Section 515.APPENDIX O Pediatric Critical Care Center Plan

I. PEDIATRIC CRITICAL CARE CENTER PLAN

Application Checklist

Instructions: Please follow and complete this checklist carefully. It outlines the components that must be included in the submitted plan. Please include any applicable supplemental documentation.

A. Organizational Structure

1. Enclosed is an organizational table identifying the administrative relationships among all departments in the hospital, especially as they relate to the pediatrics department. The table shall include, but is not limited to, the following:

board of directors

chief executive officers

emergency department

department of pediatrics

pediatric ambulatory care

trauma service

department of radiology

laboratory services

transport service team

social services

2. Enclosed is an organizational table showing the organizational structure of the department of pediatrics, including the relationship of the physician, nursing and ancillary services for both the PICU and pediatric units. Include the reporting structure for the pediatric chairman (to whom he/she reports).

Department of Pediatrics Organizational Structure (Table)

3. Enclosed is an organizational table showing the organizational structure of the emergency department, including the relationship of the physician, nursing and ancillary services. Include the reporting structure for the emergency department director (to whom he/she reports).

Emergency Department Organizational Structure (Table)

EDAP Checklist

Review the criteria in Section 515.4000(a)(1) and (2) for the physician staff qualifications and continuing medical education and submit each of the following:

A policy or medical staff bylaws that incorporate the physician qualifications and CME requirements.

A completed Credentials of Emergency Department Physicians form

A completed Credentials of Fast Track Physicians form

The curriculum vitae for the ED medical director

A current one-month physician schedule for the ED

Review the criteria in Section 515.4000(a)(3) for the ED physician coverage and submit a policy that addresses this requirement.

Review the criteria in Section 515.4000(a)(4) for ED consultation and submit a one-month on-call schedule identifying availability of board certified/board prepared pediatricians or pediatric emergency medicine physicians.

Review the criteria in Section 515.4000(a)(5) for ED physician back-up and submit a policy that addresses this requirement.

Review the criteria in Section 515.4000(a)(6) for all on-call specialty physician response time and submit a policy that addresses this requirement.

Review the criteria in Section 515.4000(b)(1) and (2) for nurse practitioner and physician assistant qualifications and continuing medical education and submit the following (as applicable):

A policy(s) that incorporates the mid-level provider qualifications and continuing education requirements

A completed Credentials of Emergency Department and Fast Track Nurse Practitioner, Clinical Nurse Specialist, and Physician Assistant form

A current one-month schedule for the emergency department and fast track area as applicable.

Review the criteria in Section 515.4000(c)(1) and (2) for nursing qualifications and continuing education and submit the following:

A policy that incorporates the nursing qualifications and CE requirements

A completed Credentials of Emergency Department Nursing Staff form

A one-month nurse staffing schedule for the emergency department

Review the criteria in Section 515.4000(d)(1) for inter-facility transfer and submit the following:

An inter-facility transfer policy that addresses pediatric transfers

A copy of current pediatric-specific transfer agreements with hospitals that provide pediatric specialty services, pediatric intensive care and burn care not available at your facility

Review the criteria in Section 515.4000(d)(2) for suspected child abuse and neglect and submit a policy that addresses this requirement.

Review the criteria in Section 515.4000(d)(3) for treatment protocols and submit all pediatric treatment protocols.

Review the criteria in Section 515.4000(d)(4) for latex allergy policy and submit a policy that addresses latex allergies and the availability of latex-free equipment and supplies.

Review the criteria in Section 515.4000(d)(5) for disaster preparedness and submit a completed pediatric disaster preparedness checklist.

Review the criteria in Section 515.4000(e)(1) for quality improvement activities and the multidisciplinary quality improvement committee and submit the following:

A quality improvement plan, including a QI policy, pediatric indicators, feedback loop and target time frames for closure of issues

The composition of the multidisciplinary QI committee

Review the criteria in Section 515.4000(e)(2) and (3) for the pediatric physician champion and the pediatric quality coordinator responsibilities and submit the following:

A curriculum vitae for the pediatric physician champion

A curriculum vitae and job description for the pediatric quality coordinator

Documentation detailing the participation of the pediatric quality coordinator in regional QI activities and how that has affected pediatric quality care in the ED

Review the criteria in Section 515.4000(f) for the list of emergency department equipment requirements and submit a completed checklist indicating the availability of all equipment.

