranial pressure. (C) Post-anesthesia recovery unit. The post-anesthesia recovery unit shall have the following supplies and equipment on site, functional, and available for use: (i) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange; (ii) Equipment for the continuous monitoring of intracranial pressure; (iii) Pulse oximetry; (iv) End-tidal CO2 determination; and (v) Thermal control equipment for patients and infusion of blood, blood products, and other fluids. (D) Intensive care unit. The intensive care unit shall have the following supplies and equipment on site, functional, and available for use: (i) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange; (ii) Equipment for the continuous monitoring of intracranial pressure; (iii) Cardiopulmonary resuscitation cart; (iv) Electrocardiograph-oscilloscope-defibrillator-pacer; and (v) Sterile surgical sets for: (I) Airway control/cricothyrotomy; (II) Thoracotomy; (III) Vascular access; and (IV) Chest decompression. (4) Policies on transfers. The hospital shall have written policies defining the medical conditions and circumstances for those emergency patients which may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another facility.