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

 

FACILITY RECOGNITION

Emergency Department with Pediatric Capabilities

 

Application Instructions

 

Follow these instructions to initiate the process to obtain recognition as an Emergency Department Approved for Pediatrics (EDAP) or Standby Emergency Department for Pediatrics (SEDP):

 

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

 

2)         Using the Emergency Department Pediatric Plan Guideline and the EDAP or SEDP requirements, complete an Emergency Department Pediatric Plan.  Attach all requested supporting documentation (credentialing forms, schedules, policies, procedures, protocols, guidelines, plans, etc.).

 

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

 

Chief, Division of EMS & Highway Safety

Illinois Department of Public Health

422 S. 5^th Street

Springfield IL 62701

 

4)         The Emergency Department Pediatric Plan shall follow the format outlined in the Emergency Department Pediatric Plan Guideline in this Appendix K and include all required documentation.  The plan shall also address how each of the EDAP/SEDP requirements is currently being or will be met.  The Pediatric Plan shall be developed through interaction and collaboration with all other appropriate disciplines.

 

5)         Any submitted requests for equipment waivers shall include the criteria by which compliance is considered to be a hardship and demonstrate that there will be no reduction in the provision of medical care.

 

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

 

7)         Appendix M provides additional resource information related to pediatric inter-facility transfer and consultation and can be used in the development of the Emergency Department Pediatrics Plan.

 

8)         For questions regarding the application process, specific requirements, or supporting documentation, please contact the Division of EMS & Highway Safety at 217-785-2080.

 

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 hospital certifies that each requirement in this Request for Recognition is met and will be in 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, credentials and title
		Contact person – Phone number, fax number and email

 

 

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 a hospital 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 Emergency Department Organizational Structure 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 (to whom he/she reports).

 

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, a description of the population served, types of pediatric patients seen, and annual emergency department visits that involve the pediatric patient.

•           Identify the age range that the hospital uses 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 or algorithm of 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 emergency department 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 use 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 emergency department requests (i.e., handle over the phone, respond directly to the emergency department, 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 RNs are assigned to the inpatient pediatric patient, i.e., only RNs who have completed the PALS course.

 

3.         Documented description 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.  Are there guidelines in place that define pediatric patients specifically by age parameters 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.  

•           Identify any board certification as outlined in the Facility Recognition Criteria (Sections 515.4000 and 515.4010).

 

b.         Document Board Certification, as identified in the Facility Recognition Criteria, on the Emergency Department Credentialing Form.

 

2.         Emergency Department Physicians

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

 

Hospital 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 (including fast track/urgent care area).

•           Provide a completed Department approved credentialing form for emergency department physician staff and a credentialing form for fast track/urgent care physicians.

•           Provide a one-month staffing schedule/calendar, including fast track/urgent care area (schedule should be from within the three month time period previous to the application submission).

•           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).

 

Hospital 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).

 

Hospital 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).

 

Hospital 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 three month time period previous to the application submission).

 

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

 

•           Provide a copy of a policy that identifies physician back-up availability to assist with critical situations, increased surge capacity or disasters.

 

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

 

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

 

3.         Emergency department nurse practitioner, clinical nurse specialist, and PA

Note – Complete this section only if nurse practitioners, clinical nurse specialists, or PAs practice in the emergency department and participate in the care of pediatric patients.

 

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

 

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

 

•           Provide a policy of emergency department nurse practitioner, clinical nurse specialist, and PA staffing, coverage, availability, responsibilities and credentialing process.

•           Provide a completed Department approved credentialing form for all emergency department fast track nurse practitioner, clinical nurse specialist, and PA staff.

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

•           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).

 

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

 

•           Provide a copy of the emergency department and fast track nurse practitioner, clinical nurse specialist, and PA continuing education policy.

•           Provide a description of how nurse practitioner, clinical nurse specialist, and PA 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).

