Section 515.APPENDIX K  Application for Facility Recognition for Emergency Department with Pediatrics Capabilities

 

FACILITY RECOGNITION

Emergency Department with Pediatric Capabilities

 

Application Instruction

 

Follow these instructions to complete the application process:

 

1)         Carefully review the application process in this Appendix K.

 

2)         Complete the application form and obtain the appropriate signatures.

 

3)         Using the Facility Recognition Application Criteria, complete an Emergency Department Pediatric Plan.  Appendix any appropriate supporting documentation (schedules, policies, procedures, protocols, guidelines, plans, etc.).

 

4)         Submit the original plus 3 additional copies of the signed application form and the Emergency Department Pediatric Plan (including supporting documentation) to:

 

Leslee Stein-Spencer, RN, MS

Chief, EMS & Highway Safety

Illinois Department of Public Health

525 West Jefferson Street

Springfield IL 62761

 

5)         The application should be submitted in a single-sided format and unstapled.

 

6)         Please note that the attached appendix to this application is to provide additional resource information for your facility related to pediatric interfacility transfer and consultation and can be utilized in the development of the Emergency Department Pediatrics Plan.

 

7)         For questions regarding the application process, specific criteria items, and/or supporting documentation, please contact the Illinois Emergency Medical Services for Children (EMSC) Office at 708-327-3672.

 

 

ILLINOIS EMSC

APPLICATION PROCESS FOR RECOGNITION OF

EMERGENCY DEPARTMENTS WITH PEDIATRIC CAPABILITIES*

 

Application Process

 

To initiate the process to obtain recognition as an Emergency Department Approved for Pediatrics (EDAP) or Standby Emergency Department for Pediatrics (SEDP), the facility shall submit all documents to:

 

Leslee Stein-Spencer, RN, MS

Chief, EMS & Highway Safety

Illinois Department of Public Health

525 W. Jefferson Street

Springfield IL 62761

 

Facilities requesting to participate in the Facility Recognition process must submit:

 

1)         A signed application form

 

2)         An Emergency Department Pediatric Plan.  This plan must follow the format provided and include all required documentation as outlined in the Pediatric Plan Guideline in this Appendix K.  The plan must also address how each of the EDAP/SEDP requirements are currently or will be met.  Please note that the Pediatric Plan should be developed through interaction and collaboration with all other appropriate disciplines.

 

3)         Any supporting documentation, which shall include but is not limited to scope of services/care, policies (both administrative and department specific), procedures, protocols, guidelines, flow charts, rosters, calendars, schedules, etc.

 

4)         The plan should be submitted in the order listed in this application.

 

Please note that the original and 3 additional copies of the plan and any supporting documentation must be submitted.

 

Any submitted requests to waive any of the requirements must include the criteria by which compliance is considered to be a hardship and demonstrate how there will be no reduction in the provision of medical care.

 

The Emergency Department Pediatric Plan Guideline can be utilized as a resource in completing the Emergency Department Pediatric Plan.

 

*Note: The term "pediatric" throughout this document refers to all children age 15 and younger.

 

Site Survey Procedure

 

1)         Within 4 to 6 weeks following receipt of the Application Form and supporting documents (schedules, policies, procedures, protocols, guidelines, etc.), the hospital will be informed as to the status of the application.  If all documentation is in order, a site visit will be scheduled.

 

2)         The site visit will include a survey of the emergency department, pediatric unit (including intensive care, if applicable), and a meeting with the following individuals:

 

a)         The Hospital's Chief Administrative/Executive Officer or designee.

 

b)         The Chief of Pediatrics or, if the hospital does not have a pediatric department, the designated pediatric consultant.

 

c)         The Medical Director of Emergency Services.

 

d)         The Nursing Director or Nursing Manager of Emergency Services.

 

e)         The Administrator of Emergency Services.

 

f)          The pediatric liaison (a member of the professional staff who has ongoing involvement in the care of the pediatric patient and development of pediatric emergency medical services).

 

g)         Mid-level provider, i.e., nurse practitioner or physician assistant for those facilities that utilize mid-level providers in their emergency department.

 

h)         For EMS Resource or Association Hospitals only: the EMS Medical Director and EMS Coordinator.

 

3)         In preparation for the site visit, hospital personnel shall prepare evidence to verify adherence to the facility recognition requirements.

 

Site Survey Team

 

The survey team will be appointed by the Chief of EMS & Highway Safety, in coordination with the Illinois EMSC Advisory Board.  Site survey teams will be composed of a physician/nurse (or nurse/nurse) team along with a representative from the Illinois Department of Public Health.  All team members shall have attended formal training in the responsibilities, expectations, process and assessment of facility recognition.

