Rules & Regulations of the State of Tennessee
Title 0720 - Health Facilities Commission
Chapter 0720-31 - Standards for Pediatric Emergency Care Facilities
Section 0720-31-.05 - BASIC FUNCTIONS

(a) In a Basic Pediatric Emergency Facility an on-call physician shall be promptly available and provide direction for the in-house nursing staff. The physician shall be competent in the care of pediatric emergencies including the recognition and management of shock and respiratory failure, the stabilization of pediatric trauma patients, advanced airway skills (intubation, needle thoracostomy), vascular access skills (including intraosseous needle insertion), and be able to perform a thorough screening neurologic assessment and to interpret physical signs and laboratory values in an age-appropriate manner. For physicians not board-certified/prepared by the American Board of Emergency Medicine, successful completion of courses such as Pediatric Advanced Life Support (PALS) or the American Academy of Pediatrics and American College of Emergency Physician's Advanced Pediatric Life Support (APLS) can be utilized to demonstrate this clinical capability. An on-call system shall be developed for access to physicians who have advanced airway and vascular access skills as well as for general surgery and pediatric specialty consultation. A back-up system must be in place for additional registered nurse staffing for emergencies.

(b) A Primary or General Pediatric Emergency Facility shall have an emergency physician in-house 24 hours per day, 7 days per week. The emergency department physician shall be competent in the care of pediatric emergencies including the recognition and management of shock and respiratory failure, the stabilization of pediatric trauma patients, advanced airway skills (intubation, needle thoracostomy), vascular access skills (including intraosseous needle insertion), and be able to perform a thorough screening neurologic assessment and to interpret physical signs and laboratory values in an age-appropriate manner. For physicians not board-certified board prepared by the American Board of Emergency Medicine, successful completion of courses such as Pediatric Advanced Life Support (PALS) or the American Academy of Pediatrics and American College of Emergency Physician's Advanced Pediatric Life Support (APLS) can be utilized to demonstrate this clinical capability. A pediatrician or family practitioner, general surgeon with trauma experience, anesthetist/anesthesiologist, and radiologist shall be promptly available 24 hours per day.

(c) A General Pediatric Emergency Facility shall have a physician director who is board certified/admissible in an appropriate primary care board. A record of the appointment and acceptance shall be in writing. The physician director shall work with administration to assure physician coverage that is highly skilled in pediatric emergencies.

(d) In a Comprehensive Regional Pediatric Center, the emergency department medical director shall be board certified in pediatric emergency medicine or board admissible. A record of the appointment and acceptance shall be in writing.

(e) A Comprehensive Regional Pediatric Center shall have 24 hours ED coverage by physicians who are board certified in pediatrics or emergency medicine, and preferably board certified, board admissible, or fellows (second year level or above) in pediatric emergency medicine. The medical director shall work with administration to assure highly skilled pediatric emergency physician coverage. All physicians in pediatric emergency medicine shall participate on at least an annual basis, in continuing medical education activities relevant to pediatric emergency care.

(f) In a Comprehensive Regional Pediatric Center the pediatric intensive care unit shall have an appointed medical director. A record of the appointment and acceptance shall be in writing. Medical directors of the pediatric intensive care center shall meet one of the following criteria:

(g) The pediatric intensive care unit and ED medical director shall participate in developing and reviewing their respective unit policies, promote policy implementation, participate in budget preparation, help coordinate staff education, maintain a database which describe unit experience and performance, supervise resuscitation techniques, lead quality improvement activities and coordinate research.

(h) The pediatric intensive care unit medical director shall name qualified substitutes to fulfill his or her duties during absences. The pediatric intensive care unit medical director or designated substitute shall have the institutional authority to consult on the care of all pediatric intensive care unit patients when indicated. He or she may serve as the attending physician on all, some or none of the patients in the unit.

(i) The pediatric intensive care unit shall have at least one physician of at least the postgraduate year 2 level available to the pediatric intensive care units in-house 24 hours per day. All physicians in pediatric critical care shall participate on at least an annual basis, in continuing medical education activities relevant to pediatric intensive care medicine.

(j) Specialist consultants shall be board certified or board prepared and actively seeking certification in disciplines in which a specialty exists. A Comprehensive Regional Pediatric Center shall be staffed with specialist consultants with pediatric subspecialty training.

(a) Emergency staff in all facilities shall be able to provide information on patient encounters to the patient's medical home through telephone contact with the primary care provider at the time of encounter, by faxing or mailing the medical record to the primary care provider, or by providing the patient with a copy of the medical record to take to the physician. Follow-up visits shall be arranged or recommended with the primary care provider whenever necessary.

