6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 21

Current through Register Vol. 47, No. 20, October 25, 2024

Part 21 - EMERGENCY SERVICES

21.1 All General Hospitals shall maintain a dedicated emergency department and shall follow the standards in Part 21.3 below.

21.2 Licensed Rehabilitation Hospitals, Psychiatric Hospitals, Hospital Units, Long-Term Care Hospitals, as defined at 42 U.S.C. 1395x(ccc), and Specialty Hospitals, as defined at Part 2.18 above, shall not be required to maintain a dedicated emergency department and shall follow the standards in Part 21.4 below. If the hospital chooses to maintain a dedicated emergency department, it shall follow the standards in Part 21.3 below.

21.3 Dedicated Emergency Department

(A) Organization

(1) The emergency department shall be formally organized as a department or service directed by a qualified member of the medical staff.

(2) The emergency department shall provide emergency services twenty-four (24) hours a day, including providing immediate lifesaving intervention, resuscitation, and stabilization.

(3) The entrance to the emergency department shall be clearly marked and separate from the main hospital entrance.

(4) The hospital shall integrate its emergency department with other hospital departments, as needed, to ensure the hospital can immediately make available the full extent of its patient resources to assess and render appropriate care.

(5) Patients shall be discharged from the emergency department only upon a physician or licensed independent practitioner's recorded authorization, including instructions given to the patient for follow-up care.

(6) The emergency department shall be conveniently located with respect to radiological and laboratory services. The emergency department shall be separate and removed from surgical and obstetrical suites.

(7) If provided, operating rooms located within the emergency department shall meet the requirements specified in Part 24, Surgical and Recovery Services.

(B) Personnel

(1) A physician or licensed independent practitioner must be available at all times to the emergency department to direct care.

(2) Nurse staffing shall be provided in accordance with the requirements of Part 14 of this chapter, Nursing Services.

(3) The hospital shall ensure the availability of additional personnel during an unexpected influx of patients.

(4) A roster of on-call medical staff members must be available in the emergency department.

(C) Scope of Services

(1) The hospital shall develop policies and procedures outlining the scope of services provided in the emergency department, including, but not limited to the following:

(a) Procedures for immediately addressing and treating any incidents of overdose or accidental poisoning.

(2) Services rendered shall be based on nationally-recognized guidelines, procedure manuals, and reference materials.

(3) The hospital shall transfer patients to a higher level of care when their needs exceed the hospital's scope of services.

(D) Minimum Services

(1) The hospital shall provide the necessary resources, including instruments, equipment, and personnel, in accordance with acceptable standards of practice, and shall ensure resources are immediately available to meet the needs of presenting patients.

(2) The hospital shall provide the necessary resources to address, at a minimum, the following types of emergencies for both adult and pediatric patients: airway, cardiac, circulatory, neurologic, obstetric, orthopedic, pulmonary, and psychiatric.

21.4 Hospitals without a Dedicated Emergency Department

(A) Signage indicating that the hospital does not have an emergency department shall be posted at all public entrances.

(B) The hospital shall have the ability to provide basic life saving measures to patients, staff, and visitors, and shall have written policies for the appraisal of emergencies, initial treatment, and transfer when appropriate.

6 CCR 1011-1 Chapter 04, pt. 21