 

Following the Site Survey

 

1)         Within 4 to 6 weeks following the site visit, the hospital shall receive results of the survey. Those facilities meeting all requirements will receive a formal "recognition" for their emergency department pediatric capabilities.  Signed copies of the recognition shall be forwarded to the Chief of EMS & Highway Safety and the Illinois EMSC office.

 

2)         Hospitals may appeal the results of the survey by submitting a written request to the Illinois Department of Public Health, Division of EMS & Highway Safety.

 

3)         Rerecognition shall occur every 3 years, with site visits scheduled as necessary.

 

4)         Withdrawal of recognition status may occur at any time, should a hospital fail to meet any of the requirements.  In this situation, the hospital shall notify the Illinois Department of Public Health, Division of EMS & Highway Safety at least 60 days prior to withdrawal and identify how area prehospital provider agencies, area hospitals, and the Illinois EMSC Office will be notified.

 

RECOGNITION OF EMERGENCY DEPARTMENT

PEDIATRIC CAPABILITIES

APPLICATION FORM

 

1)	Name and address of hospital (typed)
2)	Specify the recognition level for which your hospital is applying:
	a)	Emergency Department Approved for Pediatrics (EDAP)
	b)	Standby Emergency Department Approved for Pediatrics (SEDP)
3)	The above-named facility certifies that each requirement in this Request for Recognition is met and will be operation by the date of recognition.
	Typed name – CEO/Administrator
	Signature – CEO/Administrator			Date
	Typed name – Medical Director of Emergency Services
	Signature – Medical Director of Emergency Services			Date
	Contact person – Typed name, phone number, and fax number

 

 

EMERGENCY DEPARTMENT PEDIATRIC PLAN

GUIDELINE

 

 

Emergency Department Pediatric Plan               (Please follow this guideline carefully.  It provides information on the components that must be included in the submitted plan. Please include any applicable supplemental documentation.)

 

A.        Emergency Department Organizational Structure

 

1.     Provide an Organizational Table identifying the administrative relationships among all departments in the hospital, especially as they relate to the emergency department.  The table must include but is not limited to the following:

 

a.      Board of Directors

b.     Chief Executive Officers

c.     Emergency Department

d.     Department of Pediatrics

e.     Trauma Service (if applicable)

f.      Department of Radiology

 

2.     In addition, provide a separate table showing the organization structure of the emergency department, including the relationship of the physician, nursing and ancillary services. Include the reporting structure for the ED Medical Director (who he/she reports to).

 

a.   Emergency Department Organizational Structure (Table)

B.         Emergency Department Services

 

1.         Description of the emergency department services

•           Provide a scope of services or policy outlining emergency department services, emergency department level, description of population served, types of pediatric patients seen, annual emergency department visits that involve the pediatric patient.

•           Identify the age range that your facility utilizes to define the pediatric patient, i.e., 0-15.

•           Provide information on participation/status in EMS system and trauma  system as appropriate.

 

2.         Description of the emergency department patient flow

•           Provide a narrative description of algorithm or patient path/flow from point of entry through disposition.

•           Provide any policies/guidelines that identify triaging/urgency categorization of patients.

•           Identify whether pediatric patients are seen in the general ED or in a separate area/bed space allocated for the pediatric patient.

•           If an emergency department fast-track area exists, provide triage criteria for this area and information on physician and nursing staffing/qualifications for assignment to the fast-track area.

 

3.         Description of emergency medical services communication with identification of dedicated phone line, radio, and telemetry capabilities

•           Provide a policy or narrative description of the emergency services dedicated phone/telemetry radio communication capabilities.

•           Provide a policy outlining staffing qualifications to access and utilize such equipment.

 

4.         Description of social service availability and capabilities

•           Provide a scope of services or policy that defines the services, capabilities and availability of social service department/personnel to the emergency department.

•           Describe typical mechanism and response by social worker to ED requests (i.e., handled over the phone, respond directly to the ED, follow-up consult/appointment made).

 

C.        Pediatric Department Services

 

1.         Description of the pediatric department services

•           Identify whether there is a dedicated pediatric inpatient unit, dedicated pediatric inpatient beds and pediatric intensive care unit.

•           Provide a scope of services/policy outlining pediatric department services.

 

2.         Description of the pediatric staffing and availability

•           Provide policy or scope of services outlining pediatric unit shift nursing staffing patterns based on patient acuity and any pediatric continuing education requirements/competencies verification.

