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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 310:667-59-13. Classification of emergency pediatric medicine and trauma services
Latest version.
- (a) Level IV. A Level IV facility shall provide emergency pediatric medicine and trauma 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. The hospital shall be capable of identifying critically ill or injured pediatric patients and providing stabilizing treatment to manage airway, breathing, and circulation prior to patient transfer. A hospital shall be classified at Level IV for emergency pediatric medicine and trauma services if it meets the following requirements:(1) Clinical services and resources. No diagnostic, surgical, or medical specialty services are required. The facility shall have access by telephone or other electronic means to a regional poison control center.(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. The hospital shall have equipment for use in the resuscitation of pediatric patients on site, functional, and immediately available, including at least the following:(A) Spine board (child/adult) for cardiopulmonary resuscitation and papoose board for immobilization of infants and toddlers;(B) Airway control and ventilation equipment, including laryngoscopes and endotracheal tubes of all sizes, bag-mask resuscitator, pocket masks, oxygen, and oxygen delivery equipment. Masks and cannula shall be available in infant, child, and adult sizes;(C) Pulse oximeter with adult and pediatric probes;(D) Infant, child, adult, and thigh blood pressure cuffs;(E) Rectal thermometer probe;(F) Suction devices suitable for infants, children, and adults;(G) Electrocardiograph-oscilloscope-defibrillator-pacer with pediatric capability;(H) Standard intravenous fluids and administration devices suitable for infants, children, and adults including large-bore intravenous catheters;(I) Specialized pediatric procedure trays for:(i) Lumbar puncture;(ii) Urinary catheterization;(iii) Umbilical vessel cannulation; and(iv) Airway control/cricothyrotomy;(v) Vascular access; and(vi) Chest decompression.(J) Equipment for gastric decompression;(K) Magill forceps (pediatric and adult);(L) Equipment for gastric decompression;(M) Fracture management devices including:(i) Skeletal traction devices including cervical immobilization device suitable for pediatric patients;(ii) Extremity splints; and(iii)Child and adult femur splints.(N) Drugs necessary for pediatric emergency care with printed pediatric doses and pediatric reference materials such as precalculated drug sheets or length-based tape;(O) Infant scale;(P) Thermal control equipment for patients including a heat source or procedure for infant warming; and(Q) Two-way communication with vehicles of emergency transport system as required at OAC 310:667-29-1(c)(4).(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 transfer agreements with a hospital capable of providing burn care in a physician-directed, organized burn care center with a staff of nursing personnel trained in burn care and equipped properly for care of the extensively burned patient.(C) The facility shall have transfer agreements with a hospital capable of providing acute spinal cord and head injury management and rehabilitation.(D) The facility shall have transfer agreements with a hospital 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 injured patient.(5) Quality Improvement.(A) For a hospital licensed as a general medical surgical hospital, in addition to the requirements of OAC 310:667-11-1 through OAC 310:667-11-5, the quality improvement programs shall include:(i) Trauma registry;(ii) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(iii) Incident reports related to pediatric patients;(iv) Pediatric transfers;(v) Child abuse cases;(vi) Pediatric cardiopulmonary or respiratory arrests;(vii) Pediatric admissions within 48 hours of an emergency department visit;(viii) Pediatric surgery within 48 hours of discharge from an emergency department;(ix) Morbidity and mortality review;(x) Medical nursing audit, utilization review, tissue review; and(xi) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(B) For a hospital licensed as a critical access hospital, in addition to the requirements of OAC 310:667-39-7, the quality improvement programs shall include:(i) Trauma registry;(ii) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(iii) Incident reports related to pediatric patients;(iv) Pediatric transfers;(v) Child abuse cases;(vi) Pediatric cardiopulmonary or respiratory arrests;(vii) Pediatric admissions within 48 hours of an emergency department visit;(viii) Pediatric surgery within 48 hours of discharge from an emergency department;(ix) Morbidity and mortality review;(x) Medical nursing audit, utilization review, tissue review; and(xi) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(C) For a facility licensed as a birthing center, in addition to the requirements of OAC 310:616-5-2, the quality improvement programs shall include:(i) Trauma registry;(ii) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(iii) Incident reports related to pediatric patients;(iv) Pediatric transfers;(v) Child abuse cases;(vi) Pediatric cardiopulmonary or respiratory arrests;(vii) Pediatric admissions within 48 hours of an emergency department visit;(viii) Pediatric surgery within 48 hours of discharge from an emergency department;(ix) Morbidity and mortality review;(x) Medical nursing audit, utilization review, tissue review; and(xi) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(b) Level III. A Level III facility shall provide emergency pediatric medicine and trauma services with an organized trauma service and emergency department. A physician and nursing staff with special capability in trauma care shall be on site twenty-four (24) hours a day. General surgery and anesthesiology services shall be available either on duty or on call. The hospital shall have basic facilities for the management of minor pediatric inpatient problems. A hospital shall be classified at Level III for emergency pediatric medicine and trauma services if it meets the following requirements:(1) Clinical services and resources.