Ala. Admin. Code r. 420-5-9-.05

Current through Register Vol. 43, No. 3, December 31, 2024

Section 420-5-9-.05 - [Effective 2/14/2025] Personnel

(1) The freestanding emergency department (FED), as a department of the parent hospital, shall have personnel management as a section of the hospital's personnel system and shall be governed by the Board's Rules for Hospitals, Chapter 420-5-7, Ala. Admin. Code. The FED shall be adequately staffed at all times to meet the needs of the patient population served.

(2) Staff Qualifications for FEDs.

(a) The FED Medical Director shall be:

1. Either

(i) Board Certified by American Board of Emergency Medicine, the American Board of Physician Specialties, or a like credentialing organization for emergency medicine.

(ii) Certified or Board eligible to sit for the examination of one of the following boards: internal medicine, family medicine, or surgery. The physician shall also hold a current certificate from each of the following approved programs: Advanced Coronary Life Support; Advanced Trauma Life Support; and Advanced Pediatric Life Support; and must have at least 3 years of full-time clinical experience in emergency medicine within the past 5 years. Physicians meeting the aforesaid criteria with at least 1 but fewer than 3 years of full-time clinical experience in emergency medicine must also hold a certificate of completion for all modules of the Emergency Medicine Core Training (EMCT) Program. Physicians who are not board certified in emergency medicine will need to annually maintain one-half of their Alabama State Continuing Medical Education credits in emergency medicine.

2. Competent in management and administration of clinical services in an Emergency Department.

3. Knowledgeable about EMS operations and the regional EMS network.

4. Responsible for assessing and making recommendations to the parent hospital's credentialing body related to the qualifications of FED physicians and the clinical privileges granted to FED physicians.

5. Responsible for assuring that the clinical staff are continuously qualified, competent, and supervised in emergency care of patients.

(b) Each FED physician shall be individually credentialed by the parent hospital medical staff.

(c) At least one physician on site during hours of operation shall be either of the following:

1. Certified or Board Eligible by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine.

2. Certified or Board Eligible to sit for the examination of one of the following boards: Internal Medicine, Family Medicine, or Surgery; and shall hold a certificate from the following approved programs: Advanced Coronary Life Support; Advanced Trauma Life Support; Advanced Pediatric Life Support; and shall have 3 years of full time clinical experience in emergency medicine within the past 5 years.

(d) The Director of Nursing Services in the FED shall be a Registered Nurse with an active and unencumbered license from the Alabama Board of Nursing and shall direct all nursing services and all nursing support personnel, and must:

1. Demonstrate by education and experience competency in emergency room nursing. The designation of Certified Emergency Nurse (CEN) is a benchmark, but not required.

2. Provide evidence of competent management and administration of clinical services in an Emergency Department.

3. Ensure nursing and support staff are appropriately educated and qualified.

(e) Each Registered Nurse (RN) in an FED shall:

1. Provide evidence of at least 1 year previous Emergency Department or ICU experience as a staff nurse or completion of an Emergency Department educational program.

2. Demonstrate evidence of the knowledge and skills to deliver emergency nursing care.

(f) At least one licensed registered nurse who has training and experience in emergency care shall be on site at the FED at all times. At least one registered nurse on site shall hold a current certification in both Advanced Cardiac Life Support and Advance Pediatric Life Support, or two registered nurses on site at all times, one having current certification in Advanced Cardiac Life Support and one with current certification in Advanced Pediatric Life Support.

(g) At least one certified and registered radiology technologist shall be on site at the FED at all times.

(h) At least one person qualified to perform laboratory testing at the level of laboratory services provided on site by the FED shall be on duty at all times.

(3) Each FED shall have a full time administrative director who acts as a liaison with the parent hospital, directs the daily administrative operations of the FED, ensures the employees and staff are adequately trained, and provides oversight of the maintenance of the FED, coordination of patient safety and quality improvement programs and activities.

Ala. Admin. Code r. 420-5-9-.05

New Rule: Filled July 22, 2013; effective August 26, 2013.

Amended by Alabama Administrative Monthly Volume XLIII, Issue No. 03, December 31, 2024, eff. 2/14/2025.

Author: W. T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.