POLICIES AND PROCEDURES
§ 117.41. Emergency patient care.
(a) Emergency patient care shall be guided by written policies and procedures which delineate the proper administrative and medical procedures and methods to be followed in providing emergency care. These policies and procedures shall be clear and explicit; approved by the medical staff and hospital governing body; reviewed annually; revised as necessary; and dated to indicate the date of the latest review or revision, or both.
(b) Policies and procedures for emergency patient care should, at a minimum, do the following:
(1) Provide for the admission of a patient if, in the judgment of the physician, admission is warranted.
(2) Provide for the referral and placement of patients whose needs cannot be met by the hospital.
(3) Establish procedures to minimize the possibility of cross-infection and contamination.
(4) Provide for the discharge of patients only upon written orders of a physician. Telephone discharge orders may be accepted in accordance with § 107.62 (relating to oral orders).
(5) Specify explicitly the location and mode of storage of medications, supplies and special equipment.
(6) Establish methods for 24-hour-a-day procurement of equipment and drugs.
(7) Establish procedures for notification of the personal physician of the patient and the transmission of relevant reports to the physician.
(8) Establish procedures on disclosure of patient information. Policies on confidentiality of emergency room records must be the same as those which apply to other hospital medical records. The identity and the general condition of the patient may be released to the public after the next of kin have been notified.
(9) Plan for communication with police, local or State health or welfare authorities as appropriate, regarding accident victims and patients whose condition or its cause is reportable, for example, persons having contagious diseases or victims of suspected criminal acts such as sexual assault or gunshot wounds, see 18 Pa.C.S. § 5106 (relating to failure to report injuries by firearm or criminal act), and child abuse, see 23 Pa.C.S. Chapter 63 (relating to Child Protective Services).
(10) Instruct personnel in special procedures for handling persons who are mentally ill, under the influence of drugs or alcohol, victims of suspected criminal acts or contaminated by radioactive material or who otherwise require special care or have other conditions requiring special instructions.
(11) Instruct personnel how to deal with patients who are dead on arrival.
(12) Provide for a review by the appropriate committee of the medical staff of each death occurring on the emergency service or, if there is no service, of each death occurring during the performance of essential life-saving measures prior to transfer to another facility.
(13) Explain the role of the emergency service in the hospital’s disaster plan established in accordance with Chapter 151 (relating to fire, safety and disaster services).
(14) Delineate medical staff obligations for emergency patient care.
(15) Specify which procedures may not be performed in the emergency area.
(16) Provide for appropriate utilization of any beds used for observation.
(17) Establish procedures to be used when the patient is required to return to the hospital for treatment, for example, when treatment is impossible to arrange otherwise.
(18) Establish procedures for early transfer of severely ill or injured patients to special treatment areas within the hospital, such as the surgical suite, the intensive care unit or the cardiac care unit.
(19) Delineate instructions to be given to a patient or the patient’s family, or both, or others as appropriate regarding follow-up care.
(20) Make available to the emergency service current toxicological reference material along with the telephone numbers of the regional poison control center.
(21) Provide for the ready availability of reference materials and charts relating to the initial treatment of burns, cardiopulmonary resuscitation and tetanus immunization.
(22) Provide for effective coordination with outpatient services, where these services are provided.
(23) Establish procedures to clearly inform patients of emergency service billing policies, including prominent display of that information in the emergency service area. This information must indicate whether patients are to be billed separately for physicians’ services and other emergency services. Those hospitals having an obligation under section 2 of the Hospital Survey and Construction (Hill-Burton) Act (42 U.S.C.A. § § 291—291o), shall comply with the provisions of that act as it relates to free and low-cost care.
Authority The provisions of this § 117.41 issued under 67 Pa.C.S. § § 6101—6104 (Repealed); and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2) (Renumbered); amended under sections 102, 201(12), 801.1 and 803(2) of the Health Care Facilities Act (35 P. S. § § 448.102, 448.201(12), 448,801a and 448.803(2)); and under section 2102(a) and (g) of The Administrative Code of 1929 (71 P. S. § 532(a) and (g)).
Source The provisions of this § 117.41 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761; amended January 25, 2008, effective January 26, 2008, 38 Pa.B. 573. Immediately preceding text appears at serial pages (240222) to (240224).
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