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 O - Pediatric Critical Care Center Plan

Current through Register Vol. 48, No. 28, July 12, 2024
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:
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.