(A) Trauma service. A trauma service shall be established by the medical staff and shall be responsible for coordinating the care of injured patients, the training of personnel, and trauma quality improvement. Privileges for physicians participating in the trauma service shall be determined by the medical staff credentialing process. All patients with multiple-system or major injury shall be evaluated by the trauma service. The surgeon responsible for the overall care of the admitted patient shall be identified.(B) Emergency services. A physician deemed competent in the care of the seriously ill or injured patient and credentialed by the hospital to provide emergency medical services and nursing personnel with special capability in trauma care shall be on site twenty-four (24) hours a day. The emergency service may also serve as the trauma service.(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.(C) Poison control center. The facility shall have access by telephone or other electronic means to a regional poison control center.(D) General surgery. A board certified, board eligible, or residency trained general surgeon shall be on call twenty-four (24) hours a day and promptly available in the emergency department. For a hospital licensed as a general medical surgical hospital, surgical services shall also comply with the requirements of OAC 310:667-25-1 through OAC 310:667-25-2.(E) Anesthesia. Anesthesia services shall be on call twenty-four (24) hours a day, promptly available, and administered as required in OAC 310:667-25-2.(F) Internal medicine. A physician board certified, board eligible, or residency trained in internal medicine shall be on call twenty-four (24) hours a day and promptly available in the emergency department.(G) Operating suite. An operating suite with thermal control equipment for patients and infusion of blood and fluids shall be available twenty-four (24) hours a day.(H) 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.(I) 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.(J) 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 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.(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) Therapeutic drug monitoring;(iv) Coagulation studies;(v) Blood gas/pH analysis;(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; and(vii) Drug and alcohol screening.(viii) 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.(ix) 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.(L) Social services. Social services shall be available and provided as required in Subchapter 31 of this Chapter.(M) Burn Care. If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(U)(i) it shall have a transfer agreement with a hospital capable of providing burn care in a physician-directed, organized burn care center with a staff of nursing personnel trained in burn care and equipped properly for care of the extensively burned patient.(N) Spinal cord and head injury management. If the hospital does not meet the requirements at OAC 310:667-59-9(d)(1)(P)(i) it shall have a transfer agreement with a hospital capable of providing acute spinal cord and head injury management and rehabilitation.(O) Rehabilitation services. If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(W)(i) it shall have a transfer 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 injured patient.(P) 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.(2) Personnel.(A) Trauma service director. The medical staff shall designate a surgeon as trauma service director. Through the quality improvement process, the director shall have responsibility for all trauma patients and administrative authority for the hospital's trauma program. The director shall be responsible for recommending appointment to and removal from the trauma service.(B) Emergency services director. The medical staff shall designate a physician credentialed to provide emergency medical care as emergency services director.(C) Surgical director. The medical staff shall designate a surgeon credentialed by the hospital to be the director of care for surgical and critical care for trauma patients.(D) Pediatrics. A physician board certified, board eligible, or residency trained in pediatrics and deemed competent in the care of pediatric emergencies shall be available for consultation on site or immediately available by telephone or other electronic means twenty-four hours a day.(E) Orthopedics. A physician board certified, board eligible, or residency trained in orthopedics and deemed competent in the care of pediatric orthopedic emergencies shall be available for consultation on site or immediately available by telephone or other electronic means twenty-four hours a day.(3) Supplies and equipment.(A) Emergency department. The hospital shall have equipment for use in the resuscitation of pediatric patients on site, functional, and immediately available, including at least the following:(i) Spine board (child/adult) for cardiopulmonary resuscitation and papoose board for immobilization of infants and toddlers;(ii) Airway control and ventilation equipment, including laryngoscopes and endotracheal tubes of all sizes, bag-mask resuscitator, pocket masks, oxygen, and oxygen delivery equipment. Masks and cannula shall be available in infant, child, and adult sizes;(iii) Pulse oximeter with adult and pediatric probes;(iv) Infant, child, adult, and thigh blood pressure cuffs;(v) Rectal thermometer probe;(vi) Suction devices suitable for infants, children, and adults;(vii) Electrocardiograph-oscilloscope-defibrillator-pacer with pediatric capability;(viii) Apparatus to establish central venous pressure monitoring;(ix) Standard intravenous fluids and administration devices suitable for infants, children, and adults including infusion pumps with microinfusion capability and large-bore intravenous catheters;(x) Specialized pediatric procedure trays:(I) Lumbar puncture;(II) Urinary catheterization;(III) Umbilical vessel cannulation;(IV) Airway control/cricothyrotomy;(V) Thoracotomy;(VI) Chest decompression.(VII) Intraosseous infusion;(VIII) Vascular access; and(IX) Needle cricothyroidotomy set.(xi) Magill forceps (pediatric and adult);(xii) Equipment for gastric decompression;(xiii) Fracture management devices including:(I) Skeletal traction devices including cervical immobilization device suitable for pediatric patients;(II) Extremity splints; and(III) Child and adult femur splints.