Appendix 1 - Licensing and Audit Requirements for Emergency Department Services

Appendix 1 - Licensing and Audit Requirements for Emergency Department Services Number Urgent Care Centres Emergency Department Emergency Department with Major Trauma Centre 1. Access 24/7 (This requirement is likely to reduce as the standard for emergency departments embeds within the emirate. In the meantime urgent care centres can on an individual basis seek written exception to this requirement from HAAD) treats the least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. Ability to access, refer and prepare for the safe transportation of the patient directly to relevant specialties or to local hospital, using emergency ambulance as appropriate. All physicians trained in adult and pediatric resuscitation, Capable of providing definitive care to >70% of cases attending the Center. Have on-site diagnostic services such as phlebotomy and x-ray Open 24hours a day, seven days a week with access to comprehensive emergency services. Emergency Centres a healthcare facility devoted to providing emergency medical care, through emergency consultant clinical leadership with a certifiied and licensed emegency physician (consultant/specialist) on site at all times. Capable of providing definitive care to >90% of cases attending the emergency department. Mandatory for all public hospitals Emergency Medicine Internal Medicine General Surgery Radiology Clinical Pathology services Anaesthetics Theatres Critical Care Psychiatric assessment area Decontamination facilities Designated area for the assessment and management of paediatric patients Open 24hours a day, seven days a week access to comprehensive trauma services. Major Trauma Centres - designated healthcare facility capable of providing comprehensive tertiary trauma care, including acute emergency care, operative care, access to subspecialties and rehabilitation. Emergency Departments in facilities designated as Major Trauma Center must meet accepted international trauma standards such as 24/7 rapid access CT/MRI and have 24/7 Consultant led trauma teams. Major Trauma Centres are supported by a network of healthcare facilities designated as Trauma units, which together with pre hospital care, form the Trauma System. In addition, specialities noted in for Emergency Department. Major Trauma Centres should also have consultant led services ( supported by doctor presence 24/7 and the availablity of a consultant opinion within 30 mins) in: Neurosurgery Spinal Surgery Trauma and Orthopaedic Surgery Critical Care Vascular Surgery Cardiothoraric Surgery Plastic Surgery Interventional Radiology Oral/Maxillofacial Surgery Rehabilitation Page 1 of 13

Services that should be available within 30 mins ( though not required to be on site Obstetrics and Gynaecology General Medicine Urology Ophthalmology ENT Cardiology Neprhrology Care of the Elderly Psychiatry Endocrinology The designation of the Major Trauma Centres in the Emirate of Abu Dhabi has already taken place and the centres are as follows: - Abu Dhabi - Al Mafraq Hospital & Sheikh Khalifa Medical Centre - Al Ain - Al Ain Hospital or Tawan Hospital (to be confirmed by SEHA) 2. Assessment, stabilisation & care Immediate care but not serious to require ED visit. Assessment and early treatment of patients Patients with an immediate risk /threat to a person s life, limb, body function or long-term health are stabilized and transferred to an emergency department by emergency ambulance Resuscitation of patients with life-threatening illness or injury. Assessment and early treatment of patients with sudden serious illness or injury, including those who self-present 5 Level Triage to be used Management of patients requiring a short period of programmed investigations and observation to ensure safe discharge of patients with symptoms that might suggest serious disease and avoid unnecessary hospital admissions - Western Region - Madinet Zayed Hospital (to be confirmed by SEHA) Major Trauma Centres A designated Major Trauma Resusication Team should be in place 24/7 to manage Resuscitation of patients with lifethreatening illness or injury (trauma level). Assessment and early treatment of patients with sudden serious illness or injury, including those who self-present 5 Level Triage to be used Page 2 of 13

