PROFESSIONAL STAFF COMMON RULES AND REGULATIONS Carondelet St. Mary s (CSM), St. Joseph s (CSJ), Holy Cross (CHC), Hospitals The Professional Staffs of all of the (CHN) hospital facilities have adopted a set of Common Professional Staff Bylaws as a common governing document to promote continuity across the CHN network of affiliated providers. These Professional Staff Common Rules and Regulations correspond to those Common Professional Staff Bylaws by establishing a single set of shared rules and regulations across the CHN network. The core set of common rules and regulations are set forth in this document and for facility specific rules and regulations, each facility includes its own Rules Appendix. For each facility, references to "Rules and Regulations" means the combination of this set of Professional Staff Common Rules and Regulations, and for each facility its facility specific Rules Appendix. TABLE OF CONTENTS TOPIC PAGE A. ADMISSION OF PATIENTS... 2 B. PATIENT TRANSFERS... 5 C. DISCHARGE OF PATIENTS... 5 D. MEDICAL RECORDS... 6 E. ORDERS.11 F. MEDICAL RECORD DELINQUENCY AND SUSPENSION... 12 G. GENERAL CONDUCT OF CARE... 14 H. GENERAL RULES REGARDING SURGICAL CASES... 17 H. EMERGENCY SERVICES... 18 J. GUIDELINES, PROTOCOLS AND PATIENT CARE BUNDLES... 23 K. ALLIED HEALTH PROFESSIONAL STAFF... 23 L. PSYCHOLOGY... 23 M. SURGICAL FIRST ASSISTANTS... 24 N. ADVANCED PRACTICE PROVIDERS... 27 O. PHYSICIAN ASSISTANT... 29 P. EMERGENCY PREPAREDNESS PROGRAM RESPONSIBILITIES... 31 Carondelet St. Mary, St. Joseph s, and Holy Cross Hospitals 1 Tucson,
Carondelet St. Mary s (CSM), St. Joseph s (CSJ), Holy Cross (CHC) Hospitals PROFESSIONAL STAFF RULES AND REGULATIONS A. ADMISSION OF PATIENTS 1. A patient may be admitted to the hospital only by a practitioner on the Professional Staff with admitting privileges. Every patient is under the care of a doctor of medicine or osteopathy. All diagnostic and treatment services of the hospital shall be under the direction of a professional staff member. All practitioners shall be governed by the current Admitting Department policies and procedures. a. The admitting practitioner who provides the telephone or electronic order to admit the patient shall be the attending practitioner of record and shall be responsible for the medical care and treatment of the patient while in the hospital. If and when these responsibilities are transferred to another staff member, an order covering the transfer of responsibility shall be entered as an order in the medical record. In the case of a transfer of care to a practitioner of another specialty a notation regarding transfer of care should be made in the medical record by the transferring practitioner. A practitioner cannot admit or transfer a patient to/in another practitioner's name without that practitioner's consent. Patients in the acute care facility should be seen on a daily basis by the admitting/attending physician or advanced practice practitioner (nurse practitioner/physician assistant) or a designated practitioner. The collaborating/supervising physician is responsible for the care provided by his or her advanced practice practitioners. The identified primary care physician will be notified of all admissions by the hospital. b. Patients in a Behavioral Health Unit should be seen on a daily basis by their attending practitioner or a designated alternative. A practitioner or NP with special training or experience in behavioral health will be available, as needed, 24 hours a day, seven days a week. c. Patients in an Inpatient Rehabilitation Unit should be seen at least five (5) times a week by their attending practitioner or designated alternative. A practitioner or NP with special training or experience in the field of rehabilitation will be available, as needed, 24 hours a day, seven (7) days a week. 2. A patient admitted for elective services performed by a dentist, podiatrist, or oral maxillofacial surgeon is a dual responsibility involving the dentist, podiatrist or oral maxillofacial surgeon and a M.D. or D.O. Member of the Professional Staff. a. The dentist, podiatrist, or oral maxillofacial surgeon s responsibilities are: 2
1) Perform a medical history and physical examination (if privileged for this). 2) Provide a detailed history justifying hospital admission. 3) Provide a detailed description of the pertinent examination, including when indicated the initial and final diagnosis, surgery, and prognosis. 4) A complete operative report. 5) Write orders for services and medications as they relate to the specialty care rendered. 6) Write progress notes and final summary as they relate to the specialty care rendered. 7) Write the discharge order. When the patient is being treated for a medical condition, discharge shall be in concurrence with the M.D. or D.O. b. The M.D. or D.O. responsibilities are: 1) Perform a medical history and physical examination (if the dentist, podiatrist, or oral maxillofacial surgeon is not so privileged). 2) Provide for overall care of the patient's general health during the hospital stay. 3) Write orders for services and medications for the general care of the patient. 3. Except in an emergency, no patient shall be admitted to the hospital until a provisional diagnosis and valid reason for admission have been stated. In the case of an emergency, such statement shall be recorded / stated as soon after admission as possible. 4. On the basis of the admitting practitioner s prioritization of medical necessity the admitting staff will process the admission of patients on the basis of the following order of priorities: a. Emergency Admissions b. Urgent Admissions c. Pre-operative Admissions d. Elective Admissions 5. Within twenty-four (24) hours following an emergency admission, the attending practitioner may be asked to furnish complete documentation of the emergent condition. Evidence of willful or continued misuse of this category of admission will be brought to the attention of the division/department chair. 6. If any questions as to the validity of admission to the Intensive/Critical Care Units should arise, that decision is to be made in consultation with the Utilization Management Physician Advisor, and as applicable, Manager of the ICU/NCCU, or 3
