Current through Register Vol. 48, No. 12, March 22, 2024
a)
The
Department shall investigate the circumstances that caused a hospital in an EMS
System to go on bypass status to determine whether that hospital's decision to
go on bypass status was reasonable. (Section
3.20(c) of the
Act)
b) The hospital shall notify
the Illinois Department of Public Health, Division of Emergency Medical
Services, of any bypass/resource limitation decision, at both the time of its
initiation and the time of its termination, through status change updates
entered into the Illinois EMResource application, accessed at
https://emresource.juvare.com/login.
The hospital shall document any inability to access EMResource by contacting
IDPH Division of EMS during normal business hours.
c) In determining whether a hospital's
decision to go on bypass/resource limitation status was reasonable, the
Department shall consider the following:
1)
The number of critical or monitored beds available in the hospital at the time
that the decision to go on bypass status was made;
2) Whether an internal disaster, including,
but not limited to, a power failure, had occurred in the hospital at the time
that the decision to go on bypass status was made;
3) The number of staff after attempts have
been made to call in additional staff, in accordance with facility policy;
and
4) The approved hospital
protocols for peak census, surge, and bypass and diversion at the time that the
decision to go on bypass status was made, provided that the Protocols include
subsections (c)(1), (2) and (3).
5)
Bypass status may not be honored or deemed reasonable if three or more
hospitals in a geographic area are on bypass status and/or transport time by an
ambulance to the nearest facility is identified in the regional bypass plan to
exceed 15 minutes.
d)
Hospital diversion should be based on a significant resource limitation and may
be categorized as a System of Care (STEMI or Stroke), or other EMS transports.
The decision to go on bypass (or resource limitation) status shall be based on
meeting the following two criteria, and compliance with subsection (c)(3).
1) Lack of an essential resource for a given
type or class of patient (i.e. Stroke, STEMI, etc.) Examples include, but are
not limited to:
A) No available or monitored
beds within traditional patient care and surge patient care areas with
appropriate monitoring for patient needs;
B) Unavailability of trained staff
appropriate for patient needs; and/or
C) No available essential diagnostic and/or
intervention equipment or facilities essential for patient needs.
2) All reasonable efforts to
resolve the essential resource limitations have been exhausted including, but
not limited to:
A) Consideration for using
appropriately monitored beds in other areas of the hospital;
B) Limitation or cancellation of elective
patient procedures and admissions to make available surge patient care space
and redeploy clinical staff to surge patients;
C) Actual and substantial efforts to call in
appropriately trained off-duty staff; and
D) Urgent and priority efforts have been
undertaken to restore existing diagnostic and/or interventional equipment or
backup equipment and/or facilities to availability, including but not limited
to seeking emergency repair from outside vendors if in house capability is not
rapidly available.
3)
The hospital will do constant monitoring to determine when the bypass condition
can be lifted. Such monitoring and decision making shall include clinical and
administrative personnel with adequate hospital authority. Efforts to resolve
issues in subsection (d)(1) using all available resource under subsection
(d)(2) to come off bypass as soon as such patients can be safely
accommodated.
e) For
Trauma Centers only, the following situations would constitute a reasonable
decision to go on bypass status:
1) All
staffed operating suites are in use or fully implemented with on-call teams,
and at least one or more of the procedures is an operative trauma
case;
2) The CAT scan is not
working; or
3) The general bypass
criteria in subsection (c).
f) During a declared local or state disaster,
hospitals may only go on bypass status if they have received prior approval
from IDPH. Hospitals must complete or submit the following prior to seeking
approval from IDPH for bypass status:
1)
EMResource must reflect current bed status;
2) Peak census policy must have been
implemented 3 hours prior to the request of bypass;
3) Hospital and staff surge plans must be
implemented;
4) The following
hospital information shall be provided to IDPH:
A) Number of hours for in-patient holds
waiting for bed assignment;
B)
Longest number of hours wait time in Emergency Department;
C) Number of patients in waiting area waiting
to be seen;
D) In-house open beds
that are not able to be staffed;
E)
Percent of beds occupied by in-patient holds;
F) Number of potential in-patient discharges;
and
G) Number of open ICU
beds.
5) The IDPH
Regional EMS Coordinator will review the above information along with hospital
status in the region and determine whether to approve bypass for 2 hours, 4
hours, or an appropriate length of time as determined by the DPH Regional EMS
Coordinator, or to deny the bypass request. A by pass request may be extended
based on continued assessment of the situation, including status of surrounding
hospitals, with the DPH Regional EMS Coordinator and communication with the
requesting hospital. A hospital may be denied bypass based on regional status
or told to come off bypass if an additional hospital in the geographic area
requests bypass.
g)
The Department may impose sanctions, as set forth in Section
3.140 of the Act, upon a
Department determination that the hospital unreasonably went on bypass status
in violation of the Act. (Section
3.20(c) of the
Act)
h) Each EMS System shall
develop a policy addressing response to a system-wide crisis.