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FACILITY RECOGNITION CRITERIA
FOR THE EMERGENCY DEPARTMENT APPROVED FOR PEDIATRICS (EDAP)

 

1.   PROFESSIONAL STAFF:  PHYSICIANS
  1.1 Qualifications
 

Twenty-four hour coverage of the emergency department shall be provided by at least one physician responsible for the care of critically ill or injured children who holds one of the following qualifications:

  1. Certification in Emergency Medicine by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM) or residency trained/board eligible in Emergency Medicine and in the first cycle of the board certification process; or

  2. Certification in Pediatric Emergency Medicine by the American Board of Pediatrics/American Board of Emergency Medicine (ABP/ABEM) or residency trained/board eligible in Pediatric Emergency Medicine and in the first cycle of the board certification process; or

  3. Certification by one of the following boards and current AHA-AAP Pediatric Advanced Life Support (PALS) recognition or ACEP-AAP Advanced Pediatric Life Support (APLS) or equivalent course.

  • Certification in Family Practice by the American Board of Family Practice (ABFP) or American Osteopathic Board of Family Practice (AOBFP); or

  • Certification in Pediatrics by the ABP or American Osteopathic Board of Pediatrics (AOBP); or
     

  • Residency trained/board eligible in either Family Practice or Pediatrics and in the first cycle of the board certification process;or

  1. A physician who has received a waiver from the Illinois Department of Public Health based on one of the following criteria:

  • An emergency department physician who has already received a waiver per the Trauma Center Rules & Regulations (Section 515.2030, (e); Section 515.2040, (f); or

  • Completion of 12 months of internship followed by at least 7000 hours of hospital-based Emergency Medicine, that includes pediatric patients, over the last 60 month period (including 2800 hours within one 24-month period), verified in writing by the hospital(s) at which the internship and subsequent hours were completed and current AHA-AAP PALS or ACEP-AAP APLS recognition; or

  • Completion of professional activities spent in the practice of pediatric emergency medicine (PEM), over the last 60 month period and totaling a minimum of 6000 hours, focused on the care of patients in the pediatric age group (< 21 years) in the emergency department and demonstrated by the following:

    1. Of the 6000 hours, 2800 hours must have been accrued in a 24 month (maximum) consecutive period of time;

    2. A minimum of 4000 of the 6000 hours must have been spent in the clinical practice of PEM. (If practiced in a general ED, only time spent exclusively in pediatric practice can be used for credit);

    3. The remaining 2000 hours may be spent in either clinical care or a mixture of related non-clinical activities clearly focused on PEM including administration, teaching, prehospital care, quality improvement, research or other academic activities.

  1.2 Continuing Medical Education
  All full or part time Emergency Physicians shall have documentation of completion of a minimum of 16 hours of Continuing Medical Education (AMA Category I or II) in Pediatric Emergency topics within a 2-year period.
  1.3 Coverage

At least one (1) physician satisfying 1.1 shall be on duty in the emergency department 24 hours a day.
  1.4 Consultation
  Telephone consultation with a physician who is Board Certified or Eligible in Pediatrics or Pediatric Emergency Medicine shall be available 24 hours a day. Consultation can be with an on-staff physician or in accordance with the Illinois EMSC "Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guideline".
  1.5 Physician Back-up
  A "back-up" physician whose qualifications and training are equivalent to that of 1.1 shall be available to the EDAP within 1 hour to assist with critical situations or disasters.
  1.6 On Call Physicians
Protocols shall be available that address maximum response time for on-call physicians.
2.   PROFESSIONAL STAFF: MID-LEVEL PRACTITIONERS
(A Mid-Level Practitioner is defined as a Nurse Practitioner or Physician Assistant who works under the supervision of a licensed physician who satisfies criteria 1.1a and 1.1b)
2.1 Qualifications

  1. Nurse Practitioners shall have:
     

    1. Completed a Pediatric Nurse Practitioner program or Emergency Nurse Practitioner program or Family Practice Nurse Practitioner program or the department will grant a waiver based on the following criteria:  Has completed 2000 hours of hospital based emergency department or acute care over the last 24-month period that includes the care of the pediatric patient; and