 

4.         Emergency Department Registered Nurses

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

 

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

 

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

•           Provide a Department approved credentialing form for all emergency department nursing staff.

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

•           Provide documentation of a plan to maintain PALS, APLS or ENPC recognition.

•           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 an 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).

 

E.         Policies and Procedures

 

1.         Policy/procedure for inter-facility transfer as identified in Section 515.4000(d)(1) or 515.4010(d)(1).

 

•          Provide a written transfer agreement with a Pediatric Critical Care Center and identification of facilities to which the hospital typically transfers pediatric patients. The transfer agreements shall include a provision that addresses communication and quality improvement measures between the referral and receiving hospitals, as related to patient stabilization, treatment prior to and subsequent to transfer, and patient outcome.

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

 

2.         Policy/procedure for suspected child abuse and neglect as identified in Section 515.4000(d)(2) or 515.4010(d)(2).

 

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

 

3.         Pediatric treatment guidelines as identified in Section 515.4000(d)(3) or 515.4010(d)(3).

 

•           Provide copies of pediatric specific treatment guidelines as described.

•           The hospital shall have emergency department pediatric specific treatment guidelines, order sets or policies and procedures addressing initial assessment and management for its high-volume and high-risk pediatric population (i.e., fever, trauma, respiratory distress, seizures).

 

4.         Policy for latex allergy as identified in Section 515.4000(d)(4) or 515.4010(d)(4).

 

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

 

F.         Quality Improvement

 

1.         Describe and document the ongoing 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, required clinical indicators, "loop closure" and target time frames for closure of issues.

•          Provide documentation outlining current and planned pediatric monitoring activities.

 

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

 

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

 

•           Define the composition of the multidisciplinary QI 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 a copy of the emergency department quality improvement plan, including QI policy, pediatric indicators, feedback loop and target time frames for closure of issues. If implementation of pediatric monitoring activities is pending, define implementation plan and time frame.

 

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

 

•           Provide a curriculum vitae for the physician who will assume the pediatric physician champion role.

•           Provide the name and title of the individual who will assume the pediatric quality coordinator role.

•           Provide a job description that addresses allocation of time and resources to the role and includes each of the requirements outlined in Section 515.4000(e)(2) or 515.4010(e)(2) that will be carried out by the pediatric quality coordinator.

 

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 shall be identified, i.e., submission of a purchase order to assure that the item is on order, or equipment waiver shall be submitted for each item.

 

Requests for equipment waivers shall include the criteria by which compliance is considered to be a hardship and shall demonstrate that there will be no reduction in the provision of medical care.

 

Site Survey Procedure

 

1)         Within four to six 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 and 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 nursing executive/director of nursing or designee

 

c)         The chief of pediatrics or, if the hospital does not have a pediatric department, the designated pediatric consultant

 

d)         The nursing director or nursing manager of the pediatric unit, if applicable

 

e)         The emergency department medical director or pediatric emergency department medical director

 

f)         The emergency department nursing director or nursing manager

 

g)         The administrator of emergency services

 

h)         The administrator of pediatric services, if applicable

 

i)          The pediatric quality coordinator

 

j)          The hospital quality improvement director or designee

 

k)         The hospital emergency management/disaster preparedness coordinator

 

l)          Nurse practitioner, clinical nurse specialist, or PA, for those hospitals that use these clinicians in their emergency department

 

m)        For EMS Resource or Associate 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 hospital recognition requirements.

 

Site Survey Team

The EMSC program within the Division of EMS & Highway Safety will appoint the survey team.  Site survey teams will be composed of a physician/nurse (or two 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 four to six weeks following the site visit, the Department will provide the hospital with the results of the survey. Those hospitals meeting all requirements will receive a formal "recognition" for their emergency department pediatric capabilities. 

 

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)         Re-recognition shall occur every four years, with site visits scheduled as necessary.

 

(Source:  Amended at 44 Ill. Reg. 15619, effective September 4, 2020)