1. (a) Level III. A Level III hospital will provide Advanced Cardiac Life Support (ACLS) services with at least a licensed independent practitioner, registered nurse, licensed practical nurse, or intermediate or paramedic level emergency medical technician on site 24 hours a day. A hospital must be classified at Level III for emergency cardiology services if it provides ACLS and complies with all of this subsection:

   1. (1) Clinical services and resources.

      1. (A) Electrocardiogram. The hospital will have the immediate availability of a 12-lead electrocardiogram.
      2. (B) Thrombolytic therapy. Thrombolytic medications will be immediately available in the emergency room to provide reperfusion therapy when appropriate. No other diagnostic, surgical, or medical specialty services are required.
   2. (2) Personnel. A physician, licensed independent practitioner, registered nurse, licensed practical nurse, or Intermediate, Advanced Medical Technician (AEMT), or paramedic,as defined in OAC 310:641-1-7, will be on site 24 hours a day. In the absence of a physician, licensed independent practitioner, registered nurse, or paramedic, at least one of the practitioners on duty will have received training in advanced life support techniques and must be competent to initiate treatment of the emergency patient.

   3. (3) Supplies and equipment. In addition to OAC 310:667-59-9(a)(3), the hospital must have the following equipment and supplies on site, functional, and immediately available:

      1. (A) Oxygen and oxygen delivery equipment;
      2. (B) Equipment to perform a 12-lead electrocardiogram (ECG) with ECG monitor and printout;
      3. (C) Equipment for the electronic or facsimile transmission of ECG readings to an expert for interpretation;
      4. (D) Transcutaneous pacing capability; and

      5. (E) ACLS medications including at least:

         1. (i) Aspirin;
         2. (ii) Antianginal agents such as sublingual nitroglycerin;
         3. (iii) Medications to provide adequate analgesia such as morphine and meperidine;
         4. (iv) Sympathomimetics such as epinephrine, norepinephrine, dopamine, etc;
         5. (v) Sympatholytics such as β-adrenoceptor blocking agents;
         6. (vi) Angiotensin converting enzyme (ACE) inhibitors;

         7. (vii) Antidysrythmics including:

            1. (I) Rhythm control agents such as lidocaine, procainamide, bretylium tosylate and magnesium sulfate; and
            2. (II) Rate control agents such as atropine, adenosine, verapamil, and digitalis.
         8. (viii) Diuretics such as furosemide; and
         9. (ix) Antihypertensives such as sodium nitroprusside.

   4. (4) Agreements and policies on transfers.

      1. (A) The hospital must have written policies defining the medical conditions and circumstances for emergency patients that may be retained for treatment in-house, and for those who require stabilizing treatment and transfer to another hospital.
      2. (B) The hospital must have a written agreement with a hospital, or board certified, board eligible, or residency trained cardiologist, or group of cardiologists to provide immediate consultative services for cardiac patients 24 hours a day. These services will include the immediate interpretation of ECG results and providing instructions for the initiation of appropriate therapy and/or patient transfer.

2. (b) Level II. A Level II hospital will provide emergency medical services with an organized emergency department. A physician and nursing staff with special capability in cardiac care must be on site 24 hours a day. A hospital must be classified at Level II for emergency cardiology services if it complies with all of this subsection (b):

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A physician competent in the care of the emergent cardiac patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in cardiac care must be on site 24 hours a day. Nursing personnel mustalso have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.
      2. (B) Thrombolytic therapy. Thrombolytic medications will be immediately available in the emergency room to provide reperfusion therapy when appropriate.

      3. (C) Intensive care unit. The hospital will have an intensive care unit and/or cardiac care unit that includes:

         1. (i) Compliance with OAC 310:667-15-7 ;
         2. (ii) A registered nurse on duty in the unit when it has a patient;
         3. (iii) A registered nurse on call and immediately available when it does not have any patients; and
         4. (iv) Nursing personnel who have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.
      4. (D) Continuous electrocardiographic monitoring. The emergency room and intensive/cardiac care unit will have the capability to continuously monitor patients electrocardiographically when necessary. While a patient is continuously monitored, there will be adequate human surveillance of the monitors 24 hours a day by medical, nursing, or paramedical personnel trained and qualified in the ECG recognition of clinically significant cardiac rhythm disturbances.
      5. (E) Diagnostic imaging. The hospital must have diagnostic x-ray services available 24 hours a day. A radiology technologist will be on duty or on call and immediately available 24 hours a day.

