Section 515.4000  Facility Recognition Criteria for the Emergency Department Approved for Pediatrics (EDAP)

a)         Professional Staff: Physicians

1)         Qualifications

Twenty-four hour coverage of the emergency department shall be provided by at least one physician responsible for the care of critically ill or injured children who holds one of the following qualifications:

A)        Certification in emergency medicine by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM) or residency trained/board eligible in emergency medicine and in the first cycle of the board certification process; or

B)        Certification in pediatric emergency medicine by the American Board of Pediatrics/American Board of Emergency Medicine (ABP/ABEM) or residency trained/board eligible in pediatric emergency medicine and in the first cycle of the board certification process; or

C)        Certification by one of the following boards and current American Heart Association – American Academy of Pediatrics (AHA-AAP) Pediatric Advanced Life Support (PALS) recognition or American College of Emergency Physicians – American Academy of Pediatrics (ACEP-AAP) Advanced Pediatric Life Support (APLS) recognition or equivalent course.

i)          Certification in family practice by the American Board of Family Practice (ABFP) or American Osteopathic Board of Family Practice (AOBFP); or

ii)         Certification in pediatrics by the ABP or American Osteopathic Board of Pediatrics (AOBP); or

iii)         Residency trained/board eligible in either family practice or pediatrics and in the first cycle of the board certification process; or

D)        A physician who has received a waiver from the Illinois Department of Public Health based on one of the following criteria:

i)          An emergency department physician who has already received a waiver in accordance with Section 515.2030(e) or Section 515.2040(f) of this Part; or

ii)         Completion of 12 months of internship followed by at least 7000 hours of hospital-based emergency medicine, including pediatric patients, over the last 60-month period (including 2800 hours within one 24-month period), verified in writing by the hospitals at which the internship and subsequent hours were completed and current AHA-AAP PALS or ACEP-AAP APLS recognition; or

iii)         Completion of professional activities spent in the practice of pediatric emergency medicine (PEM), over the last 60-month period and totaling a minimum of 6000 hours, focused on the care of patients in the pediatric age group (<21 years) in the emergency department.  Of the 6000 hours, 2800 hours must have been accrued in a 24-month (maximum) consecutive period of time. A minimum of 4000 of the 6000 hours must have been spent in the clinical practice of PEM.  (If practiced in general ED, only time spent exclusively in pediatric practice can be used for credit.)  The remaining 2000 hours may be spent in either clinical care or a mixture of related non-clinical activities clearly focused on PEM, including administration, teaching, prehospital care, quality improvement, research or other academic activities.

2)         Continuing Medical Education

All full- or part-time emergency physicians shall have documentation of completion of a minimum of 16 hours of continuing medical education (AMA Category I or II) in pediatric emergency topics within a 2-year period.

3)         Physician Coverage

At least one physician meeting the requirements of subsection (a)(1) shall be on duty in the emergency department 24 hours a day.

4)         Consultation

Telephone consultation with a physician who is board certified or eligible in pediatrics or pediatric emergency medicine shall be available 24 hours a day. Consultation can be with an on-staff physician or in accordance with Appendix M of this Part.

5)         Physician Backup

A backup physician whose qualifications and training are equivalent to subsection (a)(1) shall be available to the EDAP within 1 hour after notification to assist with critical situations or disasters.

6)         On-Call Physicians

Protocols shall be established that address maximum response time for on-call physicians.

b)         Professional Staff: Mid-Level Practitioners

A mid-level practitioner is a nurse practitioner or physician assistant working under the supervision of a physician who meets the qualifications of subsection (a)(1) of this Section. 

1)         Qualifications

A)        Nurse practitioners shall have:

i)          Completed a pediatric nurse practitioner program or emergency nurse practitioner program or family practice nurse practitioner program, or the Department will grant a waiver based on the following criteria:  has completed 2000 hours of hospital-based emergency department or acute care over the last 24-month period that includes the care of the pediatric patient; and

ii)         An Illinois advanced practice nursing license within one year after employment; and

iii)         Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

B)        Physician assistants shall have:

i)          Current Illinois licensure (permanent or temporary); and

ii)         Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

C)        All nurse practitioners and physician assistants shall successfully complete and maintain current recognition in one of the following courses: the AHA-AAP Pediatric Advanced Life Support (PALS) course, the ACEP-AAP Advanced Pediatric Life Support (APLS) course or the ENA Emergency Nursing Pediatric course (ENPC).