(xiv) Slit lamp;(xv) Drugs necessary for pediatric emergency care with printed pediatric doses and pediatric reference materials such as precalculated drug sheets or length-based tape;(xvi) Infant scale;(xvii) Thermal control equipment for patients including a heat source or procedure for infant warming; and(xviii) Two-way communication with vehicles of emergency transport system as required at OAC 310:667-29-1(c)(4).(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.(5) Quality Improvement. In addition to any other applicable requirements of this Chapter, the facility quality improvement programs shall include a review of the following indicators:(A) Trauma registry;(B) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(C) Incident reports related to pediatric patients;(D) Pediatric transfers;(E) Child abuse cases;(F) Pediatric cardiopulmonary or respiratory arrests;(G) Pediatric admissions within 48 hours of an emergency department visit;(H) Pediatric surgery within 48 hours of discharge from an emergency department;(I) Morbidity and mortality review;(J) Medical nursing audit, utilization review, tissue review;(K) Published on call schedules for surgeons, neurosurgeons, and orthopedic surgeons;(L) Review of the times and reasons for trauma-related bypass; and(M) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(c) Level II. A Level II facility shall provide emergency pediatric medicine and trauma services with organized emergency and pediatrics departments and an organized pediatric trauma service with a designated general or pediatric surgeon as director. A physician and nursing staff with special capability in pediatric emergency and trauma care shall be on site twenty-four (24) hours a day. General surgery and anesthesiology services shall be available on site or on call twenty-four (24) hours a day. Services from additional clinical specialties including pediatrics, neurosurgery, orthopedics, and critical care shall be promptly available on call. A hospital shall be classified at Level II for emergency pediatric medicine and trauma services if it meets the following requirements:(1) Clinical services and resources.(A) Pediatric trauma service. A pediatric trauma service shall be established by the medical staff and shall be responsible for coordinating the care of injured pediatric patients, the training of personnel, and trauma quality improvement. Privileges for physicians participating in the pediatric trauma service will be determined by the medical staff credentialing process. All pediatric patients with multiple-system or major injury shall be evaluated by the trauma service. The surgeon responsible for the overall care of the admitted patient shall be identified.(B) Emergency services. A physician deemed competent in the care of the seriously ill or injured pediatric patient and credentialed by the hospital to provide pediatric emergency medical services and nursing personnel with special capability in pediatric emergency and trauma 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.(C) Poison control center. The facility shall have access by telephone or other electronic means to a regional poison control center.(D) Pediatric services. The hospital shall have an organized pediatric service with appropriately credentialed physicians experienced in the care of seriously ill or injured pediatric patients immediately available twenty-four (24) hours a day. Physicians shall be board certified, board eligible, or residency trained in pediatrics. On call physicians shall respond as required by the hospital's policy.(E) General surgery. A general surgeon or senior surgical resident deemed competent and appropriately credentialed by the hospital shall be on site or on call twenty-four (24) hours a day and promptly available in the emergency department. A stated goal of the general surgery service shall be to have the attending trauma surgeon authorized and designated by the trauma service director present in the emergency room at the time of the severely injured patient's arrival. For a hospital licensed as a general medical surgical hospital, surgical services shall also comply with the requirements of OAC 310:667-25-1 through OAC 310:667-25-2.(F) Anesthesia. An board certified, board eligible, or residency trained anesthesiologist shall be on site or on call twenty-four (24) hours a day and promptly available in the emergency department. If the anesthesiologist is not present in the facility, prior to the physician's arrival, anesthesia services may be provided by a certified registered nurse anesthetist (CRNA). The CRNA shall be deemed competent in the assessment of emergent situations in trauma patients and of initiating and providing any indicated treatment. All anesthesia shall be administered as required in OAC 310:667-25-2.(G) Neurologic surgery. A board certified, board eligible, or residency trained neurosurgeon or other physician deemed competent in the care of pediatric patients with neurotrauma and appropriately credentialed shall be on site or on call twenty-four (24) hours a day and promptly available in the emergency department. If care is initiated by a physician other than a neurosurgeon, the neurosurgeon on call shall respond as required by the hospital's policy.(H) Orthopedics. A physician board certified, board eligible, or residency trained in orthopedics and deemed competent in the care of pediatric orthopedic emergencies shall be on site or on call twenty-four (24) hours a day and promptly available in the emergency department.(I) Other specialties. The hospital shall also have services from the following specialties on call and promptly available:(i) Cardiac surgery;(ii) Cardiology;(iii) Neurology;(iv) Obstetric/gynecologic surgery;(v) Ophthalmic surgery;(vi) Oral/maxillofacial surgery;(vii) Orthopedic surgery;(viii) Otolaryngology;(ix) Plastic surgery;(x) Pulmonary medicine;(xi) Radiology;(xii) Thoracic surgery; and(xiii) Urology and urologic surgery.(J) 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.(K) 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.