      6. (F) Clinical laboratory service. The hospital's clinical laboratory services will be available 24 hours a day. All or part of these services may be provided by arrangements with certified reference laboratories that are available on an emergency basis 24 hours a day. These services include:

         1. (i) Standard analysis of blood, urine, and other body fluids to include routine chemistry and hematology testing;
         2. (ii) Coagulation studies;
         3. (iii) Blood gas/pH analysis; and
         4. (iv) Rapid determination of cardiac serum markers such as creatine kinase (CK), CK-MB isoform(s), and/or cardiac specific troponins T and I.
      7. (G) Social services. Social services must be available and provided in accordance with Subchapter 31 of this Chapter.

   2. (2) Personnel.

      1. (A) Emergency services director. The medical staff will designate a physician credentialed to provide emergency medical care as emergency services director.
      2. (B) Cardiologist. A physician board certified, board eligible, or residency trained in cardiovascular diseases will be available for consultation on site or immediately available by telephone or other electronic means 24 hours a day.
      3. (C) Training. Emergency room and intensive care/cardiac care unit nursing personnel must have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.

   3. (3) Supplies and equipment. In addition to the requirements at OAC 310:667-59-9(a)(3), the hospital must have the following equipment and supplies on site, functional, and immediately available:

      1. (A) Oxygen and oxygen delivery equipment including:

         1. (i) Continuous positive-pressure breathing; and
         2. (ii) Mechanical ventilation.
      2. (B) Equipment to perform a 12-lead electrocardiogram (ECG) with ECG monitor and printout;
      3. (C) Equipment for the electronic or facsimile transmission of ECG readings to an expert for interpretation;

      4. (D) Pacing equipment including at least:

         1. (i) Transcutaneous pacing capability; and
         2. (ii) Transvenous pacing electrodes.
      5. (E) the identical ACLS medications that are listed for Level III classification in (a)(3)(E) of this Section.
   4. (4) Agreements and policies on transfers. A Level II hospital is subject to the same agreement and policies on transfers requirements as a Level III hospital as set forth in (a)(4) of this Section.

3. (c) Level I. A Level I hospital will provide emergency medical services with organized emergency and cardiology departments. A physician and nursing staff with special capability in cardiac care must be on site 24 hours a day. The hospital must have the capability to provide immediate diagnostic angiography and emergency reperfusion therapy by thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG) 24 hours a day. A hospital must be classified at Level I for emergency cardiology services if it complies with all of this subsection:

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A Level I hospital is subject to the same emergency services requirements as a Level II hospital as set forth in (b)(1)(A) of this Section.
      2. (B) Thrombolytic therapy. Thrombolytic medications will be immediately available in the emergency room to provide reperfusion therapy when appropriate.
      3. (C) Cardiology and cardiovascular surgery. The hospital must have an organized cardiology and cardiovascular surgery service with appropriately credentialed physicians experienced in percutaneous and surgical revascularization immediately available 24 hours a day. Physician members of the cardiology service must be board certified, board eligible, or residency trained in cardiovascular diseases or in cardiovascular and/or vascular surgery. On call physicians will respond as required by the hospital's policy.
      4. (D) Cardiac catheterization laboratory. The hospital must include a full-service cardiac catheterization laboratory or laboratories capable of providing both diagnostic and therapeutic procedures on the heart and great vessels for a wide variety of cardiovascular diseases. Diagnostic, therapeutic, and electrophysiology laboratories are supervised by physicians with appropriate training and expertise in the procedures performed and who are properly credentialed by the medical staff. When primary percutaneous transluminal coronary angioplasty (PTCA) is performed, prompt access to emergency coronary artery bypass graft (CABG) surgery must be available.
      5. (E) Anesthesia. A board certified, board eligible, or residency trained anesthesiologist must be on site or on call 24 hours a day and promptly available. All anesthesia must be administered in accordance with OAC 310:667-25-2.
      6. (F) Operating suite. An operating suite with adequate staff, equipment , and cardiopulmonary bypass capability must be immediately available 24 hours a day. The hospital will define and document in writing the minimum staffing requirements for the operating suite. An on call schedule for emergency replacement staff must be maintained.
      7. (G) Post-anesthesia recovery unit. The hospital will 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.

      8. (H) Cardiac care unit. The hospital's cardiac care unit must include:

         1. (i) Compliance with OAC 310:667-15-7;
         2. (ii) A registered nurse on duty in the unit when it has a patient;
         3. (iii) A registered nurse on call and immediately available when the unit does not have a patient;
         4. (iv) The hospital will define and document in writing the minimum staffing requirements for the cardiac care unit; and
         5. (v) A physician with privileges in cardiac care or cardiovascular surgery will be on duty in the unit or immediately available in the hospital 24 hours a day.
      9. (I) Continuous electrocardiographic monitoring. The emergency room, cardiac catheterization laboratory(s), and cardiac care unit will have the capability to continuously monitor patients electrocardiographically. While a patient is continuously monitored, there will be adequate human surveillance of the monitors 24 hours a day by medical, nursing, or paramedical personnel trained and qualified in the ECG recognition of clinically significant cardiac rhythm disturbances.

