1. (a) Level IV. A Level IV hospital will provide basic obstetric and gynecologic services, including emergency delivery, with at least a licensed independent practitioner, registered nurse, licensed practical nurse, or Intermediate, Advanced Emergency Medical Technician (AEMT), or paramedic, as defined in OAC 310:641-1-7, on site 24 hours a day. A hospital must be classified at Level IV for emergency obstetric and gynecologic services if it complies with all of this subsection:

   1. (1) Clinical services and resources. Diagnostic, surgical, or medical specialty services are not required.
   2. (2) Personnel. A physician, licensed independent practitioner, registered nurse, licensed practical nurse, or an AEMT, or paramedic, as defined in OAC 641-1-7,is required 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 must have received training in evaluating obstetric risk factors and protocols for immediate transfer of high risk obstetric cases.

   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) Obstetrics pack;
      2. (B) Nitrazine (pH) paper for detecting amniotic fluid when membranes are ruptured;
      3. (C) Equipment to monitor fetal heart rate and pattern electronically or by auscultation;
      4. (D) Heat source or procedure for infant warming; and
      5. (E) Ophthalmic antiseptics for neonates.

   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. Written policies and procedures shall include where and how neonates shall be cared for until transfer to an appropriate facility can be completed.
      2. (B) The hospital must have a written agreement with a hospital, or obstetrician-gynecologist, or group of obstetrician-gynecologists to provide immediate consultative services for obstetric and gynecologic patients 24 hours a day. Such services shall include the immediate interpretation of obstetric and neonatal risk factors and providing instructions for the initiation of appropriate therapy and/or patient transfer.

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

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A physician competent in the care of the emergent obstetric or gynecologic patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in obstetric and gynecologic care must be on site 24 hours a day.
      2. (B) General surgery. A board certified, board eligible, or residency trained general surgeon must be on call 24 hours a day and promptly available in the emergency department.
      3. (C) Anesthesia. Anesthesia services must be on call 24 hours a day, promptly available, and administered in accordance with OAC 310:667-25-2.
      4. (D) Operating suite. An operating suite with thermal control equipment for patients and infusion of blood and fluids must be available 24 hours a day.
      5. (E) Post-anesthesia recovery unit. The hospital must have a post-anesthesia recovery room or intensive care unit that is 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.

      6. (F) Intensive care unit. The hospital's intensive care unit mustinclude:

         1. (i) Compliance with OAC 310:667-15-7;
         2. (ii) A registered nurse on duty in the intensive care unit when it has a patient;
         3. (iii) A registered nurse on call and immediately available when the unitdoes not have a patient;
         4. (iv) Written policies defining the minimum staffing requirements for the intensive care unit that must bemonitored through the quality improvement program.
      7. (G) Diagnostic imaging. The hospital will have diagnostic x-ray and ultrasonography services, including ultrasonography, available 24 hours a day. A radiology technologist and staff designated as qualified to perform ultrasonography will be on duty or on call and immediately available 24 hours a day.

      8. (H) Clinical laboratory service. The hospital must have clinical laboratory services are 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) Comprehensive immunohematology services including blood typing and compatibility testing;
         2. (ii) A supply of blood and blood products, including Rho (D) immune globulin on hand that is properly stored and adequate to meet expected patient needs;
         3. (iii) Access to services provided by a community central blood bank;
         4. (iv) Standard analysis of blood, urine, and other body fluids to include routine chemistry and hematology testing including urine and serum assays for the beta subunit of human chorionic gonadotropin (â-hCG) and quantitative or semiquantitative urine protein;
         5. (v) Blood gas/pH;
         6. (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;
         7. (vii) Drug and alcohol screening; and

         8. (viii) Coagulation studies, including:

            1. (I) Prothrombin time (PT) and activated partial thromboplastin time (aPTT);
            2. (II) Fibrinogen; and
            3. (III) Assay for fibrin degradation products or an equivalent test;
      9. (I) Social services. Social services must be available and provided as required in 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) Obstetrician-gynecologist. A physician board certified, board eligible, or residency trained in obstetrics and gynecology must be available for consultation on site or immediately available by telephone or other electronic means 24 hours a day.

   3. (3) Supplies and equipment.

