1. (a) Level III. A Level III hospital will provide services 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 III for emergency neurology 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 Intermediate, Advanced Emergency 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 will be competent to initiate treatment of the emergency patient.

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

      1. (A) Seizure control agents;
      2. (B) Thiamine and glucose for intravenous administration; and
      3. (C) Antipyretics and procedures for reducing body temperature when necessary.

   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 facility.
      2. (B) The hospital must 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 24 hours a day. These services must include 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 will be on site 24 hours a day. A hospital must be classified at Level II for emergency neurology 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 neurology patient and credentialed by the hospital to provide emergency medical services and nursing personnel must be on site 24 hours a day.

      2. (B) Diagnostic imaging. The will have diagnostic x-ray and computerized tomography services available 24 hours a day. A radiologic technologist and computerized tomography technologist must 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; and
         2. (ii) Computed tomography.

      3. (C) Clinical laboratory service. The hospital's clinical laboratory services must 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) Cerebrospinal fluid, cell count, white blood cell differential, protein, glucose, Gram stain, and antigen testing when appropriate;
         3. (iii) Coagulation studies;
         4. (iv) Blood gas/pH analysis;
         5. (v) Drug and alcohol screening; and
         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.

   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) Neurologist. A physician board certified, board eligible, or residency trained in neurology will be available for consultation on site or immediately available by telephone or other electronic means 24 hours a day.

   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) Equipment to perform electroencephalographic (EEG) testing;
      2. (B) Seizure control agents;
      3. (C) Thiamine and glucose for intravenous administration;
      4. (D) Antipyretics and procedures for reducing body temperature when necessary;

      5. (E) Sterile procedure trays for:

         1. (i) Lumbar puncture and measurement of intracranial pressure; and
         2. (ii) Gastric lavage and administration of activated charcoal.

      6. (F) Agents to manage increased intracranial pressure including:

         1. (i) Osmotic diuretics such as mannitol;
         2. (ii) Loop diuretics such as furosemide; and
         3. (iii) Corticosteriods when appropriate.
      7. (G) Drugs to manage migraine headache such as sumatriptin, ergotic agents, antinauseants, narcotic analgesics, etc.; and
      8. (H) Thrombolytic agents for treatment of acute nonhemorrhagic stroke.
   4. (4) Agreements and policies on transfers. A Level II hospital is subject to the same agreements and policies on transfers requirements as a Level III hospital as set forth in (a)(4) in this Section.

3. (c) Level I. A Level I hospital must provide emergency medical services with organized emergency, neurology, and neurosurgery departments. A physician and nursing staff with special capability in neurologic care will be on site 24 hours a day. The hospital must have the capability to provide immediate diagnostic imaging and neurosurgical intervention 24 hours a day. A hospital must be classified at Level I for emergency neurology services 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) Neurology. The hospital must have an organized neurology service with appropriately credentialed physicians experienced in neurologic procedures that must be immediately available 24 hours a day. Physician members of the neurology services must be board certified, board eligible, or residency trained in neurology. On call physicians will respond as required by the hospital's policy.
      3. (C) Neurosurgery. The hospital must have an organized neurosurgery service with appropriately credentialed physicians experienced in neurosurgical procedures that must be immediately available 24 hours a day. Physician members of the neurosurgery service must be board certified, board eligible, or residency trained in neurosurgery. On call physicians will respond as required by the hospital's policy.
      4. (D) 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 will be administered in accordance with OAC 310:667-25-2.
      5. (E) Operating suite. An operating suite with adequate staff and equipment must be immediately available 24 hours a day. The hospital will define and in writing the minimum staffing requirements for the operating suite. An on call schedule for emergency replacement staff must be maintained.
      6. (F) Post-anesthesia recovery unit. The hospital must have a post-anesthesia recovery room or intensive care unit thatis in compliance with OAC 310:667-15-7 with the nursing personnel and anesthesia services remaining in the unit until the patient is discharged from post-anesthesia care.

      7. (G) 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 whenever it has a patient;
         3. (iii) A registered nurse on call and immediately available when the unithas a patient; and
         4. (iv) Written minimum staffing requirements for the intensive care unit that will be monitored through the quality improvement program.

      8. (H) Diagnostic Imaging. The hospital will have diagnostic x-ray and computed tomography services are available 24 hours a day. A radiologic technologist and computerized tomography technologist must 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) Cerebral angiography;
         2. (ii) Myelography;
         3. (iii) Ultrasonography;
         4. (iv) Computed tomography;
         5. (v) Magnetic resonance imaging; and
         6. (vi) Neuroradiology.
      9. (I) Electrophysiologic Testing. The hospital will have electrophysiologic testing services including electroecephalography (EEG), electrocardiography (ECG), and electromyography (EMG) services available as needed.

      10. (J) Clinical laboratory service. The hospital's clinical laboratory services must 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)(C) 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; and
          4. (iv) Access to services provided by a community central blood bank.
      11. (K) Social services. Social services must be available and provided in accordance with Subchapter 31 of this Chapter.
      12. (L) Respiratory therapy. Routine respiratory therapy procedures and mechanical ventilators will be available 24 hours a dayand will comply with OAC 310:667-23-6.

      13. (M) Rehabilitation services.

          1. (i) The hospital must 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
          2. (ii) If t it is unable to satisfy (i) of this subparagraph (M),it must have a written transfer agreement with a hospital which meets the requirements of Subchapter 35 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) Neurology services director. The medical staff will designate a physician credentialed to provide neurologic and/or neurosurgical care as neurology services director.
      3. (C) Physician qualifications. All physicians of the neurology service and neurosurgical service must be board certified, board eligible, or residency trained in neurology.

   3. (3) Supplies and equipment.

      1. (A) Emergency department. In addition to the requirements at OAC 310:667-59-19(d)(3), the hospital must have the following equipment and supplies on site, functional, and immediately available:

         1. (i) All the emergency department equipment and supplies listed for Level II classification as set forth in (b)(3) of this Section;
         2. (ii) Seizure control agents;
         3. (iii) Emergency burr hole as part of the sterile procedure tray; and
         4. (iv) Equipment to monitor intracranial pressure.

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

         1. (i) Cardiopulmonary bypass capability;
         2. (ii) Operating microscope;
         3. (iii) Thermal control equipment for patients and infusion of blood, blood products, and other fluids;
         4. (iv) X-ray capability including c-arm intensifier;
         5. (v) Endoscopes;
         6. (vi) Craniotomy instruments; and
         7. (vii) Equipment for the continuous monitoring of intracranial pressure.

      3. (C) Post-anesthesia recovery unit. The post-anesthesia recovery 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) Equipment for the continuous monitoring of intracranial pressure;
         3. (iii) Pulse oximetry;
         4. (iv) End-tidal CO2 determination; and
         5. (v) Thermal control equipment for patients and infusion of blood, blood products, and other fluids.

      4. (D) 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) Equipment for the continuous monitoring of intracranial pressure;
         3. (iii) Cardiopulmonary resuscitation cart;
         4. (iv) Electrocardiograph-oscilloscope-defibrillator-pacer; and

         5. (v) Sterile surgical sets for:

            1. (I) Airway control/cricothyrotomy;
            2. (II) Thoracotomy;
            3. (III) Vascular access; and
            4. (IV) Chest decompression.
   4. (4) Policies on transfers. The policies on transfers are as set forth in(a)(4)(A) of this Section (relating to agreements and policies on transfers).

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