Indicate in the pediatric plan whether each item is currently available. If equipment/supply items are not available, a plan for securing the items shall be identified (e.g., submission of a purchase order to assure that the item is on order) or an equipment waiver request shall be submitted for each item. Requests for waiver 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.

B. PCCC Checklist

1. Hospital Requirements

Review the criteria in Section 515.4020(a) of the PCCC requirements as related to hospital resources and submit documentation identifying the ability to meet each of the following:

A scope of services/policy outlining PICU services, unit resources and capabilities. Include any guidelines that outline pediatric admission criteria based on age parameters and diagnoses

A list of the members of the PICU Committee, as well as their disciplines, to meet subsection (a)(3)

Documentation to substantiate that Section 515.4020(a)(4) (Helicopter landing) is met

A statement regarding 24-hour availability to meet Section 515.4020(a)(5) (CAT scan)

A statement regarding the ability to meet Section 515.4020(a)(6) (Laboratory)

A statement of availability or transfer agreement to meet Section 515.4020(a)(7) (Hemodialysis capabilities)

A statement or scope of service from each program identifying the availability of staff as required in Section 515.4020(a)(8) (Other staffing/services)

A list of professional pediatric critical care educational trainings that staff have provided in the past year to meet Section 515.4020(a)(9) (include information on trainings held within the facility, within the region or surrounding geographic area)

A list of pediatric emergency care classes that staff have provided in the past year to meet Section 515.4020(a)(10) (i.e., CPR, first aid, health fairs, etc., conducted for the patient population and the community, region or surrounding geographic area)

Documentation of any pediatric research the facility has been engaged in during the past year to meet Section 515.4020(a)(11) (include the research project abstract, summary of projects or listing of research activities)

II. PICU SERVICE REQUIREMENTS

A. Professional Staff

1. PICU Medical Director

Review the criteria in Section 515.4020(b) for the Medical Director and Co-Director requirements and submit each of the following:

A curriculum vitae for the appointed PICU medical director

A copy of board certification or verification of board certification

A curriculum vitae and board certification for the co-director (as applicable − see Section 515.4020(b)(1)

2. PICU Medical Staff Requirements

Review the criteria in Section 515.4020(c) and submit each of the following:

PICU Medical Staff

A policy outlining PICU physician staffing, coverage, availability, and CME requirements that incorporates Section 515.4020(c)(1)(A) and (B)

A completed Credentials of PICU Physicians form that includes the medical director (and co-director as applicable)

A one-month staffing schedule/calendar (schedule should be from within the three-month time period previous to the application submission)

Physician Specialist Availability (Section 515.4020(c)(2))

A policy or by-laws that address the response time and on-call scheduling of pediatric surgeons

A policy/process outlining board or sub-board certification or board preparedness for all specialist physicians

A policy/process outlining how pediatric proficiency is defined and assuring that all specialist physicians maintain 10 hours of pediatric CME per year

A policy/process outlining anesthesiologist on-call staffing and response time, subspecialty training in pediatric anesthesiology or pediatric proficiency as defined by institution, and 10 hours of pediatric CME per year; for Certified Registered Nurse Anesthetists, provide a copy of the by-laws that address their responsibilities and back up

On-call schedules from the last month that list physician availability to meet Section 515.4020(c)(2)(C) and (D)

3. PICU Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant Requirements

NOTE – Complete this section only if physician assistants, clinical nurse specialists, or nurse practitioners practice in the PICU.