(L) Intensive care unit. The hospital shall have an intensive care unit and/or pediatric intensive 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 intensive care unit and shall continuously monitor compliance with these requirements through the quality improvement program. A registered nurse shall be on call and immediately available when no patients are in the unit. Nursing personnel shall have completed the Pediatric Advanced Life Support Program (PALS) offered through the American Heart Association or have equivalent training. A physician with privileges in critical care shall be on duty in the unit or immediately available in the hospital twenty-four (24) hours a day.(M) Diagnostic imaging. The hospital shall have diagnostic x-ray services available twenty-four (24) hours a day. A radiology technologist and computerize 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) Angiography;(ii) Ultrasonography;(iii) Computed tomography;(iv) Magnetic resonance imaging;(v) Neuroradiology; and(vi) Nuclear medicine imaging.(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.(N) 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) Therapeutic drug monitoring;(iv) Cerebrospinal fluid and other body fluid cell counts;(v) Coagulation studies;(vi) Blood gas/pH analysis;(vii) 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(viii) Drug and alcohol screening.(ix) 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.(O) 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.(P) Social services. Social services shall be available and provided as required in Subchapter 31 of this Chapter.(Q) Burn Care. If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(U)(i) it shall have a transfer agreement with a hospital capable of providing burn care in a physician-directed, organized burn care center with a staff of nursing personnel trained in burn care and equipped properly for care of the extensively burned patient.(R) Spinal cord and head injury management. The hospital shall provide acute spinal cord and head injury management including at least the ability to initiate rehabilitative care prior to transfer and shall have a transfer agreement with a hospital that meets the requirements at OAC 310:667-59-9(d)(1)(P)(i) if comprehensive rehabilitation services are not available within the facility.(S) Rehabilitation services. If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(W)(i) it shall have a transfer 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 injured patient.(T) Acute hemodialysis. The hospital shall have the capability to provide acute hemodialysis services twenty-four (24) hours a day. All nursing staff providing hemodialysis patient care shall have documented hemodialysis training and experience.(2) Personnel.(A) Pediatric trauma service director. The medical staff shall designate a general or pediatric surgeon as trauma service director. Through the quality improvement process, the director shall have responsibility for all trauma patients and administrative authority for the hospital's trauma program. The trauma service director shall be responsible for recommending appointment to and removal from the trauma service.(B) Pediatric trauma coordinator. The hospital shall have a designated trauma coordinator who may also serve as the prevention coordinator. Under the supervision of the trauma service director, the trauma coordinator is responsible for organizing the services and systems of the trauma service to ensure there is a multidisciplinary approach throughout the continuum of trauma care. The trauma coordinator shall have an active role in the following:(i) Clinical activities such as design of clinical protocols, monitoring care, and assisting the staff in problem solving;(ii) Educational activities such as professional staff development, case reviews, continuing education, and community trauma education and prevention programs;(iii) Quality improvement activities such as development of quality monitors, audits, and case reviews in all phases of trauma care;(iv) Administrative tasks for the trauma service such as those related to services' organization, personnel, budget preparation, and accountability;(v) Trauma registry data collection, coding, scoring, and validation; and(vi) Consultation and liaison to the medical staff, prehospital emergency medical service agencies, patient families, and the community at large.(C) Prevention coordinator. The hospital shall have a designated prevention coordinator who may also serve as the trauma coordinator. Under the supervision of the trauma director, the prevention coordinator is responsible for the organization and management of the hospital's outreach, prevention, and public education activities.(D) Emergency services director. The medical staff shall designate a physician credentialed to provide emergency medical care as emergency services director.(E) Surgical director. The medical staff shall designate a surgeon credentialed by the hospital to be the director of care for surgical and critical care for trauma patients.(F) Pediatric services director. The medical staff shall designate a physician credentialed to provide pediatric care as pediatric services director.(G) Physician qualifications. A physician board certified, board eligible, or residency trained in pediatric critical care medicine shall be available for consultation on site or immediately available by telephone or other electronic means twenty-four (24) hours a day.(H) Training. Emergency room and intensive care personnel shall have completed the Pediatric Advanced Life Support (PALS) program through the American Heart Association or have equivalent training.(3) Supplies and equipment.(A) Emergency department. The hospital shall have equipment for use in the resuscitation of pediatric patients on site, functional, and immediately available, including at least the following:(i) Spine board (child/adult) for cardiopulmonary resuscitation and papoose board for immobilization of infants and toddlers;(ii) Airway control and ventilation equipment, including laryngoscopes and endotracheal tubes of all sizes, bag-mask resuscitator, pocket masks, oxygen, and oxygen delivery equipment. Masks and cannula shall be available in infant, child, and adult sizes;(iii) (iii)Pulse oximeter with adult and pediatric probes;(iv) End-tidal CO2 determination;(v) Infant, child, adult, and thigh blood pressure cuffs;(vi) Rectal thermometer probe;(vii) Suction devices suitable for infants, children, and adults;(viii) Electrocardiograph-oscilloscope-defibrillator-pacer with pediatric capability;(ix) Apparatus to establish central venous pressure monitoring;(x) Standard intravenous fluids and administration devices suitable for infants, children, and adults including infusion pumps with microinfusion capability and large-bore intravenous catheters;(xi) Specialized pediatric procedure trays:(I) Lumbar puncture;(II) Urinary catheterization;(III) Umbilical vessel cannulation;(IV) Airway control/cricothyrotomy;(V) Thoracotomy;(VI) Chest decompression.