      1. (A) Emergency department. In addition to the requirements at OAC 310:667-59-9(a)(3), the hospital must have the following equipment and supplies for use in the management of emergent obstetric, gynecologic, and neonatal patients on site, functional, and available in the emergency department, including at least the following:

         1. (i) The emergency department supplies and equipment listed in (a)(3)(A) through (E) of this Section for Level IV classification;
         2. (ii) Pulse oximetry with adult and pediatric probes;

         3. (iii) Drugs necessary for care of the emergent obstetric or gynecologic patient including:

            1. (I) Oxytocic agents;
            2. (II) Tocolytic agents;
            3. (III) Prostaglandins;
            4. (IV) Ergotic agents;
            5. (V) Antihypertensives; and
            6. (VI) Magnesium sulfate.

         4. (iv) Drugs necessary for care of the depressed neonatal patient including:

            1. (I) Epinephrine;
            2. (II) Volume expanders
            3. (III) Sodium bicarbonate;
            4. (IV) Dextrose solutions; and
            5. (V) Naloxone hydrochloride.
         5. (v) Sterile procedure trays for episiotomy; and

         6. (vi) Supplies, equipment, and written protocols for the examination of sexual assault victims and for the collection of specimens and the preservation of the chain of evidence including:

            1. (I) Preassembled sexual assault examination kits;
            2. (II) Consent, chain of evidence, and sexual assault examination forms; and
            3. (III) Long-wave ultraviolet lamp;

      2. (B) Post-anesthesia recovery unit. The post-anesthesia recovery unit will have the following supplies and equipment on site, functional, and available for use:

         1. (i) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange;
         2. (ii) Pulse oximetry;
         3. (iii) End-tidal CO2 determination; and
         4. (iv) Thermal control equipment for patients and infusion of blood, blood products, and other fluids.

      3. (C) Intensive care unit. The intensive care unit must have the following supplies and equipment on site, functional, and available for use:

         1. (i) Equipment for the continuous monitoring of temperature, hemodynamics, and gas exchange;
         2. (ii) Cardiopulmonary resuscitation cart;
         3. (iii) Electrocardiograph-oscilloscope-defibrillator-pacer;

         4. (iv) Sterile surgical sets for:

            1. (I) Airway control/cricothyrotomy;
            2. (II) Thoracotomy;
            3. (III) Vascular access; and
            4. (IV) Chest decompression.
   4. (4) Agreements and policies on transfers. A Level III hospital is subject to the same agreements and polices on transfers requirement as a Level IV hospital as set forth in (a)(4) of this Section.

3. (c) Level II. A Level II hospital will provide emergency medical services with organized emergency and obstetrics-gynecology and departments. A physician and nursing staff with special capability in obstetric and gynecologic care arerequired on site 24 hours a day. The hospital will have a dedicated obstetrics unit as well as a newborn nursery and will have the capability to provide immediate delivery by emergency cesarean section. Laparoscopy and laparotomy procedures will be immediately available when required for obstetric and gynecologic emergencies. A hospital must be classified at Level II for emergency obstetric and gynecologic services if it complies with all of this subsection:

   1. (1) Clinical services and resources.

      1. (A) Emergency services. A Level II hospital is subject to the same emergency services requirements as a Level III hospital as set forth in (b)(1)(A) of this Section.
      2. (B) Obstetrics and gynecology. The hospital will have an organized obstetrics-gynecology service with appropriately credentialed physicians experienced in obstetric and gynecologic procedures must be on call and immediately available 24 hours a day. Physician members of the obstetric-gynecology service must be board certified, board eligible, or residency trained in obstetrics and gynecology. On call physicians will respond as required by the hospital's policy.

      3. (C) Obstetrics unit. The hospital will have a dedicated obstetrics unit available 24 hours a day. Labor, delivery, and recovery areas will be:

         1. (i) appropriately equipped to manage high-risk pregnancies and deliveries including equipment and medications necessary for maternal and neonatal resuscitation procedures; and
         2. (ii) staffed with nursing personnel with special capability in obstetric and neonatal care.
      4. (D) Newborn nursery. The hospital will have a dedicated newborn nursery appropriately equipped and staffed with nursing personnel with special capability in neonatal care.
      5. (E) Pediatrics. A physician board certified, board eligible, or residency trained in pediatrics and competent in the care of pediatric emergencies must be available for consultation on site or immediately available by telephone or other electronic means 24 hours a day.
      6. (F) General surgery. A board certified, board eligible, or residency trained general surgeon must be on call 24 hours a day and promptly available.
      7. (G) Anesthesia. Anesthesia services must be on call 24 hours a day, promptly available, and administered in accordance with OAC 310:667-25-2.
      8. (H) Operating suite. An operating suite with adequate staff and equipment 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.
      9. (I) Post-anesthesia recovery unit. A Level II hospital is subject to the same post-anesthesia recovery unit requirements as a Level III hospital as set forth in (b)(1)(E) of this Section.
      10. (J) Intensive care unit. A Level II hospital is subject to the same intensive care unit requirements as a Level III hospital as set forth in (b)(1)(F) of this Section.

      11. (K) Diagnostic imaging. The hospital will have diagnostic x-ray, computerized 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 designated as 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 services include:

          1. (i) Ultrasonography;

             1. (I) Transabdominal; and
             2. (II) Endovaginal.
          2. (ii) Computed tomography; and
          3. (iii) Magnetic resonance imaging.

      12. (L) Clinical laboratory service. The hospital must have clinical laboratory services are 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) The services listed in (b)(1)(H)(i) through (vii) in this Section for Level III classification;
          2. (ii) Tests for fetal lung maturity;

          3. (iii) Serum hormone tests including:

             1. (I) Progesterone;
             2. (II) Follicle stimulating hormone;
             3. (III) Leutinizing hormone; and
             4. (IV) Prolactin.

          4. (iv) Coagulation studies including:

             1. (I) Prothrombin time (PT) and activated partial thromboplastin time (aPTT);
             2. (II) Plasminogen;
             3. (III) Factor assays;
             4. (IV) Fibrinogen; and
             5. (V) Assay for fibrin degradation products or an equivalent test.
      13. (M) Respiratory therapy. Routine respiratory therapy procedures and mechanical ventilators will be available 24 hours a day. Respiratory therapy services will comply with OAC 310:667-23-6.
      14. (N) Social services. Social services will 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) Obstetrics-gynecology services director. The medical staff will designate a physician board certified, board eligible, or residency trained in obstetrics and gynecology and credentialed to provide obstetric and gynecologic care as obstetric-gynecology services director.
      3. (C) Pediatric services director. The medical staff will designate a physician board certified, board eligible, or residency trained in pediatrics and credentialed to provide care as pediatric services director.
      4. (D) Newborn nursery services director. The medical staff will designate a physician board certified, board eligible, or residency trained in pediatrics and credentialed to provide pediatric care as the newborn nursery services director. The pediatric services director may also serve as the newborn nursery services director.
      5. (E) Physician qualifications. Physician members of the obstetrics-gynecology service must be board certified, board eligible, or residency trained in obstetrics and gynecology.
      6. (F) Training. Emergency room, obstetrics unit, and newborn nursery nursing personnel must have completed the Pediatric Advanced Life Support Program (PALS) offered through the American Heart Association or have equivalent training.

   3. (3) Supplies and equipment.

      1. (A) Emergency department. In addition to the requirements at OAC 310:667-59-9(a)(3), the hospital must have the following equipment and supplies for use in the management of emergent obstetric, gynecologic, and neonatal patients on site, functional, and available in the emergency department:

         1. (i) Obstetrics pack;
         2. (ii) Nitrazine (pH) paper for detecting amniotic fluid when membranes are ruptured;
         3. (iii) Equipment to monitor fetal heart rate and pattern electronically;
         4. (iv) Ophthalmic antiseptics for neonates;

         5. (v) Pulse oximetry with adult and pediatric probes;

            1. (I) Oxytocic agents;
            2. (II) Tocolytic agents;
            3. (III) Prostaglandins;
            4. (IV) Ergotic agents;
            5. (V) Antihypertensives; and
            6. (VI) Magnesium sulfate.