•           If pediatric patients are admitted for care to an adult inpatient unit, provide documentation that identifies unit pediatrician staffing/coverage for such patients and how nurses are assigned to the inpatient pediatric patient, i.e., only nurses who have completed PALS course.

 

3.         Description/documentation of pediatric inpatient capabilities with identification of PICU and/or pediatric general floor bed availability and unit resources

•           Provide policy or scope of services that identifies what types of pediatric patients are typically admitted, i.e., types of conditions/diagnoses.  Can all ages (from birth to 18 years) be admitted or are there guidelines in place that outline pediatric patients specifically by age parameters and/or diagnoses?

•           If a PICU is present, then a description of services, unit resources, and capabilities is needed.  If a PICU is not present, then a description of where patients requiring such care are transferred, established relationships with pediatric tertiary care center, etc., is needed.

 

D.        Professional Staff

 

1.         Emergency Department Director

 

a.         Copy of curriculum vitae

•           Provide a printed curriculum vitae.  

 

b.         Documentation of board certification (as identified in Facility Recognition Criteria)

•           Provide a copy of board certification or verification of board certification.

 

2.         Emergency Department Physicians

 

Documentation of the ability to meet facility recognition requirements in Section 515.4000 or Section 515.4010 of this Part.

 

Facility Recognition Requirement – Section 515.4000(a)(1) or 515.4010(a)(1)

•           Provide a policy or description of emergency department physician staffing, coverage and availability.

•           Provide a complete list/roster of emergency department physician staff.

•           Provide a one-month staffing schedule/calendar (schedule should be from within the 3-month time period previous to the application submission).

•           Provide copies of physician current board certification or verification of board certification (or copies of CVs for SEDP level applications).

•           Provide copies of PALS or APLS course completion certificates for physician staff or a documented plan to complete such courses within the specified timeframe.  Provide documentation of a plan to maintain PALS or APLS recognition.

•           Provide a policy that incorporates Section 515.4000(a)(1) or 515.4010(a)(1).

 

Facility Recognition Requirement – Section 515.4000(a)(2) or 515.4010(a)(2)

•           Provide a copy of the emergency department physician continuing education policy.

•           Provide a description of how physician continuing education is currently tracked.

•           Provide documentation of an implementation plan for attaining and tracking of pediatric specific continuing education hours (these hours can be integrated into the overall CME tracking process).

•           Provide a policy that incorporates Section 515.4000(a)(2) or 515.4010(a)(2).

 

Facility Recognition Requirement – Section 515.4000(a)(3) or 515.4010(a)(3)

•           Provide a staffing policy that incorporates Section 515.4000(a)(3) or 515.4010(a)(3).

 

Facility Recognition Requirement – Section 515.4000(a)(4) or 515.4010(a)(4)

•           Provide a one-month on-call schedule that identifies availability of a board certified/prepared pediatrician or pediatric emergency medicine physician for telephone consultation (schedule should be from within the 3-month time period previous to the application submission).

 

Facility Recognition Requirement – Section 515.4000(a)(5) or 515.4010(a)(5)

•           Provide a copy of a disaster policy that identifies physician on-call availability.

 

Facility Recognition Requirement – Section 515.4000(a)(6) or 515.4010(a)(6)

•           Provide a protocol/policy/bylaws that identifies maximum response time of on-call physicians.

 

3.         Emergency Department Mid-Level Providers (Physician Assistant or Nurse Practitioner)

Note – Complete this section only if physician assistants and/or nurse practitioners practice in the emergency department and participate in the care of pediatric patients.

 

Provide documentation of the ability to meet facility recognition requirements in Section 515.4000(b) or 515.4010(b) of this Part.

 

Requirement – Section 515.4000(b)(1) or 515.4010(b)(1)

•           Provide a policy of emergency department physician assistant and/or nurse practitioner staffing, coverage, availability, responsibilities and credentialing process.

•           Provide a copy of a one-month staffing schedule/calendar (schedule should be from within the 3-month time period previous to the application submission).

•           Provide a copy of printed licenses and curriculum vitaes.

•           Provide copies of PALS, APLS or ENPC course completion certificates or a documented plan to complete such courses within the specified timeframe.  Provide documentation of a plan to maintain PALS, APLS, or ENPC recognition.

•           Provide a policy that incorporates Section 515.4000(b)(1) or 515.4010(b)(1) of this Part.

 

Requirement – Section 515.4000(b)(2) or 515.4010(b)(2)

•           Provide a copy of the emergency department physician assistant/nurse practitioner continuing education policy.