      10. (J) Diagnostic Imaging. The hospital will have diagnostic x-ray, computed tomography, and ultrasonography services available 24 hours a day. A radiologic technologist, computerized tomography technologist, and staff designated as qualified to perform ultrasonography will be on duty or on call and immediately available 24 hours a day. A single technologist considered qualified by the radiologist in both diagnostic x-ray and computerized tomography procedures may be used to meet this requirement if an on call schedule of additional diagnostic imaging personnel is maintained. The diagnostic imaging service will provide the following services:

          1. (i) Angiography;
          2. (ii) Ultrasonography including echocardiography;
          3. (iii) Computed tomography;
          4. (iv) Magnetic resonance imaging; and
          5. (v) Nuclear medicine imaging.

      11. (K) Clinical laboratory service. The hospital's clinical laboratory services will be available 24 hours a day. All or part of these services may be provided by arrangements with certified reference laboratories that are available on an emergency basis 24 hours a day. These services include:

          1. (i) All the clinical laboratory services listed for Level II classification as set forth in (b)(1)(F) of this Section;
          2. (ii) Comprehensive immunohematology services including blood typing and compatibility testing;
          3. (iii) A supply of blood and blood products on hand that is properly stored and adequate to meet expected patient needs;
          4. (iv) Access to services provided by a community central blood bank; and
          5. (v) 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.
      12. (L) Respiratory therapy service. Routine respiratory therapy procedures and mechanical ventilators will be available 24 hours a day. Respiratory therapy services must beprovided in compliance with OAC 310:667-23-6.
      13. (M) Social services. Social services must be available and provided in compliance with Subchapter 31 of this Chapter.

      14. (N) Cardiac rehabilitation service.

          1. (i) The hospital must have available a formal program for rehabilitation of the cardiac patient.
          2. (ii) An individualized rehabilitation program will be designed for each patient, and when appropriate, the program will combine prescriptive exercise training with education about coronary risk factor modification techniques.
          3. (iii) Rehabilitation services must be provided in compliance with Subchapter 35 of this Chapter.

      15. (O) Post-cardiac event evaluation.

          1. (i) The hospital must have the capability of evaluating patients after a cardiac event to:

             1. (I) Assess functional capacity and the patient's ability to perform tasks at home and at work;
             2. (II) Evaluate the efficacy of the patient's current medical regimen; and
             3. (III) Risk-stratify the post-MI patient according to the likelihood of a subsequent cardiac event.

          2. (ii) Evaluation techniques include:

             1. (I) Exercise or pharmacologic ECG stress testing;
             2. (II) Exercise stress echocardiography;
             3. (III) Exercise or stress nuclear perfusion scintigraphy; and
             4. (IV) Other procedures as appropriate.

   2. (2) Personnel.

      1. (A) Emergency services director. The medical staff will designate a physician credentialed to provide emergency medical care as emergency services director.
      2. (B) Cardiology services director. The medical staff will designate a physician credentialed to provide medical and/or surgical cardiac care as cardiology services director.
      3. (C) Physician qualifications. Physician members of the cardiology service will be board certified, board eligible, or residency trained in cardiovascular diseases or be board certified, board eligible, or residency trained in cardiothoracic and/or vascular surgery.
      4. (D) Training. Emergency room, intensive care/cardiac care unit, and cardiac catheterization laboratory nursing personnel must have completed the Advanced Cardiac Life Support Program (ACLS) offered through the American Heart Association or have equivalent training.

   3. (3) Supplies and equipment. In addition to subsection (b)(3) in this Section, the hospital must have the following equipment, personnel, and supplies on site, functional, and immediately available to:

      1. (A) monitor the hemodynamic stability of cardiac patients with balloon flotation catheters when appropriate;
      2. (B) monitor intra-arterial pressure when appropriate; and
      3. (C) provide intra-aortic balloon counterpulsation therapy when appropriate.
   4. (4) Policies on transfers. The hospital must have written policies defining the medical conditions and circumstances for emergency patients that may be retained for treatment in-house, and for those requiring stabilizing treatment and transfer to another hospital.

Added at 17 Ok Reg 2992, eff 7-13-00

Amended at 20 Ok Reg 1664, eff 6-12-03

Amended at 39 Ok Reg 1392, eff 9-11-22