(VII) Intraosseous infusion;(VIII) Vascular access;(IX) Needle cricothyroidotomy set; and(X) Peritoneal lavage.(xii) Magill forceps (pediatric and adult);(xiii) Equipment for gastric decompression;(xiv) Fracture management devices including:(I) Skeletal traction devices including cervical immobilization device suitable for pediatric patients;(II) Extremity splints; and(III) Child and adult femur splints.(xv) Slit lamp;(xvi) Drugs necessary for pediatric emergency care with printed pediatric doses and pediatric reference materials such as precalculated drug sheets or length-based tape;(xvii) Infant scale;(xviii) Thermal control equipment for patients including a heat source or procedure for infant warming; and(xix) Two-way communication with vehicles of emergency transport system as required at OAC 310:667-29-1(c)(4);(B) Operating suite. The operating suite shall have the following supplies and equipment on site, functional and available for use:(i) Thermal control equipment for patients and infusion of blood, blood products, and other fluids;(ii) X-ray capability including c-arm intensifier;(iii) Endoscopes;(iv) Craniotomy instruments; and(v) Equipment appropriate for fixation of long-bone and pelvic fractures.(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) Cardiopulmonary resuscitation cart;(iii) Electrocardiograph-oscilloscope-defibrillator-pacer;(iv) 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.(5) Quality Improvement. In addition to any other applicable requirements of this Chapter, the facility quality improvement programs shall include a review of the following indicators:(A) Trauma registry;(B) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(C) Incident reports related to pediatric patients;(D) Pediatric transfers;(E) Child abuse cases;(F) Pediatric cardiopulmonary or respiratory arrests;(G) Pediatric admissions within 48 hours of an emergency department visit;(H) Pediatric surgery within 48 hours of discharge from an emergency department;(I) Morbidity and mortality review;(J) Medical nursing audit, utilization review, tissue review;(K) Published on call schedules for surgeons, neurosurgeons, and orthopedic surgeons;(L) Review of the times and reasons for trauma-related bypass; and(M) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(6) Continuing education. The hospital shall provide and document formal continuing education programs for physicians, nurses, allied health personnel, and community physicians. Continuing education programs shall be available to all state physicians, nurses, allied health personnel, and emergency medical service providers.(7) Organ Procurement. The hospital, in association with an organ procurement organization certified by CMS, shall develop policies and procedures to identify and refer potential organ donors.(8) Outreach programs. The hospital shall have organized outreach programs under the direction of a designated prevention coordinator.(A) Consultation. The hospital shall provide on-site and/or electronic consultations with community health care providers and those in outlying areas as requested and appropriate.(B) Prevention and public education programs. The hospital shall serve as a public information resource and collaborate with other institutions and national, regional, and state programs in research and data collection projects in epidemiology, surveillance, and injury prevention, and other areas.(d) Level I. A Level I facility shall provide emergency pediatric medicine and trauma services with organized emergency and pediatrics departments and an organized pediatric trauma service with a designated pediatric surgeon as director. Pediatric surgery, pediatric anesthesiology, pediatric neurosurgery, and pediatric critical care services including a dedicated pediatric intensive care unit (PICU) shall be available on site twenty-four (24) hours a day. The facility shall also have the prompt availability of additional clinical services and specialties such as pediatric cardiology, pediatric nephrology, and pediatric infectious disease specialists. A level I facility shall also have an organized trauma research program with a designated director. A hospital shall be classified at Level I for emergency pediatric medicine and trauma services if it meets the following requirements:(1) Clinical services and resources.(A) Pediatric trauma service. A pediatric trauma service shall be established by the medical staff and shall be responsible for coordinating the care of injured pediatric patients, the training of personnel, and trauma quality improvement. Privileges for physicians participating in the pediatric trauma service will be determined by the medical staff credentialing process. All pediatric patients with multiple-system or major injury shall be evaluated by the trauma service. The surgeon responsible for the overall care of the patient shall be identified.(B) Emergency services. A physician deemed competent in the care of the critically injured pediatric patient and credentialed by the hospital to provide pediatric emergency medical services and nursing personnel with special capability in pediatric emergency and trauma care shall be on site twenty-four (24) hours a day. The emergency department shall have geographically separate and distinct pediatric medical/trauma areas that have all the staff, equipment, and skills necessary for comprehensive pediatric emergency care. Separate fully equipped pediatric resuscitation rooms shall be available and capable of supporting at least two simultaneous resuscitations. 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.