ICU/NCCU Charge RN. Any patient admitted to an ICU/NCCU will be classified as stable or unstable by the Emergency Department Practitioner. All patients classified as unstable must be seen by a practitioner within one (1) hour from the end of the practitioner to practitioner communication (or longer if there has been discussion and agreement on the timing of the assessment by the receiving practitioner) regarding the admission to the ICU/NCCU. Any practitioner may deem a patient unstable if they feel they may require a more urgent assessment. All patients classified as stable must be seen within six (6) hours of admission. 7. A patient to be admitted on an emergency basis who does not have an attending practitioner shall be assigned to an appropriate practitioner by the emergency physician. If the practitioner disagrees with the admission, he/she must examine the patient in the Emergency Dept. and document his/her decision and plan of care in the record. If the practitioner agrees with the admission but for specific reasons does not wish to take care of a particular patient, it is his/her responsibility to find an alternative practitioner to care for the patient. 8. Members of the Professional Staff admitting and attending patients shall be held responsible for getting as much information as may be necessary to assure the protection of the patient from self-harm and to ensure the safety of other patients in the Hospital. 9. Each member of the Professional Staff is required to provide or arrange for the provision of appropriate and continuous care of his/her patients at all times. He/she or his/her designee must be available to respond within an appropriate time frame to any identified patient needs as they may arise. 10. Each member also agrees to provide appropriate and necessary emergency or nonemergency medical treatment within the scope of his/her documented privileges to any patient seeking such treatment, regardless of such patient s ability to pay. 11. Patients admitted to the hospital must be seen by an admitting/ attending physician/advanced practice practitioner (nurse practitioner/physician assistant within the time defined by the hospital/unit specified standard (see appendix). 12. If the Hospital s Emergency Department associates or the Emergency Department practitioner determine that a practitioner is unable to come to the emergency Department when requested to care for a patient with an emergency medical condition as the on-call practitioner because of a situation or circumstances beyond such practitioner s control, the following actions shall be initiated: a. The practitioner in the ED and the director/manager of ED or clinical supervisor, after hours, shall follow the chain of command and initiate a call to the division chief/department chair to identify another alternative, if any. b. If no other practitioner can be identified, the hospital associates and the ED physician shall facilitate the transfer of the patient with an emergency 4
medical condition to another hospital with capabilities to provide the needed care and treatment for the patient. 13. A practitioner at CSM s who is privileged in Basic Ventilator / Level I Ventilator Management is expected to seek a consultation on ventilator management with a member of the Division of Pulmonary Medicine within 24 hours of initiating ventilator support for a given patient. B. PATIENT TRANSFERS 1. The attending/admitting practitioner will be notified of all patient transfers. a. Patient Transfers within the Hospital. 1) Priorities for patient transfers within the Hospital shall be as follows: a) In-house emergencies to appropriate patient bed. b) Emergency Dept. to appropriate patient bed. c) From Medical/Surgical Intensive Care Unit (Med/Surg ICU), Cardiovascular Intensive Care Unit (CVICU), and Neuro Critical Care Unit (NCCU) to other special or general care unit. d) From Obstetric patient care area (unit) to general care area, when medically indicated. e) From temporary placement in an inappropriate geographic or clinical service area to the appropriate area for the patient. 2. Patient transfers with an emergency medical/surgical condition to other facilities in an emergency shall be governed by the hospital s Emergency Medical Treatment and Active Labor Act (EMTALA). 3. Patient transfers in all other scenarios shall be governed by the hospital s Transportation of Patients within a CHN Facility Policy. C. DISCHARGE OF PATIENTS 1. Patients shall be discharged on the order of the attending practitioner, his/her designated alternate practitioner, or his/her designated nurse practitioner/physician assistant. Should a patient leave the hospital against the advice (AMA) of the attending practitioner or by elopement, a notation of the incident shall be made in the patient s medical record. In the case of the AMA the patient will be asked to sign the acknowledgement form indicating that he/she understands he/she is leaving against medical advice. 2. All patients will be assessed for discharge planning needs upon admission. The Professional Staff shall assist the Hospital in its efforts to identify patients who 5
require planning by informing Nursing/Case Management of any patient the practitioner feels may need assistance. 3. In the event of a hospital death, the deceased shall be pronounced dead by the attending practitioner or his/her designee within a reasonable time. The declaration of death and anatomical donations shall be made in accordance with hospital policy. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of the medical staff. Exceptions shall be made in those instances of incontrovertible and irreversible terminal disease wherein the patient's course has been adequately documented prior to death. 4. The Professional Staff should attempt to secure autopsies in all cases of unusual deaths and of medical-legal and educational interest. The attending practitioner shall be notified that an autopsy will be performed. Every staff member shall be actively involved in obtaining autopsies whenever appropriate and shall act in accordance with CHN s Policy on Autopsies and Reportable Deaths. 