Stable patient should be discharged or referred to planned care according to their clinical condition. Patients with the following life threatening conditions are referred to Trauma Centre by emegency ambulance List conditions that require transfer to Major Trauma ED Anatomical Criteria (one or more of the following): Suspected spinal cord injury with paraplegia or quadriplegia Moderate-to-severe head trauma Severe (or suspected severe) penetrating injury to the head, neck, torso or groin (stab wound, RTA or GSW) A requirement for blood products to maintain vital signs Amputation above the wrist or ankle Pelvic fractures with hemodynamic instability or significant hematoma Major crush or vascular injury Trauma with burn or inhalation injury Physiological Criteria GCS <10 due to traumatic injury Significant alteration of consciousness due to trauma Hypotension (due to trauma) that is unresponsive or only transiently responsive to fluids Hypothermia (Body Temp) < 32 C (with traumatic injuries High-risk considerations that may warrant transfer to Lead Trauma Center at a lower threshold. These considerations include: Age > 55; Anticoagulation; Immunosuppression; Pregnancy; or Other significant medical problems. A CT Scan may not always be required for the decision to transfer if it will delay definitive management Management of serious patients requiring a period of programmed investigations, treatment and observation to ensure safe discharge of patients. Page 3 of 13

See section 3.4 for requirements of Urgent Care Centre See section 3.3 for requirements of Emergency Department See section 3.2 for requirements of Major Trauma Centre Information and medical record regarding patient consultation is transferred to receiving clinician. Processes and policies to ensure that ambulance staff who are providing patient care can alert ED of patient condition ahead of arrival using ATMIST/ASHICE format; seek medical advice, if needed from Lead/receiving Emergency Physician while in transit or at scene; pass responsibility for patient care to hospital staff within 20 minutes of arrival in the destination Emergency Department 90 per cent of the time; Processes and policies to ensure that ambulance staff who are providing patient care can alert ED of patient condition ahead of arrival using ATMIST/ASHICE format; seek medical advice, if needed from Lead/receiving Emergency Physician while in transit or at scene; pass responsibility for patient care to hospital staff within 20 minutes of arrival in the destination Emergency Department 90 per cent of the time; 3. Admission & Handover N/A N/A Policies and procedures to ensure that all in-patient services are available, including consultations and therapies to reduce time to definitive treatment, as soon as hospital admission is requested Patient care responsibilities must be clearly verbally communicated between the most responsible staff before and after breaks. Policies and procedures to ensure that all in-patient services are available, including consultations and therapies to reduce time to definitive treatment, as soon as hospital admission is requested Patient care responsibilities must be clearly verbally communicated between the most responsible staff before and after breaks. End-of-shift care responsibilities must be communicated with case summaries between out-going and oncoming staff. End-of-shift care responsibilities must be communicated with case summaries between out-going and on-coming staff. Summaries must highlight care plans and any patientspecific outstanding issues. Summaries must highlight care plans and any patientspecific outstanding issues. Staff scheduling must be designed to account for the time it takes to do this safely Staff scheduling must be designed to account for the time it takes to do this safely 4. Surge capacity, disaster & mass casualty events Planning, delivery, management and coordination with other facilities (hospitals, centres, clinics) Planning, delivery and management of the emergency care system at facility level and in coordination with other facilities (hospitals, centres, clinics and prehospital care) Planning, delivery and management of the emergency care system at facility level and in coordination with other facilities (hospitals, centres, clinics and pre-hospital care) Page 4 of 13

