Effective Date: 01/11/2012
Title: Section 405.19 - Emergency services

405.19 Emergency services.

(a) General.

(1) Emergency services shall be provided in accordance with this subdivision or subdivisions (b) through (e) of this section as appropriate.

(2) If emergency services are not provided as an organized service of the hospital, the governing body and the medical staff shall assure:

(i) prompt physician evaluation of patients presenting emergencies;

(ii) initial treatment and stabilization or management; and

(iii) transfer, where indicated, of patients to an appropriate receiving hospital. The hospital shall have a written agreement with local emergency medical services (EMS) to accommodate the need for timely inter-hospital transfer on a 24 hours a day, 7 days a week, 365 days a year basis.

(b) Organization. (1) The medical staff shall develop and implement written policies and procedures approved by the governing body that shall specify:

(i) the responsibility of the emergency services to evaluate, initially manage and treat, or admit or recommend admission, or transfer patients to another facility that can provide definitive treatment. Such policies and procedures shall include a written agreement with one or more local emergency medical services (EMS) to accommodate the need for timely inter-facility transport on a 24 hours a day, 7 days a week, 365 days a year basis;

(ii) the organizational structure of the emergency service, including the specification of authority and accountability for services; and

(iii) explicit prohibition on transfer of patients based on their ability or inability to pay for services.

(2) The emergency service shall be directed by a licensed and currently registered physician who is board-certified or board-admissible for a period not to exceed five years after the physician first attained board admissibility in emergency medicine, surgery, internal medicine, pediatrics or family practice, and who is currently certified in advanced trauma life support (ATLS) or has training and experience equivalent to ATLS. Such physician shall also have successfully completed a course in advanced cardiac life support (ACLS) or have had training and experience equivalent to ACLS. A licensed and currently registered physician who is board-certified or board-admissible in psychiatry for a period not to exceed five years after the physician first attained board-admissibility, in psychiatry may serve as psychiatrist director of a separately operated psychiatric emergency service. Directors of separately operated psychiatric emergency services need not be qualified to perform ACLS and ATLS.

(3) An emergency service shall have laboratory and X-ray capability, including both fixed and mobile equipment, available 24 hours a day, seven days a week, to provide test results to the service within a time considered reasonable by accepted emergency medical standards.

(c) General policies and procedures. (1) The location and telephone number of the State Department of Health-designated poison control center, shall be maintained at the telephone switchboard and in the emergency service.

(2) All cases of suspected child abuse or neglect shall be treated and reported immediately to the New York State Central Register of Child Abuse and Maltreatment pursuant to procedures set forth in article 6, title 6 of the Social Services Law.

(3) Domestic violence. The emergency service shall develop and implement policies and procedures which provide for the management of cases of suspected or confirmed domestic violence victims in accordance with the requirements of section 405.9(e) of this Part.

(4) The emergency service shall establish and implement written policies and procedures for the maintenance of sexual offense evidence as part of the hospital-wide provisions required by this Part. An organized protocol for survivors of sexual offenses, including medical and psychological care shall be incorporated into such policies and procedures. These policies, procedures and protocols shall be consistent with the standards for patient care and evidence collection established in section 405.9(c) of this Part.

(5) The emergency service, in conjunction with the discharge planning program of the hospital, shall establish and implement written criteria and guidelines specifying the circumstances, the actions to be taken, and the appropriate contact agencies and individuals to accomplish adequate discharge planning for persons in need of post emergency treatment or services but not in need of inpatient hospital care.

(6) An admission and discharge register shall be current and shall include at least the following information for every individual seeking care:

(i) date, name, age, gender, ZIP code;

(ii) expected source of payment;

(iii) time and means of arrival, including name of ambulance service for patients arriving by ambulance;

(iv) complaint and disposition of the case; and

(v) time and means of departure, including name of ambulance service for patients transferred by ambulance.

(7) There shall be a medical record that meets the medical record requirements of this Part for every patient seen in the emergency service. Medical records shall be integrated or cross-referenced with the inpatient and outpatient medical records system to assure the timely availability of previous patient care information and shall contain the prehospital care report or equivalent report for patients who arrive by ambulance.

(8) Review of the hospital emergency service shall be conducted at least four times a year as a part of the hospital's overall quality assurance program. Receiving hospitals shall report to sending hospitals and emergency medical systems, as appropriate, all patients that die unexpectedly within 24 hours upon arrival at the receiving hospitals. These patient mortalities shall be included in both hospitals' quality assurance review.

(d) Staffing. The following requirements are applicable to all organized emergency services:

(1) Emergency service physician services shall meet the following requirements:

(i) The emergency services attending physician shall meet the minimum qualifications set forth in either clauses (a) or (b) of this subparagraph.