5. Discharge summaries containing the elements defined by Joint Commission and Medicare Conditions of Participation (CoP) shall be completed (including authentication) as soon as possible but no later than fifteen (15) days following discharge of the patient. D. MEDICAL RECORDS 1. The attending/admitting practitioner shall be responsible for the preparation of a complete and legible medical record for each patient she/he admits to the hospital. 2. All entries in the medical record will be signed, dated and timed. Signatures will be universally identifiable or accompanied by the printed name. Signatures can be electronic when applicable. Stamped Signatures are not acceptable on any medical record. All dictated/transcribed reports will be electronically signed within the health information repository (Appropriate designated Electronic Medical Record (EMR). 3. Access to patient medical records shall be limited to instances in which access to the patients protected health information is necessary for Treatment, Payment, or Healthcare Operations. 4. The record shall include patient identification data and dates of service. It will also contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. 5. Each medical record should contain, as applicable, the following information: a. For all inpatients, the record should contain a history and physical, special reports such as consultations, clinical laboratory, radiology and other 6
ancillary services, provisional diagnosis, medical or surgical treatment, operative/procedure reports, pathological findings, progress notes, final diagnosis, condition on discharge, discharge medications and summary (or discharge note for uncomplicated cases with a length of stay less than 48 hours) and an autopsy report when performed. A complete medical record consists of, but is not limited to, the following documents: 1) Authenticated discharge summary or short stay note 2) Authenticated history and physical 3) Authenticated consultation(s) when performed 4) Authenticated operative and/or procedures note(s) when performed 5) Authenticated Postop Note when surgery or procedure performed 6) Authenticated ancillary test results (i.e., Radiology, Nuclear Medicine, Echocardiographs, EKGs, etc.) 7) Authenticated progress note(s) 8) Authenticated orders, (written, telephone or verbal) 9) Medication Reconciliation on admission, for a transfer of level of care, and at discharge. 10) Authenticated pre-surgical evaluation as applicable 11) Authenticated pre and post-anesthesia records (when utilized) 12) Authenticated Emergency Dept. record as applicable 13) Authenticated face sheet/diagnosis summary or Coding Query sheet 14) Other Health Information Management documents requiring completion by or the authentication of a member of the Medical Staff 6. For all ambulatory surgery patients, and any other ancillary services departments where patients receive moderate sedation/analgesia, the record should contain History and Physical, special reports such as consultations, clinical laboratory and radiology services and others; provisional diagnosis, medical or surgical treatment, operative/procedure reports, pathological findings, progress notes, final diagnosis, condition on discharge and discharge medications. 7. The current Obstetrical record shall contain a complete record as well as current information contained in the history and physical of a general admission. The prenatal record may be a legible copy of the attending practitioner s office record transferred to the hospital before the admission, but an interval note must be written or dictated that includes pertinent additions to the history and any subsequent changes in the physical findings within 24 hours of admission and in cases on the chart before a procedure or surgery is performed. 8. In the case of normal newborn infants and uncomplicated obstetrical deliveries, a final progress note or pre-printed OB Discharge Summary Form may be used in lieu of a dictated discharge summary. The discharge summary and/or the final progress note must contain the diagnosis. In cases where Cesarean Section is performed a dictated discharge summary must be done. 7
9. For Emergency Department (ED) patients the record should contain chief complaint, with a history of the present illness, past medical history, social history*, family history*, review of systems*, physical exam, special reports such as procedure notes, EKG interpretations, ED course including pertinent laboratory and radiological findings, medical decision making, impression, plan and discharge medications. (*In the Emergency Department these three are optional depending on the level of service provided.) Emergency Dept. records on all patients seen will be completed before the practitioner ends his/her shift. 10. Symbols and abbreviations may be used only when they do not appear on the unapproved abbreviation list. The official record of unapproved abbreviations is kept on file in the Health Information Management (HIM) Department and on the CHN Web site 11. The HIM Coding Query Sheet may be placed on the chart when Diagnosis and Procedure coding clarification is needed. When implemented by the HIM coding staff this form must be updated and signed by the requested practitioner with clarification of questionable or needed documentation. 12. The principal diagnosis shall be the condition established after study to be chiefly responsible for admission to the Hospital. Other diagnoses identify complications and co-morbid conditions that coexist at the time of admission, develop subsequently, or that affect treatment and/or length of stay. 13. The principal procedure is the procedure that most directly relates to the reason for admission. Other procedures are procedures performed during the hospital stay. a. Individuals having authority to make entries in the Medical Records are: professional staff, nursing staff, Advanced Practice Providers (APP), and hospital non-physician clinical and ancillary staff providing care for the patient and/or as deemed by a practitioner s order. g. A medical record shall not be permanently filed until it contains all required reports and signatures by the responsible physician or is ordered to be filed incomplete by the Chief of Staff, Chief of Staff Elect, or Medical Executive Committee (MEC) or designees under the conditions defined in the Policy titled Administrative Closure for Incomplete Medical Record. b. Corrections to entries in the medical record can be made by the individual author of the entry or his/her designee that is a member of the same physician group, or a Department chairperson or a Division chief. All hard copy corrections are made by placing one line through the error, labeling it as error, making the correction, and dating/timing and authenticating the correction. c. Corrections, modifications or late entries to dictated reports may be made in the EMR: 8