Contingency planning to cope with major incidents or periods of huge or fluctuating demand (such as a flu pandemic) Contingency planning to cope with major incidents or periods of huge or fluctuating demand (such as a flu pandemic) Contingency planning to cope with major incidents or periods of huge or fluctuating demand (such as a flu pandemic) Policies and procedures in compliance with the HAAD Standard for Medical Emergency Preparedness at Mass Gatherings Policies and procedures in compliance with the HAAD Standard for Medical Emergency Preparedness at Mass Gatherings Policies and procedures implemented in compliance with the HAAD Standard for Medical Emergency Preparedness at Mass Gatherings Development and implementation of evidence based care pathways and practice guidelines Development and implementation of evidence based care pathways and practice guidelines Development and implementation of evidence based care pathways and practice guidelines Not defined Establishment of clinical decision unit comprised of specialised multidisciplinary team to support emergency physicians with the management of certain cases where it is decided to treat a condition over several hours anticipating a patient to be discharged safely following treatment in emergency department Establishment of clinical decision unit comprised of specialised multidisciplinary team to support emergency physicians with the management of certain cases where it is decided to treat critical conditions 5. Quality & Safety Communicate clear information concerning patient treatment, management and care options appropriately to the patient or their family, including the need for referral and transfer to another care provider, where the case requires so Communicate clear information concerning patient treatment, management and care options appropriately to the patient or their family, including the need for referral and transfer to another care provider, where the case requires so Communicate clear information concerning patient treatment, management and care options appropriately to the patient or their family, including the need for referral and transfer to another care provider, where the case requires so Quality and safety committee to monitor, assess and improve performance and report on adverse incidents in accordance with the HAAD Standard for Adverse Incident Management and quality policy Quality and safety committee to monitor, assess and improve performance and report on adverse incidents in accordance with the HAAD Standard for Adverse Incident Management and quality policy Quality and safety committee to monitor, assess and improve performance and report on adverse incidents in accordance with the HAAD Standard for Adverse Incident Management and quality policy Page 5 of 13

Quality and safety indicators (in line with required HAAD standards) and measurement protocols including for clinical and service delivery n/a Quality and safety indicators (in line with required HAAD standards) and measurement protocols including for clinical and service delivery Teaching and training physicians, nurses and allied health professionals employed by the facility in the care and assessment of the ill and injured patient and embedding a culture of safety and quality Quality and safety indicators (in line with required HAAD standards) and measurement protocols including for clinical and service delivery Teaching and training physicians, nurses and allied health professionals employed by the facility in the care and assessment of the critically ill and injured patient and embedding a culture of safety and quality Clinical Audit and review Clinical Audit and review Clinical Audit and review Have on-site diagnostic equipment, including phlebotomy and x-ray (plain radiography and ultrasound) 24 hours/7 days timely access to diagnostic imaging, including plain radiography, CT and ultrasound; including timely access to radiologist consultation and image interpretation 24 hours/7 days timely access to diagnostic imaging, including plain radiography, CT and ultrasound; including timely access to radiologist consultation and image interpretation. 24 hour / 7 day per week Rapid access to Pathology Services 24 hour / 7 day per week Rapid access to Pathology Services 6. Access to diagnostic imaging, diagnostic laboratory and information technology Systems, policies and operating procedures for clinical laboratory diagnostics compliant with the requirements of HAAD Standards, including the HAAD Clinical Laboratory requirements Systems, policies and operating procedures for clinical laboratory, diagnostics and compliant with the requirements of HAAD Standards, including the HAAD Clinical Laboratory requirements Systems, policies and operating procedures for clinical laboratory, diagnostics and compliant with the requirements of HAAD Standards, including the HAAD Clinical Laboratory requirements Accreditation of clinical laboratory services from an internationally reputable clinical laboratory accrediting body Accreditation of clinical laboratory services from an internationally reputable clinical laboratory accrediting body Accreditation of clinical laboratory services from an internationally reputable clinical laboratory accrediting body Not defined Emergency information system for patient tracking and performance analysis; data must be reported to and analysed by the quality and safety committee Emergency information system for patient tracking and performance analysis; data must be reported to and analysed by the quality and safety committee Page 6 of 13

