6 Colo. Code Regs. § 1011-1 Chapter 18, pt. 21

Current through Register Vol. 47, No. 20, October 25, 2024

Part 21 - Psychiatric Emergency Services

21.1 A Psychiatric Hospital shall not be required to maintain a dedicated emergency department. If a hospital chooses to maintain a dedicated emergency department, the following standards shall apply.

21.2 Dedicated Emergency Department

(A) Organization

(1) The emergency department shall be directed by a physician who is board-eligible or board-certified in psychiatry.

(2) The emergency department shall provide emergency services twenty-four (24) hours a day, including providing immediate lifesaving intervention, resuscitation, and stabilization, within the capabilities of the hospital, for patients, staff, and visitors.

(3) The entrance to the emergency department shall be clearly marked and separate from the main hospital entrance.

(4) The hospital shall integrate its emergency department with other hospital departments, as needed, to ensure the hospital can immediately make available the full extent of its patient resources to assess and render appropriate care.

(5) patients shall be discharged from the emergency department only upon a physician or licensed independent practitioner's recorded authorization including instructions given to the patient for follow-up care.

(B) Personnel

(1) A physician or licensed independent practitioner must be available at all times to the emergency department to direct care.

(2) Nurse staffing shall be provided in accordance with the requirements of Part 14, Nursing Services.

(3) A roster of on-call medical staff members must be available in the emergency department.

(C) Scope of Services

(1) The hospital shall develop policies and procedures outlining the scope of services provided in the emergency department, which shall include but are not limited to:

(a) Triage,

(b) Comprehensive psychiatric assessment,

(c) Crisis stabilization, and

(d) Linkages to ongoing mental health services.

(2) The hospital shall develop and implement policies and procedures, in accordance with nationally-recognized guidelines and standards of care, for the care of psychiatric emergencies, which shall include, but are not limited to:

(a) Core competencies required for patient care responsibilities;

(b) Processes for admission and discharge, which are compliant with involuntary commitment laws and regulations;

(c) The assessment and management of patients presenting with parasuicidal, suicidal, agitated, or violent behavior(s);

(d) Strategies for managing patients who present in a state of intoxication; and

(e) Immediately addressing and treating any incidents of overdose or accidental poisoning.

(3) The hospital shall transfer patients to a higher level of care when their needs exceed the hospital's scope of services.

(D) Minimum Services

(1) The hospital shall provide the necessary resources, including instruments, equipment, and personnel, in accordance with acceptable standards of practice, and shall ensure resources are immediately available to meet the needs of presenting patients.

21.3 Hospitals without a Dedicated Emergency Department

(A) Signage indicating that the hospital does not have an emergency department shall be posted at all public entrances.

(B) The hospital shall have the ability to provide basic life saving measures to patients, staff, and visitors and shall have written policies for the appraisal of emergencies, initial treatment, and transfer when appropriate.

6 CCR 1011-1 Chapter 18, pt. 21