1) Preliminary reports (prior to electronic signature): If a document has yet to be e.signed, edits, additions, and deletions can be made to the document. Follow the EMR process for Modifying Preliminary Documents. 2) Final Documents (after electronic signature): If a document has been e.signed it can be accessed in the EMR and an addendum created. Follow the EMR process for Modifying Final Documents. This modification will appear as an addendum at the bottom of the document. 3) The provider will electronically sign the modified report in the EMR. Date/Time will be auto stamped by the EMR at the time of author modification and e.signature. 14. History and Physical Examinations. a. History and physical examinations shall be performed as required by regulations and addressed in the Common Professional Staff Bylaws. 1) An admission history and physical examination (H&P) should include all pertinent findings. a) A H&P performed prior (within 30 days) to the day of Outpatient surgery or procedure or prior to the patient s presentation to the hospital will be reviewed by the practitioner who will complete an update to the patient s condition noting any changes, or stating no change. This update must be dated, timed and signed by the practitioner. b) In the event the patient is currently an inpatient and requires surgery and/or an invasive procedure, the progress notes shall suffice as the update to the H&P. c) When the patient is admitted for an entirely different disease process than that of a previously recorded H&P, a new history and physical examination shall be performed and documented by a practitioner. d) When the H&P was performed greater than 30 days prior to admission or procedure, a new history and physical must be performed prior to the surgery or procedure. e) When the H&P are not recorded before an operation or any potentially hazardous diagnostic procedure, the procedure shall be canceled unless the practitioner states, in writing, that such delay would be detrimental to the patient. f) Both the H & P and any updates must be performed by a practitioner that has been granted privileges to do so. 15. History and Physical Content: 9
a. The H&P should contain sufficient information necessary to support the diagnosis/condition, and justify the care, treatment, and services required. b. The content of the H&P should contain, at a minimum, the following: 1) Chief Complaint 2) History of present illness 3) Past history 4) Medications 5) Allergies 6) Review of systems 7) Physical exams appropriate for the diagnosis and/or procedures performed as well as the Cardiopulmonary and Neurological systems. 8) Conclusion and impressions 9) Plan of Management 16. The hospital provided pre-printed Short Form H&P may be substituted for the complete dictated history and physical for admissions which are not anticipated to extend past forty-eight (48) hours. 17. Progress notes: a. Pertinent progress notes shall be recorded at the time of observation sufficient to present continuity of care and easy transfer of patient care. Whenever possible, each of the patient's clinical problems should be clearly identified in the progress notes and correlated with the specific orders as well as results of tests and treatment. Progress notes shall be written at least daily on all patients (exceptions noted in the appendices). 18. Operative and Procedure Notes: a. All operations and other invasive and/or high risk procedures performed shall be fully described by dictation utilizing the hospital s dictation system. A post-op note must be recorded in the patient s chart immediately after the procedure (written in the designated post-op progress note or electronically where applicable), before the patient leaves the procedural recovery area, to include at least the following: 1) Name of the primary surgeon and assistants, 2) Findings, 3) Technical procedure performed, 4) Specimens removed, 5) Blood Loss, if any, 6) And the post-op diagnosis. 19. Anesthesia records. 10
a. Anesthesia records shall include a pre-anesthetic evaluation and documentation of all pertinent events taking place during the induction of, maintenance of, and emergence from anesthesia, including the dosage and duration of all anesthetic agents, other drugs, intravenous fluids, and blood or blood components. Post-anesthetic notes shall be completed within twenty-four (24) hours following the completion of the anesthetic event. 20. Consultations: a. Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, and the consultant's opinion and recommendations. This report shall be made a part of the patient's record. When operative procedures are involved, the consultation note shall be recorded prior to the operation, except in emergency situations. 21. Medication Reconciliation: E. ORDERS a. The attending physician or physician responsible for the immediate care of the patient will review and reconcile the patient s current medications on admission, change in patient s level of care, and at the time of discharge. This includes any medications that have incomplete, unclear, or ambiguous information, especially when this information was provided by the patient or patient s caregiver. 1. Practitioner orders for treatment shall be given in accordance with the CHN Orders for Medical Treatment Policy. 2. All orders must be entered directly into the EMR or written clearly, signed, dated, timed, or authenticated. When the written order carries over to an additional page or pages, all pages will be signed, dated and timed. Another covering MD/DO responsible for the care of the patient may authenticate the order when the author of the order is not available. Orders, which are illegible, improperly written, or ambiguous, will not be carried out until clarified or rewritten. 3. Computerized provider order entry (CPOE) is the standard order entry process (where available). a. Telephone or verbal orders must be authenticated the earlier of the following: 1) The next time the practitioner accesses or documents on the patient s medical record, or 2) Within72 hours from the time the order was issued 11