    2. An Illinois Advanced Practice license within one year of hire; and

    3. Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

  2. Physician Assistants shall have:

    1. Current Illinois licensure (permanent or temporary); and

    2. Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

  3. All Nurse Practitioners and Physician Assistants shall successfully complete and maintain current recognition in one of the following courses: the AHA-AAP Pediatric Advanced Life Support (PALS) Course, the ACEP-AAP Advanced Pediatric Life Support (APLS) Course or the ENA Emergency Nursing Pediatric Course (ENPC).
2.2  Continuing Medical Education
  1. All full or part time Nurse Practitioners shall have documentation of a minimum of 16 hours of approved Continuing Education Units in pediatric emergency topics within a 2-year period.
     
  2. All full or part time Physician Assistants shall have documentation of a minimum of 16 hours of Continuing Medical Education (AMA Category I) in pediatric emergency topics within a 2-year period. Credit for CME shall be approved by the Accreditation Council on Continuing Medical Education (ACCME), American Osteopathic Association Council on Continuing Medical Education (AOCCME), American Academy of Family Physicians (AAFP) or American Academy of Physician Assistants (AAPA).
3.   PROFESSIONAL STAFF: NURSING
   
3.1  Qualifications

  1. At least one Registered Nurse (RN) on duty each shift who is responsible for the direct care of the child in the emergency department shall successfully complete and maintain current recognition in one of the following courses in pediatric emergency care.

  • AHA-AAP Pediatric Advanced Life Support (PALS) provider course

  • ACEP-AAP Advanced Pediatric Life Support (APLS) provider course

  • ENA Emergency Nursing Pediatric Course (ENPC)

  1. All emergency department nurses shall successfully complete and maintain current recognition in one of the above educational requirements within 24 months of employment.

3.2  Continuing Education
All nurses assigned to the emergency department shall have documentation of a minimum of 8 hours of pediatric emergency/critical care continuing education hours within a 2-year period. Continuing education may include, but is not limited to PALS, APLS, or ENPC; CEU offerings; case presentations; competency testing; teaching courses related to pediatrics and/or publications. These continuing education hours can be integrated with other existing continuing education requirements, provided that the content is pediatric specific.
4.   POLICIES AND PROCEDURES
4.1 Interfacility Transfer
The facility shall have transfer agreement(s) with Pediatric Critical Care Centers (PCCC) and policies/procedures concerning transfer of critically ill and injured patients to PCCC's. Incorporating the components of the Illinois EMSC "Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guideline" into the emergency department transfer policy/procedure will meet this requirement.
4.2 Suspected Child Abuse
The facility shall have policies/procedures addressing the identification, evaluation, treatment and referral of victims of suspected child abuse in accordance with state law.
4.3 Treatment Protocols
The facility shall have protocols addressing appropriate stabilization measures in response to critically ill or injured pediatric patients (i.e. trauma, respiratory distress, seizures).
4.4 Latex-free Policy
The facility shall have a policy addressing availability of latex-free equipment and supplies.
5.   QUALITY IMPROVEMENT
5.1 Multidisciplinary Committee
  1. Pediatric emergency medical care shall be included in the EDAP’s Emergency Department or Section quality improvement program and reported to the hospital QI committee.
     
  2. Multidisciplinary CQI activities shall be established with documented CQI monitors addressing pediatric care within the Emergency Department with identified clinical indicators and/or outcomes for care. These activities shall include children from birth up to and including 15 years of age and shall consist of, but are not limited to, all pediatric Emergency Department deaths, resuscitations, and interfacility transfers.
5.2 Pediatric "CQI" Liaison

A member of the professional staff who has on-going involvement in the care of pediatric patients shall be designated and supported by the hospital as the Pediatric Liaison. This individual may be employed in an area other than the emergency department and shall have a minimum of two (2) years of pediatric critical care or emergency department experience.  The responsibilities of the CQI Liaison shall include: 

5.2.1 Working in conjunction with the ED Nurse Manager and ED Medical Director to ensure compliance with and documentation of the pediatric continuing education of all Emergency Department professional staff in accordance with Criteria 1.1, 1.2, 2.1, 2.2, 3.1 and 3.2.

5.2.2 Maintaining a data summary and working in conjunction with the multidisciplinary CQI committee to coordinate criteria-based review and follow-up of sample pediatric emergency department visits (Criteria 5.1).

