Ga. Comp. R. & Regs. 111-8-40-.31

Current through Rules and Regulations filed through October 29, 2024

Rule 111-8-40-.31 - Emergency Services

The hospital shall provide, within its capabilities, services to persons in need of emergency care.

(a)Full-time Emergency Services. If the hospital offers emergency care as an organized service and/or holds itself out to the public as offering emergency services, the service shall be included in the scope of services submitted with the application for the hospital permit and shall be offered twenty-four (24) hours per day.

1.Organization. Supervision and organization of emergency services shall be under the direction of a qualified member of the medical staff.

(i) The director shall be responsible for the development of policies and procedures related to emergency services and the review and update of policies as necessary. The policies and procedures shall be approved by appropriate members of the medical staff.

(ii) The director shall implement systems to assess the effectiveness of the emergency service and to address improvement issues through the hospital's quality management program.

(iii) Staffing assignments shall provide for sufficient nursing, medical, and technical staff to meet the anticipated needs of emergency patient care. There shall be available to emergency room staff procedures for accessing additional staff on an as-needed basis to meet unanticipated needs.

(iv) Patient care responsibilities for emergency services staff shall be specified by written policies and procedures, which shall include training and experience requirements appropriate to the assigned responsibilities and clearly defined lines of authority.

2.Delivery of Services. When the hospital provides emergency services, the services shall comply with the following:

(i) Policies and procedures for processing patients presenting for emergency care shall be in writing and shall include the procedures for initial patient assessment, prioritization for medical screening and treatment, and patient reassessment and monitoring.

(ii) There shall be a central log of all patients presenting for emergency care, with the presenting complaint and the level of acuity or triage documented. Entries in the log must be retrievable by the date and time the patient presents for treatment;

(iii) An emergency medical record shall be maintained for each patient which includes all assessment and treatment information about the patient from the time of presentation until the time of discharge or transfer;

(iv) Written protocols and standards of practice to guide emergency interventions by non-physician staff shall be available in the emergency services area;

(v) A licensed physician shall be available to cover basic emergency room services either on-site or by telephone. Where the licensed physician is providing such coverage by telephone, the physician must be able to arrive in the emergency room within thirty (30) minutes of the need for physician services having been determined;

(vi) The emergency services area shall have operable equipment and sufficient and appropriate supplies and medications to support emergency care for patients of all ages, including at least:

(I) An emergency call system;

(II) Oxygen;

(III) Manual breathing bags and masks;

(IV) Cardiac monitoring and defibrillator equipment;

(V) Laryngoscopes and endotracheal tubes;

(VI) Suction equipment; and

(VII) Emergency drugs and supplies as specified by the medical staff;

(vii) The hospital shall integrate functions of the emergency services with other services of the hospital to ensure appropriate patient care and treatment including those patients awaiting admission or transfer to another facility, placement in a hospital bed, or transfer to another facility;

(viii) Policies and procedures shall be developed and implemented for the appropriate transfer of emergency patients to other facilities or other areas of the hospital when appropriate;

(ix) The hospital shall have policies and procedures for the management of mass casualty situations which may require the coordination of the hospital's emergency services with other facilities, the local Emergency Management Agency (EMA), and local ambulance service providers;

(x) Emergency Services Where Maternity Services Are Customarily Offered. In addition to applicable federal laws regarding the treatment of persons requesting treatment for emergency medical conditions that are enforced by the federal government, state law requires any hospital which operates an emergency service to provide appropriate and necessary emergency services to any pregnant woman who is a resident of this state and who presents herself in active labor, to the hospital, if those services are usually and customarily provided in that facility. Such services shall be provided within the scope of generally accepted practice based upon the information furnished the hospital by the pregnant woman, including such information as the pregnant woman reveals concerning her prenatal care, diet, allergies, previous births, general health information, and other such information as the pregnant woman may furnish the hospital. If, in the medical judgment of the physician responsible for the emergency service, the hospital must transfer the patient because the hospital is unable to provide appropriate treatment, the hospital shall provide appropriate treatment as set forth in O.C.G.A. § 31-8-42; and

(xi) Diversion Status - Inability to Deliver Emergency Services. The hospital shall develop and implement a diversion policy in consultation with the medical staff which describes the process of handling those times when the hospital must temporarily divert ambulances from transporting patients requiring emergency services to the hospital. The policy must include the following: when diversion is authorized to be called, who is authorized to call and discontinue diversion, efforts the hospital will make to minimize the usage of diversion, and how diversion will be monitored and evaluated. In connection with going on diversion status, the hospital shall:

(I) Notify the ambulance zoning system when it is temporarily unable to deliver emergency services and is declaring itself on diversion;

(II) Notify the ambulance zoning system when diversion status is no longer determined to be necessary; and

(III) Monitor and evaluate its usage of diversion status and make changes within its control to minimize the use of diversion status.

(b)Hospitals Without Organized Emergency Services. Hospitals not providing an organized emergency service shall have current policies and procedures and sufficient qualified staff to provide for the appraisal and initial treatment of any patients or persons presenting with an emergency medical or psychiatric condition, within the capabilities of the hospital, and for referral of the patient for further treatment when appropriate.

Ga. Comp. R. & Regs. R. 111-8-40-.31

O.C.G.A. §§ 31-7-2.1, 31-7-3.1, 31-8-42 and 31-11-82.

Original Rule entitled "Emergency Services" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.