F. MEDICAL RECORD DELINQUENCY AND SUSPENSION: 1. It is the policy of the medical staff to ensure timely completion of medical records in accordance with the regulations and quality-of-care standards applicable to this section. All medical records entries excluding dictated Discharge Summary reports with signatures shall be completed prior to discharge. a. Definitions: 1) A delinquent medical record is defined as a patient s record that does not contain the following documents, reports or signatures, dates and times as applicable, within fifteen (15) days following a patient s discharge. a) Dictated and authenticated discharge summary or short stay note b) Dictated and authenticated history and physical c) Dictated and authenticated consultation(s) when applicable d) Dictated and authenticated operative or procedure notes (when applicable) e) Authenticated Emergency Dept. Record dictation when applicable f) Any handwritten, preprinted form or report from the office that suffices the above reports shall be completed and authenticated/dated and timed. g) All orders including telephone/verbal orders. h) Completed and authenticated HIM Coding Query. i) Other Health Information documentation as deemed delinquent by the Medical Executive Committee. 2) Delinquent list: Names of providers with records greater than 15 days post episode. 3) Temporary suspension by the Medical Executive Committee (MEC). a) The practitioner may NOT schedule elective admission, surgeries, or procedures. b) The practitioner may NOT interpret ancillary tests. c) The practitioner may NOT accept transfer of inpatients from another practitioner. d) The practitioner may NOT consult on inpatients. e) The practitioner may be required to attend MEC meeting. f) The practitioner will maintain responsibility for his/her call obligations while on temporary suspension. 12
4) Unavailability of the practitioner a) Out of town b) Medically incapacitated 5) Unavailability of medical record a) Not available at time of request 2. The admitting physician is responsible for completion of the medical record. However, the physician may make arrangements with another covering Licensed Independent Practitioner familiar with the patient to complete the medical record. The admitting physician will have ultimate responsibility for completion of the medical record except as outlined by the Hospital Medicine Division. 3. Temporary MEC suspension will continue until all incomplete records (delinquent and non-delinquent) are completed or until the Health Information Management Department, the Chief of Staff, or the Medical Executive Committee (MEC) declare the records complete. If an appointee for reapplication is on temporary MEC suspension for incomplete medical records at the time that his/her application is being processed by his/her respective Department Chair, his/her file will not be further processed until the applicant has addressed his/her deficiencies and is no longer on the suspension list. If an appointee resigns from the Professional Medical Staff with incomplete medical records, he/she will not be considered to have resigned in good standing, and such status may be shared with other entities, should inquiries be made on his/her behalf. 4. Failure to complete the medical record within 15 days will result in being placed on the HIM Delinquent List. 5. Exemptions to being placed on the HIM Delinquent List will include (a) unavailability of the medical record and (b) unavailability of the practitioner. 6. All other medical record entries will be monitored on a weekly basis by the HIM department. These medical record entries may consist of but are not limited to authentication, date and time on: Verbal/Telephone orders, Progress notes, consents, intra-operative record, etc. The results of these monitors will be reported to the Professional Staff Committees as appropriate, the MEC and/or the Patient Safety and Quality Council for further action. 7. When a name remains on the HIM Delinquent List for greater than two (2) weeks, the provider will be placed on the MEC temporary suspension list for medical record delinquency. 8. When a provider remains on the MEC temporary suspension List for an excessive number of weeks with an excessive number of charts (as determined by the Chief of Staff and/or MEC), attendance at the MEC may be required. The Chief of Staff 13
Elect will call the provider and the Chief of Staff will send a letter to the provider to notify him/her that attendance at MEC will be required. Repeat offenders may be suspended from the Professional Staff and reported to the State Medical Board. G. GENERAL CONDUCT OF CARE 1. Each member of the Professional Staff must assure timely and appropriate medical care for inpatients and outpatients under their care when it is their duty to do so. When the requirement to provide such care is in effect (on-call or on-duty), and the physician is unable to do so, alternative coverage must be arranged by the physician and, at that time, communicated to the Professional Staff services office and all affected patient care areas. The physician must respond to his/her initial contact within 15 minutes. If the situation is an emergency vs. urgent or routine, the physician must be available in the hospital 30 minutes from the time that the contact is answered (exceptions to this requirement include clinical situations that define an alternative response time). These times are what is allowed and should not be construed as the standard to be achieved. Physicians should strive for the shortest response time possible given the individual circumstances. If a physician or NP does not make arrangements for an eligible, alternative to care for his/her patients during the absence, notice shall be given to the Medical Executive Committee for corrective action consistent with the Professional Staff Bylaws. 