5.2.3 Coordinating a review of prehospital provider transported pediatric cases and providing feedback to the EMS System Coordinator and the EMS Regional Advisory Board.

5.2.4 Preparing a written CQI report and attending the EMS Regional CQI subcommittee, which activities shall be supported by the hospital. One representative from the CQI subcommittee shall report to the EMS Regional Advisory Board.

5.2.5 Providing CQI information to the Illinois Department of Public Health upon request.
6.   EQUIPMENT, TRAYS, AND SUPPLIES
Please refer to Pediatric Equipment Recommendations for Emergency Departments

 

FACILITY RECOGNITION CRITERIA
FOR THE STAND BY EMERGENCY DEPARTMENT APPROVED FOR PEDIATRICS (SEDP)

 
   
1.   PROFESSIONAL STAFF:  PHYSICIANS
   
  1.1 Qualifications
 
  1. All Physicians shall have training in the care of pediatric patients either through residency training, clinical training, or practice.
     
  2. All Physicians shall successfully complete and maintain current recognition in the AHA-AAP Pediatric Advanced Life Support (PALS) Course, or the ACEP-AAP Advanced Pediatric Life Support (APLS) course or equivalent course. (Physicians who are Board Certified or Eligible in Emergency Medicine (ABEM or AOBEM) or in Pediatric Emergency Medicine (ABP/ABEM) are excluded from this criteria).
   
  1.2 Continuing Medical Education
  All full or part time Emergency Physicians shall have documentation of a minimum of 16 hours of Continuing Medical Education (AMA Category I or II) in Pediatric Emergency topics within a 2-year period.
   
  1.3 Coverage
  At least one (1) physician meeting the requirements of 1.1 (or physician assistant or nurse practitioner satisfying 2.1) shall be on duty in the emergency department 24 hours a day or immediately available. A policy shall be available that defines when a physician is to be consulted/called in at times when the emergency department is covered by a mid-level practitioner.
   
  1.4 Consultation
  Telephone consultation with a physician who is Board Certified or Eligible in Pediatrics or Pediatric Emergency Medicine shall be available 24 hours a day. Consultation can be with an on-staff physician or in accordance with the Illinois EMSC "Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guideline".
   
  1.5 Physician Back-up
  A "back-up" physician whose qualifications and training are equivalent to that of 1.1 shall be available to the SEDP within 1 hour after notification to assist with critical situations or disasters.
   
  1.6 On Call Physicians
  Protocols shall be available that address maximum response time for on-call physicians.
   
   
2.   PROFESSIONAL STAFF: MID-LEVEL PRACTITIONERS
  (A Mid-Level Practitioner is defined as a Nurse Practitioner or a Physician Assistant who works under the supervision of a licensed physician who satisfies criteria 1.1a and 1.1b)
   
  2.1 Qualifications
 

  1. Nurse Practitioners shall have:

    1. Completed a Pediatric Nurse Practitioner program or Emergency Nurse Practitioner program or Family Practice Nurse Practitioner program, or the department will grant a waiver based on the following criteria:  Has completed 2000 hours of hospital-based emergency department or acute care over the last 24 month period that includes the care of the pediatric patient; and

    2. An Illinois Advanced Practice license within one year of hire; and

    3. Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

  1. Physician Assistants shall have:
     

    1. Current Illinois licensure (permanent or temporary);

    2. Credentialing that reflects orientation, ongoing training and specific competencies in the care of the pediatric emergency patient.

  2. All Nurse Practitioners and Physician Assistants shall successfully complete and maintain current recognition in one of the following courses: the AHA-AAP Pediatric Advanced Life Support (PALS) Course, the ACEP-AAP Advanced Pediatric Life Support (APLS) Course or the ENA Emergency Nursing Pediatric Course (ENPC).
   
 

2.2 Continuing Medical Education
 

  1. All full or part time Nurse Practitioners shall have documentation of a minimum of 20 hours of approved Continuing Education Units in pediatric emergency topics within a 2-year period.

