It's about 10AM on a Wednesday morning in your hospital's outpatient infusion center located about five miles away from your main campus. A patient receiving a blood transfusion suddenly becomes hypotensive. What are your obligations under the CMS Conditions of Participation? The interpretive guidance under Appendix A of the State Operations Manual for §482.12(f)(3) form the basis for this discussion.

If you have an emergency department at your hospital, then you are required to have written policies and procedures for any off-site setting on how you will manage emergencies at that location. The policies and procedures must address at least the following:

Appraisal of the Person
Your policies must assure that there are clinical personnel at the off-site location who have the licensure, education, and training necessary to recognize when an individual has a need for emergency services. For settings where a physician, mid-level provider, or registered nurse are on-site, this won't be an issue. But there are outpatient settings (think physical therapy) where clinical staff may not automatically have the necessary skill set to recognize a medical emergency. In addition, there may be settings where there are only licensed practical nurses and unlicensed staff available. In these areas, there is technically no one who is usually permitted by licensure to perform assessment activities. In both these situations, the hospital is responsible for assuring the presence of qualified staff that can perform assessments necessary to determine an individual’s need for emergency services.

Referral when Appropriate
Your policies and procedures also need to address how personnel at the off-site location will determine if an individual requires referral or transfer to the hospital. This includes arrangement for appropriate transport of the individual along with the transfer of any medical information so that the receiving hospital may treat the medical emergency more efficiently.

Initial Treatment
While CMS does not expect off-campus locations to provide initial treatment of emergencies, they do expect that you are able to provide treatment and stabilization consistent with the complexity of services, the type and qualifications of clinical staff, and the resources available at that location. For example, it would be reasonable to expect any off-site setting to provide basic life support services by trained personnel. It would also be reasonable to expect most locations to have an automatic external defibrillator (AED) available for use. More advanced capability would depend on the nature and complexity of care rendered.

CMS would also expect that off-site settings that provide comparable services would have a comparable ability to provide initial treatment in an emergent situation. It would not, for example, be appropriate to have one primary care clinic have an AED but not the other one.

Use of 9-1-1
A hospital policy or practice that relies on calling 9-1-1 in order for EMS to substitute its emergency response capabilities for those the hospital is required to maintain at its off-campus departments/locations is not permitted by CMS. For example, it is not permissible to call 9-1-1 for EMS to come to the location to administer CPR when that capability should have been provided by staff at the location. However, it would be appropriate to call 9-1-1 for advanced life support services at an off-site location that only provides basic life support capability.

Individuals can present with a potentially emergent condition at any of your hospital's sites of care. Having a good understanding of CMS requirements will help assure that your hospital’s management of emergencies will pass survey.

Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.

Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.

Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.