(a) The emergency services attending physician shall be a licensed and currently registered physician who is board-certified in emergency medicine, surgery, internal medicine, pediatrics or family practice and who is currently certified in advanced trauma life support (ATLS) or has training and experience equivalent to ATLS. Such physician shall also have successfully completed a course in advanced cardiac life support (ACLS) or have had training and experience equivalent to ACLS. A licensed and currently registered physician who is board-certified in psychiatry may serve as psychiatrist attending in a separately operated psychiatric emergency service. A licensed and currently registered physician who is board-admissible in one of these specialty areas and is currently certified in ATLS or who has training and experience equivalent to ATLS and has successfully completed a course in ACLS or has had training and experience equivalent to ACLS may be designated as attending physician for a period not to exceed five years after the physician has first attained board-admissibility except that the requirement to be qualified to perform ATLS and ACLS shall not be applicable to qualified psychiatrist attendings in a separately operated psychiatric emergency service. Physicians who are board-certified or admissible, for a period not to exceed five years after the physician first attained board-admissibility, in other specialty areas may be designated as attending physicians for patients requiring their expertise.

(b) The emergency services attending physician shall be a physician who:

(1) is licensed and currently registered;

(2) has successfully completed one year of post-graduate training;

(3) has, within the past five years accumulated 7,000 documented patient contact hours or hours of teaching medical students, physicians-in-training, or physicians in emergency medicine. Up to 3,500 hours of documented experience in hospital-based settings or other settings in the specialties of internal medicine, family practice, surgery or pediatrics may be substituted for the required hours of emergency medicine experience on an hour-for-hour basis;

(4) has acquired in each of the last three years, an average of fifty hours or more per year of continuing medical education pertinent to emergency medicine or to the specialties of practice which contributed to meeting the 7,000 hours requirement specified in subclause (3) of this clause;


(5) is currently certified in ATLS or has training and experience equivalent to ATLS; and

(6) has successfully completed a course in advanced cardiac life support (ACLS) or has had training and experience equivalent to ACLS.

(ii) There shall be at least one emergency service attending physician on duty 24 hours a day, seven days a week. For hospitals that exceed 15,000 unscheduled visits annually, the attending physician shall be present and available to provide patient care and supervision in the emergency service. As necessitated by patient care needs, additional attending physicians shall be present and available to provide patient care and supervision. Appropriate subspecialty availability as demanded by the case mix shall be provided promptly in accordance with patient needs. For hospitals with less than 15,000 unscheduled emergency visits per year, the supervising or an attending physician need not be present but shall be available within thirty minutes, provided that at least one physician, nurse practitioner, or registered physician assistant shall be on duty in the emergency service 24 hours a day, seven days a week;

(iii) Other medical staff practitioner services provided in the emergency service shall be in accordance with the privileges granted the individual; and

(iv) Every medical-surgical specialty on the hospital's medical staff which is organized as a department or clinical service and where practitioner staffing is sufficient, shall have a schedule to provide coverage to the emergency service by attending physicians in a timely manner, 24 hours a day, seven days a week, in accordance with patient needs.

(2) Nursing services:

(i) There shall be at least one supervising emergency services registered professional nurse present and available to provide patient care services in the emergency service 24 hours a day, seven days a week;

(ii) Emergency services supervising nurses shall be licensed and currently registered and possess current, comprehensive knowledge and skills in emergency health care. They shall have at least one year of clinical experience, be able to demonstrate skills and knowledge necessary to perform basic life support measures, have successfully completed a course in ACLS or have had training and experience equivalent to ACLS and maintain current competence in ACLS as determined by the hospital;

(iii) Registered professional nurses in the emergency service shall be licensed and currently registered professional nurses who possess current, comprehensive knowledge and skills in emergency health care. They shall have at least one year of clinical experience, have successfully completed an emergency nursing orientation program and be able to demonstrate skills and knowledge necessary to perform basic life support measures. Within one year of assignment to the emergency service, each emergency service nurse shall have successfully completed a course in ACLS or have had training and experience equivalent to ACLS and shall maintain current competence in ACLS as determined by the hospital.