(C) Poison control center. The facility shall have access by telephone or other electronic means to a regional poison control center.(D) Pediatric services. The hospital shall have an organized pediatric service with appropriately credentialed physicians experienced in the care of seriously ill or injured pediatric patients immediately available twenty-four (24) hours a day. Physicians shall be board certified, board eligible, or residency trained in pediatrics. On call physicians shall respond as required by the hospital's policy.(E) 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 percutaneous transluminal coronary angioplasty (PTCA) is performed, prompt access to emergency coronary arterial bypass graft (CABG) surgery shall also be available.(F) Pediatric surgery. A board certified, board eligible, or residency trained pediatric surgeon or senior surgical resident deemed competent and appropriately credentialed by the hospital shall be on site twenty-four (24) hours a day and promptly available in the emergency department. A stated goal of the pediatric surgery service shall be to have the attending pediatric trauma surgeon authorized and designated by the pediatric trauma service director present in the emergency room at the time of the severely injured pediatric patient's arrival. For a hospital licensed as a general medical surgical hospital, surgical services shall also comply with the requirements of OAC 310:667-25-1 through OAC 310:667-25-2.(G) Pediatric anesthesia. An board certified, board eligible, or residency trained pediatric anesthesiologist shall be on site twenty-four (24) hours a day and promptly available in the emergency department. If the anesthesiologist is not present in the facility, prior to the physician's arrival, anesthesia services may be provided by a certified registered nurse anesthetist (CRNA). The CRNA shall be deemed competent in the assessment of emergent situations in pediatric patients and of initiating and providing any indicated treatment. All anesthesia shall be administered as required in OAC 310:667-25-2. All anesthesia shall be administered as required in OAC 310:667-25-2.(H) Neurologic surgery. A board certified, board eligible, or residency trained neurosurgeon or other physician deemed competent in the care of pediatric patients with neurotrauma and appropriately credentialed shall be on site twenty-four (24) hours a day and promptly available in the emergency department. If care is initiated by a physician other than a neurosurgeon, the neurosurgeon on call shall respond as required by the hospital's policy.(I) Orthopedics. A physician board certified, board eligible, or residency trained in orthopedics and deemed competent in the care of pediatric orthopedic emergencies shall be on site or on call twenty-four (24) hours a day and promptly available in the emergency department.(J) Other specialties. The hospital shall also have services from the following specialties on call and promptly available:(i) Cardiovascular surgery;(ii) Hand surgery;(iii) Microvascular surgery;(iv) Ophthalmology;(v) Oral/maxillofacial surgery;(vi) Otolaryngology;(vii) Pediatric allergy/immunology;(viii) Pediatric cardiology;(ix) Pediatric endocrinology;(x) Pediatric gastroenterology;(xi) Pediatric hematology/oncology;(xii) Pediatric infectious disease;(xiii) Pediatric intensivist;(xiv) Pediatric nephrology;(xv) Pediatric neurology;(xvi) Pediatric pulmonology;(xvii) Plastic surgery;(xviii) Psychiatry/psychology;(xix) Radiology; and(xx) Urology and urologic surgery.(K) 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.(L) Post-anesthesia recovery unit. The hospital shall have a post-anesthesia recovery room or surgical 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.(M) Pediatric intensive care unit (PICU).(i) The hospital shall have a pediatric 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). The hospital shall define and document in writing the minimum staffing requirements for the pediatric intensive care unit. A registered nurse shall be on call and immediately available when no patients are in the unit. A physician with privileges in pediatric critical care shall be on duty in the unit or immediately available in the hospital twenty-four (24) hours a day.(ii) The pediatric intensive care unit shall be a distinct, separate unit within the hospital, with privileges of physicians and allied health personnel delineated in writing.(iii) Written policies shall be established and approved by the medical director and medical staff for at least the following:(I) Admission/discharge;(II) Minimum staffing;(III) Patient monitoring;(IV) Safety;(V) Nosocomial infection;(VI) Patient isolation;(VII) Visitation;(VIII) Traffic control;(IX) Equipment operation and maintenance;(X) Coping with and recovering from the breakdown of essential equipment; and(XI) Patient record-keeping.(N) Diagnostic Imaging. The hospital shall have diagnostic x-ray 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) Angiography;(ii) Ultrasonography;(iii) Computed tomography;(iv) Magnetic resonance imaging;(v) Neuroradiology; and(vi) Nuclear medicine imaging.(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.(O) 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. The clinical laboratory shall have the capability to analyze microspecimen volumes when appropriate. 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) Therapeutic drug monitoring;(iv) Cerebrospinal fluid and other body fluid cell counts;(v) Coagulation studies;(vi) Blood gas/pH analysis;(vii) Comprehensive microbiology services with immediate availability of Gram stain preparations and at least appropriate supplies for the collection, preservation, and transport of clinical specimens for aerobic and anaerobic bacterial, mycobacterial, and fungus cultures; and(viii) Drug and alcohol screening.(ix) 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.(P) 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.(Q) Acute hemodialysis. The hospital shall have the capability to provide acute hemodialysis services twenty-four (24) hours a day. All nursing staff providing hemodialysis patient care shall have documented hemodialysis training and experience with pediatric patients.(R) Social services. Social services shall be available and provided as required in Subchapter 31 of this Chapter.