(b) In Basic Pediatric Emergency Facilities at least one RN or physician's assistant shall be physically present 24 hours per day, 7 days per week, and capable of recognizing and managing shock and respiratory failure and stabilizing pediatric trauma patients, including early recognition and stabilization of problems that may lead to shock and respiratory failure. At least one emergency room registered nurse or physician's assistant per shift shall have successfully completed courses such as the Emergency Medical Services for Children/American Heart Association Pediatric Advanced Life Support (EMSC/PALS) course, or the Emergency Nurses Association Emergency Nursing Pediatric Course (ENPC) and can demonstrate this clinical capability. Documentation of current expiration date for the above courses shall be maintained by the facility and available upon request.

(c) In Primary or General Pediatric Emergency Facilities at least one RN shall be physically present 24 hours per day, 7 days per week, and capable of recognizing and managing shock and respiratory failure and stabilizing pediatric trauma patients, including early recognition and stabilization of problems that may lead to shock and respiratory failure. At least one emergency room nurse per shift shall have successfully completed courses such as the PALS or ENPC and can demonstrate this clinical capability.

(d) A Pediatric General Emergency Facility shall have an emergency department nursing director/manager and at least one nurse per shift with pediatric emergency nursing experience. Nursing administration shall assure adequate staffing for data collection and performance monitoring.

(e) A Comprehensive Regional Pediatric Center shall have a pediatric emergency department director/manager and a registered nurse responsible for ongoing staff education.

(f) In a Comprehensive Regional Pediatric Center nursing administration shall provide nursing staff experienced in pediatric emergency and trauma nursing care.

(g) In a Comprehensive Regional Pediatric Center nursing administration shall provide a nurse manager dedicated to the pediatric intensive care unit. The nurse manager shall have specific training and experience in pediatric critical care and shall participate in the development of written policies and procedures for the pediatric intensive care unit, coordination of staff education, coordination or research, family-centered care and budget preparation, with the medical director, in collaboration with the pediatric intensive care unit. The nurse manager shall name qualified substitutes to fulfill his or her duties during absences.

(h) In a Comprehensive Regional Pediatric Center nursing administration shall provide a nurse educator for pediatric emergency care and critical care education.

(i) In a Comprehensive Regional Pediatric Center nursing administration shall provide an orientation to the pediatric emergency department and the pediatric intensive care unit staff and specialized nursing staff shall be Pediatric Advanced Life Support certified. Nursing administration shall assure staff competency in pediatric emergency care and intensive care.

(a) The respiratory therapy department shall have a supervisor responsible for performance and training of staff, maintaining equipment and monitoring quality improvement and review. Under the supervisor's direction, respiratory therapy staff assigned primarily to the pediatric intensive care unit shall be in-house 24 hours per day.

(b) Biomedical technicians shall be either in-house or available within 1 hour, 24 hours per day. Unit secretaries (clerks) shall be available to the pediatric intensive care unit and emergency department 24 hours per day. A radiology technician and pharmacist must be in-house 24 hours per day. In addition, social workers, physical therapists, occupational therapists and nutritionists must be available. The availability of child life specialists and clergy is strongly encouraged.

(a) A General Pediatric Emergency Facility shall have access to a pediatric intensive care unit. This requirement may be fulfilled by having transfer and transport agreements available for moving critically ill or injured patients to a Comprehensive Regional Pediatric Center.

(b) A Comprehensive Regional Pediatric Center shall have a pediatric intensive care unit.

(c) A Comprehensive Regional Pediatric Center shall be qualified and competent as a pediatric trauma center, and satisfy the requirements in Table 1. A CRPC may fulfill this requirement by having written agreements with another CRPC that meets the State's criteria for level I trauma or an Adult Level I trauma center within the same region.

(d) Equipment for communication with Emergency Medical Services mobile units is essential if there is no higher-level facility capable of receiving ambulances or there are no resources for providing medical control to the pre-hospital system.

(e) An emergency cart or other systems to organize supplies including resuscitation equipment, drugs, printed pediatric drug doses and pediatric reference materials must be readily available. Equipment, supplies, trays, and medications shall be easily accessible, labeled and logically organized. Antidotes necessary for a specific geographic area should be determined through consultation with a poison control center. If the listed medications are not kept in the emergency department, they should be kept well organized and together in a location easily accessible and proximate to the emergency department.

(f) A Comprehensive Regional Pediatric Center emergency department must have geographically separate and distinct pediatric medical/trauma areas that have all the staff, equipment and skills necessary for comprehensive pediatric emergency care. Separate fully equipped pediatric resuscitation rooms must be available and capable of supporting at least two simultaneous resuscitations. A pediatric intensive care unit must be available within the institution.

(a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Pediatric Emergency Care Facility will encourage all staff and independent practitioners to obtain an influenza vaccination;

(b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);

(c) Education of all employees about the following:

(d) An annual evaluation of the influenza vaccination program and reasons for nonparticipation; and

(e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner's designee.