2. Informed consent is required for all invasive procedures performed under nonemergent conditions as outlined in the Consent for Treatment Policy. It is the responsibility of the physician or licensed professional performing the procedure to obtain informed consent from the patient or legal representative. 3. Patient transfers are addressed by the EMTALA Policy for the Emergency Department and the Transfer of Patients to Other Facilities where appropriate. 4. For the protection of patients, personnel, and the hospital, precautions to be taken in the care of the potentially suicidal patient include: a. Any patient known or suspected to be suicidal in intent shall be admitted to an appropriate medical or behavioral health unit. If necessary, the patient may be referred, if possible, to another institution where suitable facilities are available. b. When a transfer is not possible due to a patient s medical condition, the patient may be admitted to a general area of the hospital and special nursing supervision will be provided. c. Any patient known to be suicidal should have a consultation by a member of the behavioral health staff and the nursing staff should be notified of the consult by a note on the order sheet. The consult should be obtained by a physician s order that specifies the reason for the consult. 14
5. Medications for patients are routinely supplied through the hospital pharmacy on order of the physician, or qualified APP. a. Medications, which are brought into the hospital with patients, shall not be used unless they are specifically ordered by a physician. The order shall state, Patient may take own medications and shall contain the name and strength of the medications, route of administration, and the dosage schedule. b. Administration of a patient s own medication by hospital staff or a patient self-administration of medication shall be governed by the Self- Administration Medications Policy. c. Pharmacy personnel may dispense and nursing personnel may administer "Formulary equivalent" medication in lieu of a particular brand or trade name of medication ordered by practitioners. A "Formulary Equivalent" is a drug of therapeutic and/or chemical equivalence. d. Blanket medication orders such as meds as at home, resume pre-op meds, or continue same medications are not acceptable. e. All medication orders are discontinued for patients transferred from rehab or mental health to an inpatient unit or vice versa, as this represents an admission/discharge process. f. Certain classes of medications shall be given an automatic stop order based on the various risks associated with each class. Automatic stop orders shall be determined by each individual hospital. 6. The hospital shall approve the use of medications and devices under investigation by the U.S. Department of Health and Human Services and the Food and Drug Administration through their Institutional Review Board, which shall address such issues as patient selection, informed consent to participate in the trial. 7. In the event the medical needs of the patient exceed the Clinical Privileges of the attending practitioner, appropriate consultation will be obtained. In the event appropriate consultation is not obtained, the chief/chairperson of the attending s division/department may be notified. a. Any qualified practitioner with Clinical Privileges in this hospital can be called for consultation within his/her area of expertise. A satisfactory consultation includes examination of the patient and record. A written opinion signed by the consultant must be included in the medical record. When operative procedures are involved, the consultation note, except in an emergency, shall be recorded prior to the operation. b. Except in an emergency, consultations with another qualified practitioner are required in cases which fall outside the competence of the practitioner. 15
c. The recommendations of the consultants will not justify a violation of the Ethical and Religious Directives. The hospital may require consultation in certain cases. d. The attending practitioner is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant. He/she will provide written authorization to permit another attending practitioner to attend or examine his/her patient, except in an emergency. 8. In House Consultations: a. The requested physician s name must be entered directly in the EMR or an order for the consultation must be entered in the physician s orders section. The order must be entered directly in the EMR or legibly written, timed, and dated by the requesting physician. b. The order for consultation shall include the following: 1) The consultant s full and correct name and specialty or 2) On call practitioner for specialty service requested. 3) Specify what is requested of the consultant (procedure to be performed, consultation and treatment, or consultation only, etc.) with a specific reason for consultation legibly written/entered in the physician's orders section. 4) Clearly explain any qualifying data with respect to patient s requests or other stipulations. 5) Specify a requested time for completion (routine, urgent, or emergent). c. Consultation response times are defined as follows: 1) Routine: Consultation will be performed within twenty-four (24) hours. 2) Urgent: Consultation will be performed within twelve (12) hours 3) Emergent: Consultation will be performed within four (4) hours. d. If the consultation request is urgent or emergent, the ordering physician will communicate directly with the consultant the reason for consultation, what is requested, important clinical data, and the requested time frame for completion. e. If the requesting physician is unable to procure an emergency consultation for an in house patient, the physician on call for the emergency dept. in the appropriate specialty is ultimately responsible to perform the consultation. 16
