16.1 General
1. If emergency services are provided, the healthcare organization shall ensure that the appropriate organization and management requirements are met under the direction of a qualified member of the medical staff.
2. The healthcare organization shall meet the emergency needs of its patients in accordance with acceptable standards of practice and integration with other clinical services offered (See requirements of 4.1.3–4.1.5).
3. The medical staff shall be responsible for developing and maintaining policies and procedures governing the medical care delivered. These policies and procedures shall be in compliance with applicable regulations.
4. Emergency services integration shall include but are not limited to:
a) coordination and communication between the emergency department and other healthcare organization services/departments;
b) physical access for emergency department patients to the services, equipment, personnel, and resources of other healthcare organization departments/services;
c) the immediate availability of services, equipment, personnel, and resources of other organization departments/services to emergency patients;
d) provision of care serving patients within the timeframes required by acceptable standards of emergency department practice;
e) discharge requirements as determined by the healthcare organization and this standard (See requirements of 4.1.3–4.1.5).
16.2 Personnel
1. The healthcare organization shall ensure the emergency service personnel resources needs and requirements are met.
2. Appropriate medical and nursing staff shall be present to meet the emergency needs determined and defined by the healthcare organization defined scope of practice (See 7.3).
3. A qualified registered nurse (RN) shall perform triage upon a patient presenting to the emergency department.
4. The healthcare organization shall ensure that a qualified member of the medical staff is on premises and available to supervise the provision of emergency services at all times.
5. The healthcare organization shall have an emergency plan to address all resource needs including appropriate staffing levels during times of emergency/disaster.
16.3 Emergency Services Not Provided
1. If emergency services are not provided at the healthcare organization, the Top management shall assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate.
16.4 Off-campus Departments
1. The medical staff shall have written policies and procedures for evaluating and referring emergencies that occur in off-campus departments where emergency services are not provided.
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