Regulation .04 Operating Room.

The facility shall have a written agreement with a hospital which has operating room neurosurgical services available 24 hours a day with appropriately trained support staff.

Neurosurgical coverage shall be documented in a written plan approved by the covering neurosurgeon or neurosurgeons, stroke program leaders, and any involved facilities.

Neurosurgical services shall be available to patients within 2 hours of it being deemed necessary.

There shall be a written protocol for transfer that includes communication and feedback from the receiving facility.