Risk management processes to improve the quality of care and to minimize risk to patient wellbeing, including recording, rectifying and auditing noncompliance events Risk management processes to improve the quality of care and to minimize risk to patient wellbeing, including recording, rectifying and auditing noncompliance events Risk management processes to improve the quality of care and to minimize risk to patient wellbeing, including recording, rectifying and auditing non-compliance events All physicians trained in adult and pediatric resuscitation All physicians trained in adult and pediatric resuscitation, trauma and airway management (ACLS, PALS, Airway certification) All physicians trained in adult and pediatric resuscitation, trauma and airway management (ACLS, PALS, Airway certification) 7. Risk management & security Implement and demonstrate compliance with HAAD EHSMS policy and standards Provision of urgent care services to be in an appropriate location and in an environment that is safe and that supports all age groups, giving consideration to disability access Implement and demonstrate compliance with HAAD EHSMS policy and standards Provision of emergency care services to be in an appropriate location and in an environment that is safe and that supports all age groups, giving consideration to disability access Implement and demonstrate compliance with HAAD EHSMS policy and standards Provision of emergency care services to be in an appropriate location and in an environment that is safe and that supports all age groups, giving consideration to disability access Equipment, functional space for urgent care patients in accordance with the HAAD Facility Guideline standards and comparable to international evidence based standards Equipment, functional space and emergency accommodation in accordance with the HAAD Facility Guideline standards and comparable to international evidence based standards Equipment, functional space and trauma accommodation in accordance with the HAAD Facility Guideline standards and comparable to international evidence based standards Clinical director (authorised for decision making) to oversee, monitor and report on the urgent care services Consultant level Emergency Medicine Clinical Director (authorised for decision making) to oversee, monitor and report on the Emergency Department services Consultant level Clinical Director (authorised for decision making) to oversee, monitor and report on the Trauma Department services 8. Clinical Staffing and Staff review Consultant, Specialist or GP led services per shift. The facility must demonstrate it has in place adequate systems to inform adequate nurse staffing as per number Consultan/Speciality level Emergency Medicine Physicians on FTE capacity per shift. Emergency Department Services must have 24 hour cover from general surgeons. The facility must demonstrate it has in place adequate systems to inform adequate capacity of nurses as per number of patients seen, acuity and scope of services. Requisite mix of Consultant/Speciality level Emergency Medicine Physicians on FTE capacity per shift, together with Consultant/Speciality level subspecialties noted in section 1 access. Services must have 24 hour cover from general surgeons. The facility must demonstrate it has in place Page 7 of 13

of patients seen, acuity and scope of services. Appropriate and effective mechanisms to facilitate communication and transfer to emergency care services Availability of appropriate mix of multidisciplinary urgent care team. All full-time and part-time physicians working in Urgent care departments must have a performance review of their work annually, completed by the facility s Clinical Director N/A Professional qualities that should be considered in performance review are Clinical, Privileges, Teaching/Research, Administrative, Quality Improvement, Communication and Team Work, Appropriate and effective mechanisms to facilitate consultation with emergency physicians and other specialty care physicians (specialists/consultants) Availability of appropriate mix of multidisciplinary emergency care team, its members possessing the requisite levels of knowledge and skills in accordance with their role in providing emergency care to patients of varied acuity levels, and that staff receive appropriate and up to date training to support quality and safe emergency care Paediatric emergency departments can be staffed by trained paediatircs emergency physician (consultant or specialist), trained emergency medicine physicians (consutant or specialist) or paediatricians with exeperience in emergency medicine of no less than 5 years. All full-time and part-time physicians working in Emergency departments must have a performance review of their Emergency department work annually, completed by the facility s Emergency Medicine Director The facility Emergency Medicine Director should have a performance review annually with the Chief Medical Officer of the facility Professional qualities that should be considered in performance review are Clinical, Privileges, Teaching/Research, Administrative, Quality Improvement, Communication and Team Work, Community Outreach Involvement, Continuing adequate systems to inform adequate capacity of nurses as per number of patients seen, acuity and scope of services. Appropriate and effective mechanisms to facilitate consultation with emergency physicians and other specialty care physicians (specialists/consultants) Availability of appropriate mix of multidisciplinary emergency care team, its members possessing the requisite levels of knowledge and skills in accordance with their role in providing emergency care to patients of varied acuity levels, and that staff receive appropriate and up to date training to support quality and safe trauma care Paediatric emergency departments can be staffed by trained paediatircs emergency physician (consultant or specialist), trained mergency medicine physicians (consutant or specialist) or paediatricians with exeperience in emergency medicine of no less than 5 years. All full-time and part-time physicians working in Trauma care departments must have a performance review of their Emergency department work annually, completed by the facility s Emergency Medicine Director The facility Trauma Medicine Director should have a performance review annually with the Chief Medical Officer of the facility Professional qualities that should be considered in performance review are Clinical, Privileges, Teaching/Research, Administrative, Quality Improvement, Communication and Team Work, Community Outreach Involvement, Continuing Education (specific to Emergency Page 8 of 13

