Regulation .19 Policies, Protocols, and Agreements.

The hospital shall develop, distribute, and monitor implementation of the following patient treatment and care protocols:

(1)

Pediatric resuscitation protocol;

(2)

Procedural sedation protocols for children;

(3)

Transfusion and massive transfusion protocol;

(4)

Infection control protocol;

(5)

Pediatric trauma resuscitation team activation protocol;

(6)

Physician call schedule and notification protocol;

(7)

Interhospital transfer protocol;

(8)

Helicopter safety protocol;

(9)

Organ procurement protocol;

(10)

Child protection team protocol;

(11)

Pediatric psychosocial care protocol; and

(12)

Pediatric rehabilitation care protocol.

The hospital shall have written transfer agreements with specialty and pediatric rehabilitation centers.