(iv) Additional registered professional nurses and nursing staff shall be assigned to the emergency service in accordance with patient needs. If, on average:

(a) the volume of patients per eight-hour shift is under 25, an additional registered professional nurse shall be available as needed to assist the supervising registered professional nurse with delivery of direct patient care; or

(b) the volume of patients per eight-hour shift is over 25, there shall be a minimum of two registered professional nurses per shift assigned to provide direct patient care. As patient volume and intensity increases, the total number of available registered professional nurses shall also be increased to meet patient care needs;

(3) Registered physician's assistants and nurse practitioners:

(i) patient care services provided by registered physician's assistants shall be in accordance with section 405.4 of this Part;

(ii) patient care services provided by certified nurse practitioners shall be in collaboration with a licensed physician whose professional privileges include approval to work in the emergency service and in accordance with written practice protocols for these services; and

(iii) the registered physician assistants and the nurse practitioners shall meet the following standards:

(a) the registered physician assistants and the nurse practitioners in the emergency service shall have successfully completed a course in ACLS or have had training and experience equivalent to ACLS when determined necessary by the hospital to meet anticipated patient needs or when a physician assistant or nurse practitioner is serving as the sole practitioner on duty in a hospital with less than 15,000 unscheduled emergency visits per year;

(b) registered physician assistants and nurse practitioners in the emergency service shall have had training and experience equivalent to ATLS when determined necessary by the hospital to meet anticipated patient needs or when a physician assistant or nurse practitioner is serving as the sole practitioner on duty in a hospital with less than 15,000 unscheduled emergency visits per year.

(4) Support personnel. There shall be sufficient support personnel assigned to the emergency service to perform the following duties on a timely basis: patient registration, reception, messenger service, acquisition of supplies, equipment, delivery and labelling of laboratory specimens, responsible for the timely retrieval of laboratory reports, obtaining records, patient transport and other services as required.

(e) Patient care. (1) The hospital shall assure that all persons arriving at the emergency service for treatment receive emergency health care that meets generally accepted standards of medical care.

(2) Every person arriving at the emergency service for care shall be promptly examined, diagnosed and appropriately treated in accordance with triage and transfer policies and protocols adopted by the emergency service and approved by the hospital. Such protocols must include written agreements with local emergency medical services (EMS) in accordance with subparagraph (b)(1)(i) of this section. All patient care services shall be provided under the direction and control of the emergency services director or attending physician. In no event shall a patient be discharged or transferred to another facility, unless evaluated, initially managed, and treated as necessary by an appropriately privileged physician, physician assistant, or nurse practitioner. No later than eight hours after presenting in the emergency service, every person shall be admitted to the hospital, or assigned to an observation unit in accordance with subdivision (g) of this section, or transferred to another hospital in accordance with paragraph (6) of this subdivision, or discharged to self-care or the care of a physician or other appropriate follow-up service. Hospitals which elect to use physician assistants or nurse practitioners shall develop and implement written policies and treatment protocols subject to approval by the governing body that specify patient conditions that may be treated by a registered physician assistant or nurse practitioner without direct visual supervision of the emergency services attending physician.

(3) Hospitals that have limited capability for receiving and treating patients in need of specialized emergency care shall develop and implement standard descriptions of such patients, and have triage and treatment protocols and formal written transfer agreements with hospitals that are designated as being able to receive and provide definitive care for such patients. Patients in need of specialized emergency care shall include, but not be limited to:

(i) trauma patients and multiple injury patients;

(ii) burn patients with burns ranging from moderate uncomplicated to major burns as determined by use of generally acceptable methods for estimating total body surface area;

(iii) high risk maternity patients or neonates or pediatric patients in need of intensive care;

(iv) head-injured or spinal-cord injured patients;

(v) acute psychiatric patients;

(vi) replantation patients;

(vii) dialysis patients; and

(viii) acute myocardial infarction patients including but not limited to patients with ST elevation.

(4) Hospitals shall verbally request ambulance dispatcher services to divert patients with life threatening conditions to other hospitals only when the chief executive officer or designee appointed in writing, determines that acceptance of an additional critical patient would endanger the life of that patient or another patient. Request for diversion shall be documented in writing and, if warranted, renewed at the beginning of each shift.

(5) Reserved.

(6) Patients shall be transferred to another hospital only when:

(i) the patient's condition is stable or being managed;

(ii) the attending practitioner has authorized the transfer; and

(iii) administration of the receiving hospital is informed and can provide the necessary resources to care for the patient; or

(iv) when pursuant to paragraph (2) of this subdivision, the patient is in need of specialized emergency care at a hospital designated to receive and provide definitive care for such patients.

(7) Hospitals located within a city with a population of one million or more persons shall apply and, if accepted, participate to the full extent of their capability, in the emergency medical service which is operated by such city or such city's health and hospitals corporation.

(f) Quality assurance.

(1) Quality assurance activities of the emergency service shall be integrated with the hospital-wide quality assurance program and shall include review of:

(i) arrangements for medical control and direction of prehospital emergency medical services;

(ii) provisions for triage of persons in need of specialized emergency care to hospitals designated as capable of treating those patients;

(iii) emergency care provided to hospital patients, to be conducted at least four times a year, and to include prehospital care providers, emergency services personnel and emergency service physicians; and

(iv) adequacy of staff training and continuing education.