Community Outreach Involvement, Continuing Education (specific to Emergency Medicine, Nursing or Paramedicine), 360 feedback from colleagues (peers, staff, consultants, other) and patient generated feedback Education (specific to Emergency Medicine, Nursing or Para-medicine), 360 feedback from colleagues (peers, staff, consultants, other) and patient generated feedback. Medicine, Nursing or Para-medicine), 360 feedback from colleagues (peers, staff, consultants, other) and patient generated feedback 9. Surgical / Medical Residency Not required. As per HAAD approval and residency accreditation standards and to include 24 hour on site, consultant led availability of specialists including, As per HAAD approval and residency accreditation standards and to include a surgical residency programme with: Emergency Medicine Internal Medicine General Surgery Radiology Anaesthetics Critical Care 24 hours on site support as noted in Emergency Department In addition, specialities noted in for Emergency Department. Major Trauma Centres should also have consultant led services ( supported by doctor presence 24/7 and the availability of a consultant opinion within 30 mins ) in: Neurosurgery Spinal Surgery Trauma and Orthopaedic Surgery Critical Care Vascular Surgery Cardiothoracic Surgery Plastic Surgery Interventional Radiology Oral/Maxillofacial Surgery Rehabilitation Services that should be available within 30 mins ( though not required to be on site Obstetrics and Gynaecology General Medicine Page 9 of 13

Urology Ophthalmology ENT Cardiology Neprhrology Care of the Elderly Psychiatry Endocrinology An internationally peer reviewed and recognized program of clinical research including in emergency medicine; A trauma care education and training program satisfying the HAAD CME/CPD accreditation requirements 10. Registry and monitoring Establishment of an urgent care registry, including related functions of coordination of urgent care service communication and family practitioner and follow up and reporting Establishment of local emergency registry that is linked with HAAD trauma registry including related functions of coordination of trauma communication and trauma case management and follow up, and trauma data analysis, monitoring and reporting Establishment of a trauma registry that is linked with HAAD trauma registry including related functions of coordination of trauma communication and trauma case management and follow up, and trauma data analysis, monitoring and reporting Have system in place to measure in real time capacity /activity within the ED is at any given time. There should be a hospital wide escalation policy for when an ED is approaching full and the associated risks. Criteria for escalation should be determined locally. An escalation policy should involve all specialties with responsibilities for acute care. Have system in place to measure in real time capacity /activity within the ED is at any given time. There should be a hospital wide escalation policy for when an ED is approaching full and the associated risks. Criteria for escalation should be determined locally. An escalation policy should involve all specialties with responsibilities for trauma care. Emergency services have in place a Triage system that categorises patients by severity or priority for care. Routine triage in a healthcare facility should use an internationally recognised five level triage systems specific for Emergency Medicine. Trauma services have in place a Triage system that categorises patients by severity or priority for care. Routine triage in a healthcare facility should use an internationally recognised five level triage systems specific for Emergency/Trauma. Page 10 of 13

11. Support System Implementation of a comprehensive system to support urgent care service management and improvements Implementation of a comprehensive system to support emergency service management and improvements Implementation of a comprehensive system to support trauma service management and improvements 12. Patient Referral, Retrieval and Transfer The facility will have in place a patient transfer agreement with the nearest emergency care centre as per the HAAD Standard for interfacility patient transfer. The facility will have in place a patient transfer and retrieval agreement per the HAAD Standard for interfacility patient transfer for urgent care centres and trauma centres The facility will have in place a patient transfer and retrieval agreement per the HAAD Standard for inter-facility patient transfer for urgent care centres, emergency departments and trauma centres N/A The facility will have an emergency retrieval service authorised by HAAD and in accordance with the HAAD requirements for Interfacility Patient Transfer The facility will have an trauma retrieval service authorised by HAAD and in accordance with the HAAD requirements for Interfacility Patient Transfer The facility will have an urgent care response team which is defined and available to manage patients until an emergency care team arrive The facility will have an in place a defined emergency care team as per their scope of practice and be readily available for dispatch The facility will have an in place a defined trauma care team as per their scope of practice and be readily available for dispatch N/A The facility will meet the emergency transfer requirements as set out by HAAD Standard for patient referral Development and implementation of a comprehensive set of policies and procedures covering the range of Emergency services provided, and including in particular, patient hand over procedures; evidence based clinical pathways and practice guidelines; medication management and monitoring; quality and safety and outcomes reporting; and risk management The facility will meet the emergency transfer requirements as set out by HAAD standard for patient referral 13. Services Policies & Procedures Development and implementation of a comprehensive set of policies and procedures covering the range of Urgent care services provided, and including in particular, patient hand over procedures; evidence based clinical pathways and practice guidelines; medication management and monitoring; quality and safety and outcomes reporting; and risk management. Development and implementation of a comprehensive set of policies and procedures covering the range of trauma services provided, and including in particular, patient hand over procedures; evidence based clinical pathways and practice guidelines; medication management and monitoring; quality and safety and outcomes reporting; and risk management Page 11 of 13