  2. All full or part time Physician Assistants shall have documentation of a minimum of 20 hours of Continuing Medical Education (AMA Category I) in pediatric emergency topics within a 2-year period. Credit for CME shall be approved by the Accreditation Council on Continuing Medical Education (ACCME), American Osteopathic Association Council on Continuing Medical Education (AOCCME), American Academy of Family Physicians (AAFP) or American Academy of Physician Assistants (AAPA).
   
   
3.   PROFESSIONAL STAFF: NURSING
   
  3.1 Qualifications
 

At least one Registered Nurse (RN) on duty each shift who is responsible for the direct care of the child in the emergency department shall successfully complete and maintain current recognition in one of the following courses in pediatric emergency care.

  1. AHA-AAP Pediatric Advanced Life Support (PALS) provider course

  2. ACEP-AAP Advanced Pediatric Life Support (APLS) provider course

  3. ENA Emergency Nursing Pediatric Course (ENPC)
   
  3.2 Continuing Education
  At least one Registered Nurse (RN) on duty each shift who is responsible for the direct care of the child in the emergency department shall have documentation of a minimum of 8 hours of pediatric emergency/critical care continuing education hours within a 2-year period. Continuing education may include, but is not limited to PALS, APLS, OR ENPC; CEU offerings; case presentations; competency testing; teaching courses related to pediatrics and/or publications. These continuing education hours can be integrated with other existing continuing education requirements, provided that the content is pediatric specific.
   
   
4.   POLICIES AND PROCEDURES
   
  4.1 Interfacility Transfer
  The facility shall have transfer agreement(s) with Pediatric Critical Care Centers (PCCC) and policies/procedures concerning transfer of critically ill and injured patients to PCCC's. Incorporating the components of the Illinois EMSC "Interfacility Pediatric Trauma and Critical Care Consultation and/or Transfer Guideline" into the emergency department transfer policy/procedure will meet this requirement.
   
  4.2 Suspected Child Abuse
  The facility shall have policies/procedures addressing the identification, evaluation, treatment and referral of victims of suspected child abuse in accordance with state law.
   
  4.3 Treatment Protocols
  The facility shall have protocols addressing appropriate stabilization measures in response to critically ill or injured pediatric patients (i.e. trauma, respiratory distress, seizures).
   
  4.4 Latex-free Policy
 

The facility shall have a policy addressing availability of latex-free equipment and supplies
   
   
5.   QUALITY IMPROVEMENT
   
  5.1 Multidisciplinary Committee
 

Pediatric emergency medical care shall be included in the SEDP’s Emergency Department or Section quality improvement program and reported to the hospital QI committee.

Multidisciplinary CQI activities shall be established with documented CQI monitors addressing pediatric care within the Emergency Department with identified clinical indicators and/or outcomes for care. These activities shall include children from birth up to and including 15 years of age and shall consist of, but are not limited to, all pediatric Emergency Department deaths, resuscitations, and interfacility transfers.
   
  5.2 Pediatric "CQI" Liaison
 

A member of the professional staff who has on-going involvement in the care of pediatric patients shall be designated and supported by the hospital as the Pediatric Liaison. This individual may be employed in an area other than the emergency department and shall have a minimum of two (2) years of pediatric critical care or emergency department experience.  The responsibilities of the CQI Liaison shall include: 

5.2.1 Working in conjunction with the ED Nurse Manager and ED Medical Director to ensure compliance with and documentation of the pediatric continuing education of all Emergency Department professional staff in accordance with Criteria 1.1, 1.2, 2.1, 2.2, 3.1 and 3.2.

5.2.2 Maintaining a data summary and working in conjunction with the multidisciplinary CQI committee to coordinate criteria-based review and follow-up of sample pediatric emergency department visits (Criteria 5.1).

5.2.3 Coordinating a review of prehospital provider transported pediatric cases and providing feedback to the EMS System Coordinator and the EMS Regional Advisory Board.

5.2.4 Preparing a written CQI report and attending the EMS Regional CQI subcommittee, which activities shall be supported by the hospital. One representative from the CQI subcommittee shall report to the EMS Regional Advisory Board.

5.2.5 Providing CQI information to the Illinois Department of Public Health upon request.
   
   
6.   EQUIPMENT, TRAYS, AND SUPPLIES
  Please refer to Pediatric Equipment Recommendations for Emergency Departments

 

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