2)         Continuing Education

A)        All full- or part-time nurse practitioners shall have documentation of a minimum of 16 hours of approved continuing education units in pediatric emergency topics within a 2-year period.

B)        All full- or part-time physician assistants shall have documentation of a minimum of 16 hours of continuing medical education (AMA Category I) in pediatric emergency topics within a 2-year period. Credit for CME shall be approved by the Accreditation Council on Continuing Medical Education (ACCME), American Osteopathic Association Council on Continuing Medical Education (AOCCME), American Academy of Family Physicians (AAFP) or American Academy of Physicians Assistants (AAPA).

c)         Professional Staff: Nursing

1)         Qualifications

A)        At least one registered nurse (RN) on duty each shift who is responsible for the direct care of the child in the emergency department shall successfully complete and maintain current recognition in one of the following courses in pediatric emergency care:

i)          AHA-AAP Pediatric Advanced Life Support (PALS) course;

ii)         ACEP-AAP Advanced Pediatric Life Support (APLS) course; or

iii)         ENA Emergency Nursing Pediatric course (ENPC).

B)        All emergency department nurses shall successfully complete and maintain current recognition in one of the above educational requirements within 24 months after employment.

2)         Continuing Education

All nurses assigned to the emergency department shall have documentation of a minimum of 8 hours of pediatric emergency/critical care continuing education hours within a 2-year period.  Continuing education may include, but is not limited to, PALS, APLS or ENPC; CEU offerings; case presentations; competency testing; teaching courses related to pediatrics; and/or publications. These continuing education hours can be integrated with other existing continuing education requirements, provided that the content is pediatric specific.

d)         Policies and Procedures

1)         Interfacility Transfer

The facility shall have transfer agreements with Pediatric Critical Care Centers (PCCC) and policies/procedures concerning transfer of critically ill and injured patients to PCCCs.  Incorporating the components of Appendix M of this Part into the emergency department transfer policy/procedure will meet this requirement.

2)         Suspected Child Abuse

The facility shall have policies/procedures addressing the identification, evaluation, treatment and referral of victims of suspected child abuse in accordance with State law.

3)         Treatment Protocols

The facility shall have protocols addressing appropriate stabilization measures in response to critically ill or injured pediatric patients (i.e., trauma, respiratory distress, seizures).

4)         Latex-free Policy

The facility shall have a policy addressing the availability of latex-free equipment and supplies.

e)         Quality Improvement

1)         Multidisciplinary Committee

A)        Pediatric emergency medical care shall be included in the EDAP's emergency department or section quality improvement (QI) program and reported to the hospital QI committee.

B)        Multidisciplinary continuous quality improvement (CQI) activities shall be established with documented CQI monitors addressing pediatric care within the emergency department, with identified clinical indicators and/or outcomes for care.  These activities shall include children from birth up to and including 15 years of age and shall consist of, but are not limited to, all pediatric emergency department deaths, resuscitations, and interfacility transfers.

2)         Pediatric CQI Liaison

A member of the professional staff who has ongoing involvement in the care of pediatric patients shall be designated and supported by the hospital as the pediatric liaison.  This individual may be employed in an area other than the emergency department and shall have a minimum of 2 years of pediatric critical care or emergency department experience.  The responsibilities of the pediatric liaison shall include:

A)        Working in conjunction with the ED nurse manager and ED medical director to ensure compliance with and documentation of the pediatric continuing education of all emergency department staff in accordance with subsections (a), (b), and (c) of this Section.

B)        Maintaining a data summary and working in conjunction with the multidisciplinary CQI committee to coordinate criteria-based review and followup of sample pediatric emergency department visits.

C)        Coordinating a review of pre-hospital provider transported pediatric cases and providing feedback to the EMS System Coordinator and the EMS Regional Advisory Board.

D)        Preparing a written CQI report and attending the EMS Regional CQI subcommittee, which activities shall be supported by the hospital.  One representative from the CQI subcommittee shall report to the EMS Regional Advisory Board.

E)         Providing CQI information to the Illinois Department of Public Health upon request.  (See Section 3.110(a) of the Act.)

f)          Equipment, Trays, and Supplies

See Appendix L of this Part.

(Source:  Added at 26 Ill. Reg. 18367, effective December 20, 2002)