         6. (vii) Drugs necessary for care of the depressed neonatal patient including:

            1. (I) Epinephrine;
            2. (II) Volume expanders
            3. (III) Sodium bicarbonate;
            4. (IV) Dextrose solutions; and
            5. (V) Naloxone hydrochloride.
         7. (viii) Radiant warmer;
         8. (ix) Sterile procedure trays for episiotomy; and

         9. (x) Supplies, equipment, and written protocols for the examination of sexual assault victims and for the collection of specimens and the preservation of the chain of evidence including:

            1. (I) Preassembled sexual assault examination kits;
            2. (II) Consent, chain of evidence, and sexual assault examination forms; and
            3. (II) Long-wave ultraviolet lamp;

      2. (B) Obstetrics unit. The obstetrics unit will have the following supplies and equipment on site, functional, and available for use:

         1. (i) Cardiopulmonary resuscitation cart;
         2. (ii) Electrocardiograph-oscilloscope-defibrillator-pacer;
         3. (iii) Equipment for continuous electronic fetal monitoring;
         4. (iv) Equipment for external tocography

         5. (v) An open, stable area under a radiant warmer with available oxygen and suction and the following equipment for use in neonatal resuscitation:

            1. (I) Bulb syringe;
            2. (II) Assorted suction catheters;
            3. (III) Neonatal oral airways of various sizes;
            4. (IV) Neonatal endotracheal tubes of various sizes and stylets;
            5. (V) Neonatal ventilation masks and bag-mask resuscitator;
            6. (VI) Neonatal laryngoscope with #0 and #1 blades; and
            7. (VII) Neonatal orogastric tube.

         6. (vi) Drugs necessary for care of the depressed neonatal patient including:

            1. (I) Epinephrine;
            2. (II) Volume expanders
            3. (III) Sodium bicarbonate;
            4. (IV) Dextrose solutions; and
            5. (V) Naloxone hydrochloride.

      3. (C) Operating suite. The operating suite must have the following supplies and equipment on site, functional and available for use:

         1. (i) Thermal control equipment for patients and infusion of blood, blood products, and other fluids;
         2. (ii) X-ray capability including c-arm intensifier; and
         3. (iii) Endoscopes.
      4. (D) Post-anesthesia recovery unit. A Level II hospital is subject to the same post-anesthesia recovery unit requirements as a Level III hospital as set forth in (b)(3)(B) of this Section.
      5. (E) Intensive care unit. A Level II hospital is subject to the same post-anesthesia recovery unit requirements as a Level III hospital as set forth in (b)(3)(B) of this Section.
   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.

4. (d) Level I. A Level I hospital will provide emergency medical services with organized emergency, obstetrics-gynecology and neonatology departments. A physician and nursing staff with special capability in obstetric and gynecologic care arerequired on site 24 hours a day. The hospital must have a dedicated obstetrics unit as well as a newborn nursery and neonatal intensive care unit. The hospital will have the capability to provide immediate delivery by emergency cesarean section. Laparoscopy and laparotomy procedures will be immediately available when required for obstetric and gynecologic emergencies. A hospital must be classified at Level I for emergency obstetric and gynecologic 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 (c)(1)(A) of this Section.
      2. (B) Obstetrics and gynecology. A Level I hospital is subject to the same obstetrics and gynecology requirements as a Level II hospital as set forth in (c)(1)(B) of this Section.
      3. (C) Neonatology. The hospital will have organized neonatology service with appropriately credentialed physicians experienced in the care of the seriously ill neonatal patient on call and immediately available 24 hours a day. Physician members of the neonatology service must be board certified, board eligible, or residency trained in neonatology. On call physicians will respond as required by the hospital's policy.
      4. (D) Obstetrics unit. A Level I hospital is subject to the same obstetrics unit requirements as a Level II hospital as set forth in (c)(1)(C) of this Section.
      5. (E) Pediatrics. A Level I hospital is subject to the same pediatrics requirements as a Level II hospital as set forth in (c)(1)(E) of this Section.
      6. (F) Newborn nursery. A Level I hospital is subject to the same newborn nursery requirements as a Level II hospital as set forth in (c)(1)(D) of this Section.

      7. (G) Neonatal intensive care unit. The hospital will have a dedicated neonatal intensive care unit appropriately equipped and staffed with nursing personnel with special capability in neonatal care.