f. Consultant will accept or decline routine consult within 2 hours of notification. They may advise the ordering physician or the unit clerk who will notify the ordering physician. g. In general, consultants may write orders in the physician s orders section. h. The consultant will complete preliminary note in the progress notes section of the patient s medical record when assessing the patient and dictate a complete consultation note within 24 hours of initial patient assessment. H. GENERAL RULES REGARDING SURGICAL CASES 9. Surgical procedures shall be scheduled with the surgery scheduling department. History, physical and provisional diagnosis shall be completed and physically available in the operating room before any surgical procedure begins, except when such delay would constitute a hazard to the patient's life. The surgeon must certify that such a situation exists. Failure to complete the record except as herein stated shall place in effect the same rule, as being late for surgery, and the same penalty shall apply. Appropriate laboratory work, as ascertained by the Attending practitioner or surgeon shall be obtained and recorded prior to any elective procedure. 10. For details on the designated tissues removed during an operation, handling and disposition of surgical specimens, see the Patient Care Services Surgical Specimens Policy. 11. The surgeons and anesthesiologists shall be on time for scheduled surgical procedures. Failure to adhere to scheduling start times is addressed in the Block Scheduling Policy. 12. A physician's assistant (PA), RNFA, SFA, CSA, or Nurse Practitioner (NP) may be first assistant provided he/she is credentialed and authorized to assist for the procedure being performed. 13. No unauthorized personnel will be allowed in surgery or in the delivery room. 14. Any person administering a major anesthetic will be required to make a pre- and post-operative note on the chart as to the patient's condition and any pertinent findings. All patients getting deep sedation must have an ASA Risk/Rating Assessment according to the Deep Sedation / Analgesia Policy. 15. Emergency procedures will be expedited as much as possible. In general, such procedures shall follow the elective procedures previously scheduled for the day. When the seriousness of the case justifies the need, it will take precedent over all elective procedures. The practitioner requesting the emergency procedure will call the practitioner with the scheduled/elective procedure to request the schedule change. The call priority sequence would be a partner with a scheduled procedure 17
followed by an alternative practitioner. If the two practitioners involved cannot agree, the problem will be presented to the Chair of the Surgery/Neurosciences/Women & Infant Department or his/her designated representative who will determine a suitable plan. 16. All non-credentialed individuals may observe in surgery as part of an overall educational program having prior approval of the hospital, the attending physician, and the patient or his/her authorized representative. 17. No flammable anesthetizing agent shall be used in any location of the hospital. 18. Surgeons are expected to adhere as closely as possible to their scheduled times. H. EMERGENCY SERVICES 1. The Professional Staff shall adopt a method of providing medical coverage in the emergency services area. This shall be in accord with the hospital's basic plan for the delivery of such services, including the delineation of clinical privileges for all professional staff members who render emergency care. The Medical Executive Committee shall supervise call panels through each division/department. a. CSJ s and CHC only: The rules as outlined in this Section H. shall also pertain to the Labor and Delivery Services area call schedule for walk-in patients. 2. Each division/department within the hospital shall provide a roster of practitioners who will be "on-call" to the Department of Emergency Services for a period of time on a rotating basis. The schedule of the "on-call" practitioners shall be the responsibility of the various divisions/departments and it shall be presented to the Department of Emergency Services on a periodic basis where it will be posted. These practitioners will visit the emergency or call patients at the request of the Emergency Department practitioner. 3. All Emergency Department patients will be seen by a practitioner and/or an Advanced Practice Provider (APP). The APPs who are credentialed by and authorized to work in the Emergency Department may see and treat patients in the Emergency Department and will be supervised by a physician. 4. Individual practitioners shall maintain sole responsibility for his/her assigned call and their names are to be identified on the list. Physician group names are not acceptable for identifying the on-call practitioner. Staff members assigned to Emergency Dept. Call may arrange for either intermittent or permanent coverage of this duty with another practitioner(s) who maintains the required staff privileges. However, it remains the responsibility of the individual practitioner to make arrangements with his/her chosen substitute and to notify the Medical Staff Office and the Emergency Department on a weekend, holiday or for a same day change of the substitute to ensure that the Emergency Department is notified when the Medical Staff Office is closed. When practitioners are on the Emergency Dept. 18
Call roster and are chronically absent from active presence in the facility or actively taking call, the situation will be brought to the MEC to be evaluated and addressed. Chronic absence is defined by absence in the facility providing patient care over a six (6) month period. 5. All practitioners on the call schedule for stroke patients (identified as Brain Attack) and cardiac patients (identified as STEMI call) shall be available to respond within five (5) minutes either by telephone or in person at the hospital and arrive at the hospital within thirty (30) minutes from the notification. 6. When a Particular Specialty Is Unavailable to Provide On-Call Coverage: If the Hospital has determined that there is a particular specialty, which is unavailable to provide on-call coverage during certain days per month or on an ongoing basis due to a lack of specialists to provide such on-call coverage, the hospital director/manager of the Emergency Department or clinical supervisor and Emergency Department practitioner shall facilitate the transfer of the patient with an emergency medical condition to another hospital with capabilities and capacity to provide the needed care and treatment to the patient. The Memorandum of Transfer (MOT) shall reflect the patient s transfer is for a higher level of care since the particular specialty is unavailable at the Hospital at the time the patient with the emergency medical condition presented to the Emergency Department. The Hospital shall comply with all other requirements to effectuate an appropriate patient transfer. 