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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 310. Oklahoma State Department of Health |
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Chapter 667. Hospital Standards |
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Subchapter 59. Classification of Hospital Emergency Services |
SECTION 310:667-59-11. Classification of emergency cardiology services
Latest version.
- (a) Level III. A Level III facility shall 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 twenty-four (24) hours a day. A hospital shall be classified at Level III for emergency cardiology services if it meets the following requirements:(1) Clinical services and resources.(A) Electrocardiogram. The hospital shall have the immediate availability of a 12-lead electrocardiogram.(B) Thrombolytic therapy. Thrombolytic medications shall be immediately available in the emergency room to provide reperfusion therapy when appropriate. No other 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) Oxygen and oxygen delivery equipment;(B) Equipment to perform a 12-lead electrocardiogram (ECG)with ECG monitor and printout;(C) Equipment for the electronic or facsimile transmission of ECG readings to an expert for interpretation;(D) Transcutaneous pacing capability; and(E) ACLS medications including at least:(i) Aspirin;(ii) Antianginal agents such as sublingual nitroglycerin;(iii) Medications to provide adequate analgesia such as morphine and meperidine;(iv) Sympathomimetics such as epinephrine, norepinephrine, dopamine, etc;(v) Sympatholytics such as ß-adrenoceptor blocking agents;(vi) Angiotensin converting enzyme (ACE) inhibitors;(vii) Antidysrythmics including:(I) Rhythm control agents such as lidocaine, procainamide, bretylium tosylate and magnesium sulfate; and(II) Rate control agents such as atropine, adenosine, verapamil, and digitalis.(viii) Diuretics such as furosemide; and(ix) Antihypertensives such as sodium nitroprusside.(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 cardiologist, or group of cardiologists to provide immediate consultative services for cardiac patients twenty-four (24) hours a day. Such services shall include the immediate interpretation of ECG results and 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 with special capability in cardiac care shall be on site twenty-four (24) hours a day. A hospital shall be classified at Level II for emergency cardiology 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 cardiac patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in cardiac care shall be on site twenty-four (24) hours a day. Nursing personnel shall have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.(i) For a hospital licensed as a general medical surgical hospital or a 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) Thrombolytic therapy. Thrombolytic medications shall be immediately available in the emergency room to provide reperfusion therapy when appropriate.(C) Intensive care unit. The hospital shall have an intensive care unit and/or cardiac care unit in compliance with OAC 310:667-15-7 with a registered nurse on duty in the unit whenever the unit has a patient(s). A registered nurse be on call an immediately available when no patients are in the unit. Nursing personnel shall have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.(D) Continuous electrocardiographic monitoring. The emergency room and intensive/cardiac care unit shall have the capability to continuously monitor patients electrocardiographically when necessary. While a patient is continuously monitored, there shall be adequate human surveillance of the monitors twenty-four (24) hours a day by medical, nursing, or paramedical personnel trained and qualified in the ECG recognition of clinically significant cardiac rhythm disturbances.(E) Diagnostic imaging. The hospital shall have diagnostic x-ray services available twenty-four (24) hours a day. A radiology technologist shall be on duty or on call and immediately available twenty-four (24) hours a day.(i) For a hospital licensed as a general medical surgical hospital or a specialty hospital, diagnostic imaging services shall also comply with the applicable requirements in Subchapter 23 of this Chapter.(ii) 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.(F) 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) Coagulation studies;(iii) Blood gas/pH analysis; and(iv) Rapid determination of cardiac serum markers such as creatine kinase (CK), CK-MB isoform(s), and/or cardiac specific troponins T and I.(v) For a hospital licensed as a general medical surgical hospital or a specialty hospital, clinical laboratory services shall also comply with the applicable requirements in Subchapter 23 of this Chapter.(vi) For a hospital licensed as a critical access hospitals, clinical laboratory services shall also comply with the applicable requirements in Subchapter 39 of this Chapter.(G) Social services. Social services shall be available and provided as required in Subchapter 31 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) Cardiologist. A physician board certified, board eligible, or residency trained in cardiovascular diseases shall be available for consultation on site or immediately available by telephone or other electronic means twenty-four (24) hours a day.(C) Training. Emergency room and intensive care/cardiac care unit nursing personnel shall have completed the Advanced Cardiac Life Support Program offered through the American Heart Association or have equivalent training.(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) Oxygen and oxygen delivery equipment including:(i) Continuous positive-pressure breathing; and(ii) Mechanical ventilation.(B) Equipment to perform a 12-lead electrocardiogram (ECG) with ECG monitor and printout;(C) Equipment for the electronic or facsimile transmission of ECG readings to an expert for interpretation;(D) Pacing equipment including at least:(i) Transcutaneous pacing capability; and(ii) Transvenous pacing electrodes.(E) ACLS medications including at least:(i) Aspirin;(ii) Antianginal agents such as sublingual nitroglycerin;(iii) Medications to provide adequate analgesia such as morphine and meperidine;(iv) Sympathomimetics such as epinephrine, norepinephrine, dopamine, etc;(v) Sympatholytics such as ß-adrenoceptor blocking agents;(vi) Angiotensin converting enzyme (ACE) inhibitors;(vii) Antidysrythmics including:(I) Rhythm control agents such as lidocaine, procainamide, bretylium tosylate and magnesium sulfate; and(II) Rate control agents such as atropine, adenosine, verapamil, and digitalis.(viii) Diuretics such as furosemide; and(ix) Antihypertensives such as sodium nitroprusside.