New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 12 - EMERGENCY DEPARTMENT AND TRAUMA SERVICES › Section 8:43G-12.2 - Emergency department policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The emergency
				department shall have written policies and procedures for medical, trauma, and
				pediatric patients, that are reviewed at least once every three years, revised more
				frequently as needed, and implemented.
(b) Each hospital shall develop and implement
				policies and procedures for the evaluation and treatment by qualified medical
				personnel of all patients who come to the emergency department. An advanced practice
				nurse functioning as qualified medical personnel evaluating and treating patients in
				the emergency department shall establish and maintain a collaborative relationship,
				described in these policies and procedures, with an emergency physician regularly
				practicing in that hospital's emergency department. A physician assistant
				functioning as qualified medical personnel evaluating and treating patients in the
				emergency department shall be supervised by an emergency physician regularly
				practicing in that hospital's emergency department. Emergency physicians shall meet
				the qualifications required in
				8:43G-12.3(b).
(c) There shall be a transfer protocol that
				governs interhospital transfers of patients, including but not limited to pediatric
				and trauma patients, in need of specialized care not provided in the hospital.
				Transfer protocols for trauma patients shall be in accordance with
				8:43G-12.15(c) through
				(g).
(d) The emergency department shall have a written
				protocol that governs the management of psychiatric patients who require special
				services not available in the hospital. This protocol addresses the roles and
				involvement of hospital health professionals, social work services, law enforcement
				officials, and mental health services, when indicated.
(e) The emergency department shall have a written
				protocol that addresses the ability of family members and significant others to
				remain with patients during treatment. The protocol shall also address the special
				needs of patients who are unable to communicate for reasons of language, disability,
				age, or level of consciousness.
(f) The
				emergency department shall have a written protocol that governs referrals if a
				clinical speciality service is not available.
(g) The emergency department shall have policies
				to ensure compliance with regulations at
				42 CFR
				489.24 and
				42
				CFR 489.20 requiring examination and treatment for
				emergency conditions and women in labor.
(h) The emergency department shall have written
				policies for airway maintenance, adult and pediatric sedation, analgesia, and rapid
				sequence intubation.
(i) The hospital
				shall maintain a trauma registry in accordance with
				8:43G-12.21(a) through
				(c).
(j) The hospital shall develop and implement
				written policies and procedures to support breastfeeding mothers in the emergency
				department.
1. These policies and procedures shall
				require responsible staff to:
i. Determine whether
				a woman who presents for treatment at the emergency department is
				breastfeeding;
ii. Facilitate the
				expression, storage, and use of the breast milk from the mother, as
				necessary;
iii. Document the findings in
				(j)1i and ii above in the medical record as soon as possible or before the woman is
				released from the emergency department area; and
iv. Review these policies and procedures every
				three years and revise at any time as necessary.