Review the criteria in Section 515.4020(d) and submit each of the following:

Nurse Practitioner (Section 515.4020(d)(1))

A policy outlining PICU nurse practitioner staffing, coverage, availability, responsibilities and credentialing process

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

A completed Credentials of PICU Nurse Practitioner, Clinical Nurse Specialist, and Physician Assistant form

Clinical Nurse Specialist (Section 515.4020(d)(2))

A policy outlining PICU clinical nurse specialist staffing, coverage, availability, responsibilities and credentialing process

A copy of a one-month staffing schedule or calendar (schedule should be from within the three-month time period previous to the application submission)

A completed Credentials of PICU Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant form

Physician Assistant (Section 515.4020(d)(3))

A policy outlining PICU physician assistant staffing, coverage, availability, responsibilities and credentialing process

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

A completed Credentials of PICU Nurse Practitioner, Clinical Nurse Specialist, and Physician Assistant form

Education (Section 515.4020(d)(4) and (54))

A policy that incorporates APLS, PALS or ENPC (Section 515.4020(d)(3))

A copy of the PICU nurse practitioner, clinical nurse specialist, and physician assistant continuing education policy that incorporates Section 515.4020(d)(4)

4. PICU Nursing Staff Requirements

Review the criteria in Section 515.4020(e) and submit each of the following:

PICU Nurse Manager

A curriculum vitae for the PICU manager

A policy or job description that incorporates Section 515.4020(e)(1)(C)

PICU Pediatric Clinical Nurse Expert

A policy or job description of the role and responsibilities of the pediatric clinical nurse expert in the PICU

A resume of the PICU pediatric clinical nurse expert

A policy that incorporates Section 515.4020(e)(2)(C) and (D)

Nursing Patient Care Services

A policy/documentation outlining current nursing shift staffing plan/patterns

A completed Credentials of PICU Nursing Staff form that includes the PICU nurse manager and PICU pediatric clinical nurse expert

A policy or job description for the PICU nurse that outlines the orientation process to the unit responsibilities and requirements of the Department (Section 515.4020(e)(3)(C) and (D))

A copy of a one-month nurse staffing schedule/calendar (schedule shall be from within the three-month time period previous to the application submission)

A policy reflecting yearly competency review requirements for the PICU staff

D. Policies, Procedures and Treatment Protocols

Review the criteria in Section 515.4020(f) and submit each of the following:

An admission and discharge criteria policy

A staffing policy that addresses nursing shift staffing patterns based on patient acuity

A policy for managing the psychiatric needs of the PICU patient

Protocols, order sets, pathways or guidelines for management of high- and low- frequency diagnoses

E. Inter-facility Transfer/Transport Requirements

Review the criteria in Section 515.4020(g) and submit each of the following:

A copy of the last annual report containing the number of annual transfers to the facility from transferring institutions

A policy outlining the feedback process to transferring hospitals on the status of the referral patient and the methods for quality review of the transfer process

Documentation outlining the pediatric inter-facility transport system capabilities and resources

A transfer policy that addresses pediatric inter-facility transfers

F. Quality Improvement Requirements

Review the criteria in Section 515.4020(h) and submit each of the following:

A list of the members of the Multidisciplinary Pediatric Quality Improvement Committee and their respective positions/disciplines

An institutional Quality Improvement Organizational Chart

The PICU outcome analysis plan and pediatric monitoring activities that meet Section 515.4020(h)(2) (minutes from the past year that reflect the activities of the Multidisciplinary Pediatric Quality Improvement Committee will be requested at the time of site survey)

G. Equipment

Review the criteria in Section 515.4020(i) and submit the following:

Indicate in the Pediatric Plan whether each item is currently available. If equipment/supply items are not available, a plan for securing the items shall be identified (e.g., submission of a purchase order to assure that the item is on order); if the item is not on order, an equipment waiver request shall be submitted for each item. Requests for an equipment waiver 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.