         1. (i) A board certified, board eligible, or residency trained neonatologist or senior resident competent and appropriately credentialed by the hospital must be on site 24 hours a day at all times when patients are in the unit.
         2. (ii) If a senior neonatology resident is staffing the unit, then an attending neonatologist must be on call and promptly available 24 hours a day.
      8. (H) General surgery. A Level I hospital is subject to the same general surgery requirements as a Level II hospital as set forth in (c)(1)(F)of this Section.
      9. (I) Anesthesia. A Level I hospital is subject to the same anesthesia requirements as a Level III hospital as set forth in (b)(1)(C) of this Section.
      10. (J) Operating suite. A Level I hospital is subject to the same operating suite requirements as a Level II hospital as set forth in (c)(1)(H) of this Section.
      11. (K) Post-anesthesia recovery unit. A Level I hospital is subject to the same post-anesthesia recovery unit requirements as a Level III hospital as set forth in (b)(1)(E) of this Section.
      12. (L) Intensive care unit. A Level I hospital is subject to the same intensive care unit requiremenst as a Level III hospital as set forth in (b)(1)(F) of this Section.

      13. (M) Diagnostic imaging. The hospital will have diagnostic x-ray, computerized 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 services include:

          1. (i) All diagnostic imaging services listed for Level II classification as set forth in (c)(1)(K) of this Section;
          2. (ii) Angiography;
          3. (iii) Neuroradiology; and
          4. (iv) Nuclear medicine imaging.
      14. (N) Clinical laboratory service. A Level I hospital is subject to the same clinical laboratory service requirements as a Level II hospital as set forth in (c)(1)(L) of this Section.
      15. (O) Respiratory therapy. A Level I hospital is subject to the same respiratory therapy requirements as a Level II hospital as set forth in (c)(1)(M) of this Section.
      16. (P) Acute hemodialysis. The hospital will provide acute hemodialysis services 24 hours a day. All staff providing hemodialysis patient care will have documented hemodialysis training and experience.
      17. (Q) Social services. Social services will 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) Obstetrics-gynecology services director. A Level I hospital is subject to the same obstetrics-gynecology services director requirements as a Level II hospital as set forth in (c)(2)(B) of this Section.
      3. (C) Pediatric services director. A Level I hospital is subject to the same pediatric services director requirements as a Level II hospital as set forth in (c)(2)(C) of this Section.
      4. (D) Newborn nursery services director. A Level I hospital is subject to the same newborn nursery services director requirements as a Level II hospital as set forth in (c)(2)(D) of this Section.
      5. (E) Neonatology services director. The medical staff will designate a physician board certified, board eligible, or residency trained in neonatology and credentialed to provide neonatal care as neonatology services director.

      6. (F) Physician qualifications.

         1. (i) Physician members of the obstetrics-gynecology service must be board certified, board eligible, or residency trained in obstetrics and gynecology.
         2. (ii) Physician members of the neonatology service must be board certified, board eligible, or residency trained in neonatology.
      7. (G) Training. Emergency room, obstetrics unit, newborn nursery, and neonatal intensive care unit nursing personnel must have completed the Pediatric Advanced Life Support Program (PALS) and or the Neonatal Advanced Life Support Program (NALS) offered through the American Heart Association or have equivalent training.

   3. (3) Supplies and equipment.

      1. (A) Emergency department. A Level I hospital is subject to the same emergency department requirements as a Level II hospital as set forth in (c)(3)(A) in this Section.
      2. (B) Obstetrics unit. A Level I hospital is subject to the same obstetrics requirements as a Level II hospital as set forth in (c)(3)(B) of this Section.

      3. (C) Operating suite. The operating suite shall have the following supplies and equipment on site, functional and available for use:

         1. (i) All the supplies and equipment listed for Level II classification [see (c)(3)(C) in this Section];
         2. (ii) Cardiopulmonary bypass capability; and
         3. (iii) operating microscope.

      4. (D) Post-anesthesia recovery unit. The post-anesthesia recovery unit will have the following supplies and equipment on site, functional, and available for use:

         1. (i) the post-anesthesia supplies and equipment listed for Level III classification set forth in (b)(3)(B) of this Section; and
         2. (ii) Equipment for the continuous monitoring of intracranial pressure.
      5. (E) Intensive care unit. A Level I hospital is subject to the same intensive care unit requirements as a Level III hospital as set forth in (b)(3)(C) of this Section.
   4. (4) Policies on transfers. A Level I hospital is subject to the same policies on transfers requirements as a Level II hospital as set forth in (c)(4) of this Section.

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