7. When the on-call physician is unable to respond due to a situation or circumstances beyond the practitioner s control: If the Hospital s Emergency Department associates or the Emergency Department practitioner determine that a physician is unable to come to the Emergency Department when requested to care for a patient with an emergency medical condition as the on-call physician because of a situation or circumstances beyond such practitioner s control, the following actions shall be initiated: a. The physician in the ED and the director/manager of ED or clinical supervisor, after hours, shall initiate a call to the chief/chair of the division/department and the administrator on call to identify other alternatives, if any. b. If no other practitioner can be identified, the hospital associates and the ED physician shall facilitate the transfer of the patient with an emergency medical condition to another hospital with capabilities and capacity to provide the needed care and treatment to the patient. 1) The MOT shall list the name of the on-call practitioner and describe the situation or the circumstances as to why the on-call practitioner is unable to respond to support the need for the patient s transfer. The MOT shall include a practitioner certification should the patient be transferred in an unstable 19
condition. The Hospital shall comply with all other requirements to effectuate an appropriate patient transfer. 2) For purposes of this policy, situations or circumstances that are beyond a practitioner s control include, without limitation, the practitioner is caring for patients with an emergency medical condition at another facility, the practitioner has experienced a personal family emergency, the practitioner has been in a accident or the practitioner is suffering from an illness or medical condition that prevented the practitioner from arranging another practitioner to take the on-call coverage. 8. Once consulted by an Emergency Department practitioner, the "on-call" practitioner is responsible for providing or arranging for the patient's follow-up care regardless of the patient's ability to pay. For emergent and non-emergent patients requiring consultation, a verbal communication between the Emergency Department practitioner and the on call practitioner must occur. 9. If an "on-call" practitioner is unable to provide care for an Emergency Department patient,, it will be his/her responsibility to find or assist in finding an alternate practitioner to care for the patient unless engaged in providing emergency call care. The practitioner or designee must notify the Emergency Physician that the practitioner is engaged in providing emergency call care. 10. The Medical Staff shall abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) laws and regulations. Violations of such laws and regulations shall be reported to Risk Management. 11. Qualified Medical Person (QMP) Means an individual who is licensed or certified by the Hospital s Bylaws or in the following professional categories and who has demonstrated current competence in the performance of the Medical Screening Exam competencies for professional staff which are maintained by the Medical Staff Offices. OB Nurse competencies for CSJ are maintained by Women s Health Education Coordinator. a. The following are the designated QMP s, for each facility, as defined by Emergency Department Rules and Regulations and Medical Executive Committee: 1) St. Mary s Hospital: Physicians, CHN Emergency Department Physicians, Physician Assistants, and Nurse Practitioners. 2) St. Joseph s Hospital: Physicians, CHN Emergency Department Physicians, Physician Assistant s, Nurse Practitioners and OB Nurses for Labor and Delivery. 20
3) Holy Cross Hospital: Physicians, CHN Emergency Department Physicians, Physician Assistant s, Nurse Practitioners, OB Nurses for Labor and Delivery, and the OB Manager. 12. Failure to comply is defined as, when on the Carondelet St. Mary s, St. Joseph s, and Holy Cross Hospitals Emergency Department call list for unassigned patients: a. Signing out to a practitioner not on staff at CSM, CHC, &/or CSJ (as applicable). b. Refusal to make best efforts to find an alternative practitioner to care for an Emergency Department patient if for any reason the on-call practitioner cannot comply. c. Refusal of a practitioner to whom the on-call practitioner has signed out to, to care for the patient. In this instance, the practitioner refusing to care for the patient is failing to comply. d. Refusal to visit, or care for the patient, or refusal to make best efforts to respond within 30 minutes at the Emergency Practitioner s explicit request. e. Refusals to either see or arrange for appropriate follow-up care by the practitioner s office for a call patient. f. Failure to make best efforts to respond to a call from the CSM, CHC, &/or CSJ Emergency Department, which includes but is not limited to: not answering a call, page, or message from the Emergency Department within 15 minutes. g. Failure to notify the Medical Staff Office and the Emergency Department on a weekend, holiday or for a same day change of the substitute to ensure that the Emergency Department is notified when the Medical Staff Office is closed of alternate arrangements made with another practitioner(s) to provide scheduled ER call. h. For any reported failure of an on-call practitioner to comply with their responsibilities as defined by these Rules and Regulations. 13. The investigation of the reported violation shall be carried out by the Chairs of the appropriate Departments in conjunction with the Medical Staff Office. If after investigation the Chairs of the respective Departments and/or Division Chief where appropriate feel that the practitioner s actions (with respect to noncompliance with the call schedule) constitute a violation of the Professional Staff Rules and Regulations, the Chair of the Emergency Department shall contact the Chief of Staff or his/her designee and provide all appropriate documentation concerning their investigative findings. 21