(2) hospitals as represented by emergency department practitioners and other clinical practitioners relevant to the care provided should also collaborate, as provided under Public Health Law Section 3006, in the quality improvement programs of their local EMS to review prehospital care issues including review of specific patient cases.

(g) Observation units. Observation units shall be under the direction and control of the emergency service and, unless a contrary requirement is specified in this subdivision, observation units shall be subject to all requirements of this section applicable to emergency services.

(1) Patient Care: An observation unit shall be used only for observation, diagnosis and stabilization of those patients for whom diagnosis and a determination concerning admission, discharge, or transfer cannot be accomplished within eight hours, but can reasonably be expected within twenty-four hours. Patients shall be assigned to the observation unit by physician order and within twenty-four hours of the issuance of an order assigning the patient to an observation unit, the patient must be admitted to the inpatient service, be transferred in accordance with paragraph (6) of subdivision (e) of this section, or be discharged to self-care or the care of a physician or other appropriate follow-up service.

(2) Physical Space:

(i) The total number of dedicated observation unit beds in a hospital shall be limited to five percent of the hospital's certified bed capacity, and shall not exceed forty, provided that in a hospital with less than 100 certified beds, an observation unit may have up to five beds.

(ii) The observation unit shall be located within a distinct physical space, except in a hospital designated as a critical access hospital pursuant to subpart F of part 485 of Title 42 of the Code of Federal Regulations or a sole community hospital pursuant to section 412.92 of Title 42 of the Code of Federal Regulations or any successor provisions.

(iii) The observation unit shall comply with the applicable provisions of Parts 711 and 712-2 and section 712-2.4 of this Title for construction projects approved or completed after January 1, 2011.

(iv) Observation unit beds shall not be counted within the state certified bed capacity of the hospital and shall be exempt from the public need provisions of Part 709.

(v) The observation unit shall be marked with a clear and conspicuous sign that states: "This is an observation unit for visits of up to 24 hours. Patients in this unit are not admitted for inpatient services."

(3) Staffing.

(i) Patients in an observation unit shall be cared for, pursuant to a defined staffing plan, by staff, appropriately trained and in sufficient numbers to meet the needs of patients in the observation unit.

(ii) At a minimum, a physician, nurse practitioner, or physician assistant shall be responsible for oversight of the medical care of the patients assigned to the observation unit. Such physician, nurse practitioner, or physician assistant assigned to oversee the observation unit shall be immediately available to meet the needs of patients in the observation unit and shall not be assigned concurrent duties that will interfere with such availability.

(4) Organization. The medical staff shall develop and implement written policies and procedures approved by the governing body for the observation unit that shall include, but not be limited to:

(i) the integration of the observation unit and its services with the emergency service and other related services of the hospital; and

(ii) appropriate use of the observation unit, including documentation of the clinical reasons and indications that warrant the period of observation, rather than admission or discharge, consistent with section 405.10 of this Part.

(5) Opening and Closure.

(i) Any hospital seeking to establish an observation unit shall:

(a) if no construction, as defined in subdivision 5 of section 2801 of the Public Health Law, will be needed, and no service will be eliminated:

(1) submit a written notice to the Department on a form developed by the Department, not less than 90 days prior to opening the unit, indicating the hospital's intent to establish such a unit; the number of beds to be located in the unit; the location of the unit within the facility, and such other information as the Department may require; and

(2) submit a certification from a licensed architect or engineer, in the form specified by the Department, that the space complies with the applicable provisions of Parts 711 and 712-2 and section 712-2.4 of this Title for construction projects approved or completed after January 1, 2011; or

(b), if construction, as defined in subdivision 5 of section 2801 of the Public Health Law, will be needed or a service will be eliminated:

(1) comply with Part 710 of this Title, provided that for purposes of Part 710, a construction project involving only the creation of an observation unit and the addition of observation unit beds shall not be subject to review under section 710.1(c)(2) or (3) of this Title, unless the total project cost exceeds $15 million or $6 million respectively; and

(2) comply with the applicable provisions of Parts 711 and 712-2 and section 712-2.4 of this Title for construction projects approved or completed after January 1, 2011.

(ii) No hospital may discontinue operation of an observation unit without providing written notification to the Department of the impending closure not less than 90 days prior to the closure.

(6) Transition. A hospital operating an observation unit pursuant to a waiver granted by the Department shall be required to comply with the provisions of this subdivision within 24 months of its effective date.



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