III. PEDIATRIC INPATIENT CARE SERVICE REQUIREMENTS

A. Professional Staff

1. Pediatric Unit Physician Requirements

Review the criteria in Section 515.4020(j) and submit each of the following:

A curriculum vitae and a copy of board certification for the pediatric inpatient director

A policy or a scope of services for the pediatric unit that defines responsibility for medical management of care

If pediatric hospitalists are used, documentation that defines their scope of service, including their responsibilities to other attending physicians

A completed Credentials of Pediatric Unit Hospitalists form

A policy that incorporates Section 515.4020(j)(1)(B)

A policy or scope of services outlining the responsibility of the PICU medical director or his/her designee as being available on call and for consultation on all pediatric in-house patients who may require critical care

2. Pediatric Unit Nurse Manager Requirements

Review the criteria in Section 515.4020(j)(2) and submit each of the following:

A curriculum vitae for the pediatric unit manager

A job description or policy incorporating Section 515.4020(j)(2)(C)

3. Pediatric Unit Nursing Care Services

Review the criteria in Section 515.4020(j)(3) and submit each of the following:

A policy/documentation outlining current nursing shift staffing plan/patterns

A policy describing annual competency review requirements for the pediatric nursing staff (Section 515.4020(j)(3)(B))

A policy or job description for the pediatric unit nurse that outlines the orientation process to the unit responsibilities and requirements of the Department that address Section 515.4020(j)(3)(A) through (D)

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

A completed Credentials for the Pediatric Unit Nursing Staff form that includes the Pediatric Unit Nurse Manager

B. Policies, Procedures and Treatment Protocols

Review the criteria in Section 515.4020(k) and submit each of the following:

A policy or scope of services that outlines the pediatric department services, ages of patients served and admission guidelines

A staffing policy that addresses nursing shift staffing patterns based on patient acuity

A safety and security policy for the patient in the unit

An inter-facility transport policy that addresses safety and acuity

An intra-facility transport policy that addresses safety and acuity

A latex allergy policy

A pediatric organ procurement/donation policy

An isolation precautions policy that incorporates appropriate infection control measures

A disaster policy that addresses the specific medical and psychosocial needs of the pediatric population

Protocols, order sets, pathways or guidelines for management of high- and low-frequency diagnoses

A pediatric policy that addresses the resources available to meet the psychosocial needs of patients and family, and appropriate social work referral for the following indicators (see Pediatric Bill of Rights in Appendix N):

• Child death

• Child has been a victim of or witness to violence

Family needs assistance in obtaining resources to take the child home

• Family needs a payment resource for their child's health needs

Family needs to be linked back to their primary health, social service or educational system

• Family needs support services to adjust to their child's health condition or the increased demands related to changes in their child's health condition

• Family needs additional education related to the child's care needs to care for the child at home

A discharge planning policy or protocol that includes the following:

1. Documentation of appropriate primary care/specialty follow-up provisions

2. Mechanism to access a primary care resource for children who do not have a provider

3. Discharge summary provision to appropriate medical care provider, parent/guardian, that includes:

• Information on the child's hospital course

• Discharge instructions and education

• Follow-up arrangements

4. Appropriate referral of patients to rehabilitation or specialty services for children who may have any of the following problems:

• Require the assistance of medical technology

• Do not exhibit age-appropriate activity in cognitive, communication or motor skills, behavioral or social/emotional realms

• Have additional medical or rehabilitation needs that may require specialized care, such as medication, hospice care, physical therapy, home health or speech/language services

• Have a brain injury – mild, moderate or severe

• Have a spinal cord injury

• Exhibit seizure behavior during an acute care episode or have a history of seizure disorder and are not currently linked with specialty follow-up

• Have a submersion injury, such as a near drowning

• Have a burn (other than a superficial burn)

• Have a pre-existing condition that experiences a change in health or functional status

• Have a neurological, musculoskeletal or developmental disability

• Have a sudden onset of behavioral change, for example, in cognition, language or affect

C. Quality Improvement Requirements

Review the criteria in Section 515.4020(l) and submit the following:

The titles of the pediatric unit representatives that serve on the Multidisciplinary Pediatric Quality Improvement Committee

D. Equipment Requirements

Review the criteria in Section 515.4020(m) and submit the following:

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