(S) Physical and occupational therapy services. Physical and occupational therapy shall be available and provided as required in Subchapter 23 of this Chapter.(T) Dietetic and nutrition services. Dietetic and nutrition services shall be available and provided as required in Subchapter 17 of this Chapter.(U) Burn Care.(i) The hospital shall provide burn care in a physician-directed, organized burn care center with a staff of nursing personnel trained in burn care and equipped properly for care of the extensively burned patient; or(ii) If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(U)(i), it shall have a written transfer agreement with a hospital capable of providing burn care in a physician-directed, organized burn care center with a staff of nursing personnel trained in burn care and equipped properly for care of the extensively burned patient.(V) Spinal cord and head injury management. The hospital shall provide acute spinal cord and head injury management including at least the ability to initiate rehabilitative care prior to transfer and shall have a transfer agreement with a hospital that meets the requirements at OAC 310:667-59-9(d)(1)(P)(i) if comprehensive rehabilitation services are not available within the facility.(W) 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 injured patient; or(ii) If the hospital does not meet the requirements at OAC 310:667-59-13(d)(1)(W)(i) it shall have a written transfer 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 injured patient.(2) Personnel.(A) Pediatric trauma service director. The medical staff shall designate a board certified, board eligible, or residency trained pediatric surgeon as pediatric trauma service director. Through the quality improvement process, the director shall have responsibility for all pediatric trauma patients and administrative authority for the hospital's pediatric trauma program. The pediatric trauma service director shall be responsible for recommending appointment to and removal from the pediatric trauma service.(B) Pediatric trauma coordinator. The hospital shall have a designated pediatric trauma coordinator who may also serve as the prevention coordinator. Under the supervision of the pediatric trauma service director, the pediatric trauma coordinator is responsible for organizing the services and systems of the pediatric trauma service to ensure there is a multidisciplinary approach throughout the continuum of pediatric trauma care. The pediatric trauma coordinator shall have an active role in the following:(i) Clinical activities such as design of clinical protocols, monitoring care, and assisting the staff in problem solving;(ii) Educational activities such as professional staff development, case reviews, continuing education, and community trauma education and prevention programs;(iii) Quality improvement activities such as development of quality monitors, audits, and case reviews in all phases of pediatric trauma care;(iv) Administrative tasks for the pediatric trauma service such as those related to services' organization, personnel, budget preparation, and accountability;(v) Trauma registry data collection, coding, scoring, and validation; and(vi) Consultation and liaison to the medical staff, prehospital emergency medical service agencies, patient families, and the community at large.(C) Prevention coordinator. The hospital shall have a designated prevention coordinator who may also serve as the pediatric trauma coordinator. Under the supervision of the pediatric trauma director, the prevention coordinator is responsible for the organization and management of the hospital's outreach, prevention, and public education activities.(D) Emergency services director. The medical staff shall designate a physician credentialed to provide pediatric emergency medical care as emergency services director.(E) Surgical director. The medical staff shall designate a board certified, board eligible, or residency trained pediatric surgeon credentialed by the hospital to provide pediatric critical care as the surgical director for trauma patients.(F) Research director. The medical staff shall designate a physician as research director who may also serve as the pediatric trauma service director. The research director is responsible for the organization and management of the hospital's trauma and emergency operative research activities.(G) PICU medical director. The medical staff shall designate a physician board certified, board eligible, or residency trained in critical care medicine as PICU medical director. The PICU medical director shall participate in developing and reviewing PICU policies, promote policy implementation, participate in budget preparation, help coordinate staff education, supervise resuscitation techniques, lead quality improvement activities, and coordinate research.(H) PICU nurse manager. The hospital shall have a PICU nurse manager with training and experience in pediatric critical care dedicated to the PICU. The PICU nurse manager shall participate in the development of written policies and procedures for the PICU, coordinate staff education, budget preparation, and coordination of research.(3) Supplies and equipment.(A) Emergency department. The hospital shall have equipment for use in the resuscitation of pediatric patients on site, functional, and immediately available, including at least the following:(i) Spine board (child/adult) for cardiopulmonary resuscitation and papoose board for immobilization of infants and toddlers;(ii) Airway control and ventilation equipment, including laryngoscopes and endotracheal tubes of all sizes, bag-mask resuscitator, pocket masks, oxygen, and oxygen delivery equipment. Masks and cannula shall be available in infant, child, and adult sizes;(iii) Pulse oximeter with adult and pediatric probes;(iv) End-tidal CO2 determination;(v) Infant, child, adult, and thigh blood pressure cuffs;(vi)Rectal thermometer probe;(vii)Suction devices suitable for infants, children, and adults;(viii) Electrocardiograph-oscilloscope-defibrillator-pacer with pediatric capability;(ix) Portable electroencephalographic equipment;(x) Apparatus to establish central venous pressure monitoring;(xi) Standard intravenous fluids and administration devices suitable for infants, children, and adults including infusion pumps with microinfusion capability and large-bore intravenous catheters;(xii) Specialized pediatric procedure trays:(I) Lumbar puncture;(II) Urinary catheterization;(III) Umbilical vessel cannulation;(IV) Airway control/cricothyrotomy;(V) Thoracotomy;(VI) Chest decompression.