Section 515.4010  Facility Recognition Criteria for the Standby Emergency Department Approved for Pediatrics (SEDP)

a)         Professional Staff: Physicians

1)         Qualifications

A)        All physicians shall have training in the care of pediatric patients through residency training, clinical training, or practice.

B)        All physicians shall successfully complete and maintain current recognition in the American Heart Association – American Academy of Pediatrics (AHA-AAP) Pediatric Advanced Life Support (PALS) course, or the American College of Emergency Physicians – American Academy of Pediatrics (ACEP-AAP) Advanced Pediatric Life Support (APLS) course or equivalent course.  (Physicians who are board certified or eligible in emergency medicine (ABEM or AOBEM) or in pediatric emergency medicine (ABP/ABEM) are excluded from this requirement.)

2)         Continuing Medical Education

All full- or part-time emergency physicians shall have documentation 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)         Coverage

At least one physician meeting the requirements of subsection (a)(1) (or physician assistant or nurse practitioner meeting the requirements of subsection (b)(1)) shall be on duty in the emergency department 24 hours a day or immediately available.  A policy shall be available that defines when a physician is to be consulted/called in at times when the emergency department is covered by a mid-level provider.

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 may be with an on-call 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) of this Section shall be available to the SEDP within 1 hour after notification to assist with critical situations or disasters.

6)         On-Call Physicians

Protocols shall be available 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 physician assistant 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 course (ENPC).

2)         Continuing Education

A)        All full- or part-time nurse practitioners shall have documentation of a minimum of 20 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 20 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 Physician Assistants (AAPA).

c)         Professional Staff: Nursing

1)         Qualifications

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:

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

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

C)        ENA Emergency Nursing Pediatric Course (ENPC).

2)         Continuing Education

At least one registered nurse (RN) on duty on each shift who is responsible for the direct care of the child in 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.  The continuing education hours may 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 availability of latex-free equipment and supplies.

e)         Quality Improvement

1)         Multidisciplinary Committee

A)        Pediatric emergency medical care shall be included in the SEDP'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 professional 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 follow-up of sample pediatric emergency department visits.

C)        Coordinating review of prehospital 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)