(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 cardiologist, or group of cardiologists to provide immediate consultative services for cardiac patients twenty-four (24) hours a day. Such services shall include the immediate interpretation of ECG results and 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 and cardiology departments. A physician and nursing staff with special capability in cardiac care shall be on site twenty-four (24) hours a day. The facility shall 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) twenty-four (24) hours a day. A hospital shall be classified at Level I for emergency cardiology 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 cardiac patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in cardiac care shall be on site twenty-four (24) hours a day. Nursing personnel shall have completed the Advanced Cardiac Life Support Program (ACLS) offered through the American Heart Association or have equivalent training. 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) Thrombolytic therapy. Thrombolytic medications shall be immediately available in the emergency room to provide reperfusion therapy when appropriate.(C) Cardiology and cardiovascular surgery. The facility shall have an organized cardiology and cardiovascular surgery service with appropriately credentialed physicians experienced in percutaneous and surgical revascularization immediately available twenty-four (24) hours a day. Physician members of the cardiology service shall be board certified, board eligible, or residency trained in cardiovascular diseases or be board certified, board eligible, or residency trained in cardiovascular and/or vascular surgery. On call physicians shall respond as required by the hospital's policy.(D) Cardiac catheterization laboratory. The facility shall have 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 shall be supervised by physicians with appropriate training and expertise in the procedures performed and who are properly credentialed by the medical staff. When primary PTCA is performed, prompt access to emergency CABG surgery shall also be available.(E) 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.(F) 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. The operating suite shall have cardiopulmonary bypass capability.(G) 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.(H) Cardiac care unit. The hospital shall have a cardiac care unit in compliance with OAC 310:667-15-7 with a registered nurse on duty in the unit whenever the unit has a patient(s). The hospital shall define and document in writing the minimum staffing requirements for the cardiac care unit. A registered nurse shall be on call and immediately available when no patients are in the unit. A physician with privileges in cardiac care or cardiovascular surgery shall be on duty in the unit or immediately available in the hospital twenty-four (24) hours a day.(I) Continuous electrocardiographic monitoring. The emergency room, cardiac catheterization laboratory(s), and cardiac care unit shall have the capability to continuously monitor patients electrocardiographically when necessary. While a patient is continuously monitored, there shall be adequate human surveillance of the monitors twenty-four (24) hours a day by medical, nursing, or paramedical personnel trained and qualified in the ECG recognition of clinically significant cardiac rhythm disturbances.(J) Diagnostic Imaging. The hospital shall have diagnostic x-ray, computed tomography, and ultrasonography services available twenty-four (24) hours a day. A radiologic technologist, computerized tomography technologist, and staff designated as qualified to perform ultrasonography 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) Angiography;(ii) Ultrasonography including echocardiography;(iii) Computed tomography;(iv) Magnetic resonance imaging; and(v) Nuclear medicine imaging.(vi) 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.(K) 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) Coagulation studies;(iv) Blood gas/pH analysis;(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; and(vi) Rapid determination of cardiac serum markers such as creatine kinase (CK), CK-MB isoform(s), and/or cardiac specific troponins T and I.(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.(L) Respiratory therapy service. 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) Social services. Social services shall be available and provided as required in Subchapter 31 of this Chapter.(N) Cardiac rehabilitation service. The hospital shall have available a formal program for rehabilitation of the cardiac patient. An individualized rehabilitation program shall be designed for each patient, and when appropriate, the program shall combine prescriptive exercise training with education about coronary risk factor modification techniques. Rehabilitation services shall also comply with the requirements of Subchapter 35 of this Chapter.(O) Post-cardiac event evaluation. Through the use of exercise or pharmacologic ECG stress testing, exercise stress echocardiography, exercise or stress nuclear perfusion scintigraphy or other procedures as appropriate, the hospital shall have the capability of evaluating patients after a cardiac event to:(i) Assess functional capacity and the patient's ability to perform tasks at home and at work.(ii) Evaluate the efficacy of the patient's current medical regimen; and(iii) Risk-stratify the post-MI patient according to the likelihood of a subsequent cardiac event.(2) Personnel.(A) Emergency services director. The medical staff shall designate a physician credentialed to provide emergency medical care as emergency services director.(B) Cardiology services director. The medical staff shall designate a physician credentialed to provide medical and/or surgical cardiac care as cardiology services director.(C) Physician qualifications. Physician members of the cardiology service shall 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.(D) Training. Emergency room, intensive care/cardiac care unit, and cardiac catheterization laboratory nursing personnel shall have completed the Advanced Cardiac Life Support Program (ACLS) offered through the American Heart Association or have equivalent training.(3) Supplies and equipment. In addition to the requirements at OAC 310:667-59-11(b)(3), the hospital shall have the following equipment and supplies on site, functional, and immediately available:(A) The hospital shall have the equipment and personnel to monitor the hemodynamic stability of cardiac patients with balloon flotation catheters when appropriate;(B) The hospital shall have the equipment and personnel to monitor intra-arterial pressure when appropriate; and(C) The hospital shall have the equipment and personnel to provide intra-aortic balloon counterpulsation therapy when appropriate.(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.