Meets Major Incident and Disaster preparedness requirements and stipulated by HAAD Meets Major Incident and Disaster preparedness requirements and stipulated by HAAD Meet the requirements of NCEMA Business Continuity Standard and Guide AE/HSC/NCEME 7000:2012 version 1 Meet the requirements of NCEMA Business Continuity Standard and Guide AE/HSC/NCEME 7000:2012 version 1 Meet the requirements of NCEMA Business Continuity Standard and Guide AE/HSC/NCEME 7000:2012 version 1 Meet the requirement that all HAAD Healthcare facilities must provide the immediately necessary treatement to necessary to all patients regardless of insurance, residency, nationality or ability to pay. In the case of an emergency patient that requires transfer refer to section 12 above, Patient Referral, Retrieval and Transfer. All HAAD licensed Emergency Departments must clinically triage and treat all patients regardless of insurance, residency, nationality or ability to pay. The Emergency Department must provide all the necessary diagnostic and medical treatment to avoid loss of life or occurrence of damage to limb, body function or longterm health. All HAAD licensed Emergency Departments must clinically triage and treat all patients regardless of insurance, residency, nationality or ability to pay. The Emergency Department must provide all the necessary diagnostic and medical treatment to avoid loss of life or occurrence of damage to limb, body function or long-term health. 14. Clear Definition of Management & Operational Roles, Responsibilities & Accountabilities Documentation of clearly defined roles, responsibilities and accountabilities for management oversight, operational aspects (medical care and diagnostic equipment and IT systems), quality and security of medical records. The service will have clearly defined management and operational roles and responsibilities for the following : Governing Board Administration Medical Staff Nursing Services Imaging Services Documentation of clearly defined roles, responsibilities and accountabilities for management oversight, operational aspects (medical care and diagnostic equipment and IT systems), quality and security of emergency registry. The service will have clearly defined management and operational roles and responsibilities for the following: Governing Board Administration Medical Staff Nursing Services Emergency Services Documentation of clearly defined roles, responsibilities and accountabilities for management oversight, operational aspects (medical care and diagnostic equipment and IT systems), quality and security of trauma registry. The service will have clearly defined management and operational roles and responsibilities for the following : Governing Board Administration Medical Staff Nursing Services Trauma Services Medical Records Page 12 of 13

Pathology or Laboratory Services, and Medical Records Imaging Services Pharmacy Services. Imaging Services Pathology or Laboratory Services, and There is a clear sign for the facility as an urgent care centre Pathology or Laboratory Services, and Pharmacy Services. Pharmacy Services. 15. Clinical Staff Performance Evaluation and Review System A clinical staff performance evaluation and review system, linked to training and development requirements A clinical staff performance evaluation and review system, linked to training and development requirements A clinical staff performance evaluation and review system, linked to training and development requirements 17. Signage and patient information Urgent Care Centre Signage Patient information is appropriate to the facilities scope of services Emergency Department Signage Patient information is appropriate to the facilities scope of services Emergency Department Signage Patient information is appropriate to the facilities scope of services Page 13 of 13