Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart K - COMPREHENSIVE STROKE CENTERS, PRIMARY STROKE CENTERS AND ACUTE STROKE-READY HOSPITALS › Appendix K - Application for Facility Recognition for Emergency Department with Pediatrics Capabilities

Current through Register Vol. 48, No. 28, July 12, 2024
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. 5th
				  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/AdministratorDate
____________________________________________________________________
Typed name - Medical Director of Emergency
				  Services
____________________________________________________________________
Signature - Medical Director of Emergency
				  ServicesSignature -
				  CEO/AdministratorDate
____________________________________________________________________
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.