•           Provide a description of how physician assistant/nurse practitioner continuing education is currently tracked.

•           Provide documentation of an implementation plan for attaining and tracking of pediatric specific continuing education hours (these hours can be integrated into overall continuing education tracking process).

•           Provide a policy that incorporates Section 515.4000(b)(2) or 515.4010(b)(2) of this Part.

 

4.         Emergency Department Registered Nurses

 

Provide documentation of the ability to meet facility recognition requirements in Section 515.4000(c) or 515.4010(c) of this Part.

 

Requirement – Section 515.4000(c)(1) or 515.4010(c)(1)

•           Provide a policy/documentation outlining current nursing shift staffing plan/patterns.

•           Provide a list/roster of all emergency department nursing staff.

•           Provide a copy of a one-month nursing staffing schedule/calendar (schedule should be from within the 3-month time period previous to the application submission).

•           Provide copies of current course completion cards for nursing staff who have completed PALS, APLS, or ENPC courses.

•           Provide a policy that incorporates Section 515.4000(c)(1) or 515.4010(c)(1)

 

Requirement – Section 515.4000(c)(2) or 515.4010(c)(2)

•           Provide a policy identifying continuing education requirements and competency testing for emergency department nursing staff.

•           Provide a description of how continuing education is currently tracked.

•           Provide documentation of a feasible implementation plan for attaining and tracking of pediatric specific continuing education hours.

•           Provide a policy that incorporates Section 515.4000(c)(2) or 515.4010(c)(2) of this Part.

 

E.         Policies and Procedures

 

1.         Policy/procedure for interfacility transfer as identified in Section 515.4000(d)(1) or 515.4010(d)(1) of this Part.

•          Provide a transfer agreement with a Pediatric Critical Care Center and a transfer policy that incorporates the physiologic/other criteria identified in Appendix M: EMSC Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guideline.

 

2.         Policy/procedure for suspected child abuse as identified in Section 515.4000(d)(2) or 515.4010(d)(2) of this Part.

•           Provide a policy that includes age-specific identification, assessment, evaluation and management measures for the suspected child abuse patient.

 

3.         Treatment protocols as identified in Section 515.4000(d)(3) or 515.4010(d)(3) of this Part.

•           Provide copies of pediatric treatment protocols as described.

•           If limited pediatric-specific treatment protocols are available, submit a letter of commitment to the development and implementation of additional pediatric-specific treatment protocols.  (It is recommended that protocols be based on high volume/high risk diagnoses with inclusion of age-specific stabilization measures.  It is recommended that protocols include desired outcomes in order to facilitate quality improvement monitoring.)

 

4.         Policy for latex-free supplies as identified in Section 515.4000(d)(4) or 515.4010(d)(4) of this Part.

•           Provide a policy that addresses availability of latex-free equipment and supplies.

 

F.         Quality Improvement

 

1.         Describe and document the emergency department program for conducting outcome analysis or quality improvement and how pediatrics is integrated into the process.

•          Provide a policy/guideline that outlines the emergency department quality improvement program, i.e., describe the quality improvement process, clinical indicators and/or outcome analysis and follow-up mechanisms, i.e., "loop closure" and target timeframes for closure of issues.

•          Provide documentation outlining current and planned pediatric monitoring activities.

 

2.         Document the ability to meet facility recognition requirements in 515.4000(e) or 515.4010(e) of this Part.

 

Requirement – Section 515.4000(e)(1) or 515.4010(e)(1)

•           Please define composition of the multidisciplinary CQI committee (recommend broadening composition of committee beyond physician/nursing to include other essential disciplines such as pediatric, social services, respiratory therapy), frequency of committee meetings and reporting structure.

•           Provide copies of current pediatric monitor tools and outcome criteria. If implementation of pediatric monitoring activities is pending, define implementation plan and timeframe.

 

Requirement – Section 515.4000(e)(2) or 515.4010(e)(2)

•           Provide the name and title of the individual who will assume the pediatric CQI liaison role.

•           Identify in a policy format that each of the requirements outlined in Section 515.4000(e)(2) or 515.4010(e)(2) will be carried out by the pediatric CQI liaison.

 

G.        Equipment

Using the equipment list provided in Appendix L, place an "X" next to each equipment item that is currently available (as appropriate for the level applied for).  If equipment/supply items are not available, a plan for securing the items must be identified, i.e., submission of a purchase order to assure that the item is on order, or a waiver must be submitted for each item.

 

Requests for waiver must include the criteria by which compliance is considered to be a hardship and must demonstrate how there will be no reduction in the provision  of medical care.

 

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