(VII) Intraosseous infusion;(VIII) Vascular access;(IX) Needle cricothyroidotomy set;(X) Peritoneal lavage; and(XI) Subdural access.(xiii) Magill forceps (pediatric and adult);(xiv) Equipment for gastric decompression;(xv) Fracture management devices including:(I) Skeletal traction devices including cervical immobilization device suitable for pediatric patients;(II) Extremity splints; and(III) Child and adult femur splints.(xvi) Slit lamp;(xvii) Drugs necessary for pediatric emergency care with printed pediatric doses and pediatric reference materials such as precalculated drug sheets or length-based tape;(xviii) Infant scale;(xix) Thermal control equipment for patients including a heat source or procedure for infant warming; and(xx) Two-way communication with vehicles of emergency transport system as required at OAC 310:667-29-1(c)(4).(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;(v) Pediatric endoscopes and bronchoscopes;(vi) Craniotomy instruments; and(vii) Equipment appropriate for fixation of long-bone and pelvic fractures.(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 oximeter with adult and pediatric probes;(iv) End-tidal CO2 determination; and(v) Thermal control equipment for patients and infusion of blood, blood products, and other fluids.(D) Pediatric intensive care unit. The pediatric 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. Bedside monitors in the pediatric intensive care unit shall have audible and visible high and low alarms for each statistic, provide a hard copy of the heart rhythm strip, and have the capability of simultaneously monitoring:(I) Systemic arterial pressure;(II) Central venous pressure;(III) Pulmonary arterial pressure;(IV) Intracranial pressures;(V) Heart rate and rhythm;(VI) Respiratory rate; and(VII) Temperature.(ii) Cardiopulmonary resuscitation cart;(iii) Electrocardiograph-oscilloscope-defibrillator-pacer;(iv) 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.(5) Quality Improvement. In addition to any other requirements of this Chapter, the hospital quality improvement program shall include:(A) Trauma committee. The hospital shall establish a multidisciplinary trauma committee composed of the trauma service director, emergency services director, trauma coordinator, and other members of the medical and nursing staff that treat trauma and emergency operative patients. The trauma committee shall meet regularly to review and evaluate patient outcomes and the quality of care provided by the trauma service. The quality improvement program shall include:(i) Trauma registry;(ii) Audit for all pediatric deaths to include prehospital care and care received at a transferring facility;(iii) Incident reports related to pediatric patients;(iv) Pediatric transfers;(v) Child abuse cases;(vi) Pediatric cardiopulmonary or respiratory arrests;(vii) Pediatric admissions within 48 hours of an emergency department visit;(viii) Pediatric surgery within 48 hours of discharge from an emergency department;(ix) Morbidity and mortality review;(x) Regularly scheduled multidisciplinary trauma and emergency operative services review conference;(xi) Medical nursing audit, utilization review, tissue review;(xii) Published on call schedules for surgeons, neurosurgeons, and orthopedic surgeons;(xiii) Review of the times and reasons for trauma-related bypass;(xiv) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored; and(xv) Quality improvement staff with the time dedicated to and specific for trauma and emergency operative services.(B) PICU committee. The hospital shall establish a PICU committee composed of physicians, nurses, and other allied health personnel directly involved with activities in the PICU. The PICU committee shall meet regularly to review and evaluate patient outcomes and the quality of care provided by the PICU. The PICU quality improvement program may be conducted in conjunction with the trauma and emergency operative services program and shall include:(i) Special audit for all PICU deaths;(ii) Morbidity and mortality review;(iii) Medical nursing audit, utilization review, tissue review;(iv) Regularly scheduled multidisciplinary PICU review conference;(v) Review of prehospital care;(vi) Published on call schedules for surgeons, neurosurgeons, and orthopedic surgeons; and(vii) The availability and response times of on call staff specialists shall be defined in writing, documented, and continuously monitored.(6) Continuing education. The hospital shall provide and document formal continuing education programs for physicians, nurses, allied health personnel, and community physicians. Continuing education programs shall be available to all state physicians, nurses, allied health personnel, and emergency medical service providers.(7) Organ Procurement. The hospital, in association with the local organ procurement organization, shall develop policies and procedures to identify and refer potential organ donors.(8) Outreach programs. The hospital shall have organized outreach programs under the direction of a designated prevention coordinator.(A) Consultation. The hospital shall provide on-site and/or electronic consultations with community health care providers and those in outlying areas as requested and appropriate.(B) Prevention and public education programs. The hospital shall serve as a public information resource and collaborate with other institutions and national, regional, and state programs in research and data collection projects in epidemiology, surveillance, and injury prevention, and other areas.(9) Research programs. The hospital shall have an organized pediatric services research program under the direction of a designated research director. Research groups shall meet regularly and all research proposals shall be approved by an Institutional Review Board (IRB) prior to launch. The research director shall maintain evidence of the productivity of the research program through documentation of presentations and copies of published articles.