Rules and Regulations of the Medical Staff

Rules and Regulations of the Medical Staff

Medical Staff Bylaws, Part C



The hospital shall accept patients for care and treatment except for direct abortion, elective sterilization and artificial insemination. The hospital shall accept on an emergency basis only a) acute alcoholic intoxication with acute complications, and b) drug addiction. Patients whose condition cannot be further improved by acute hospitalization should be discharged to an appropriate lower level of care setting such as a skilled nursing facility, intermediate care, personal care home, or to their homes. Staff members shall make referrals or arrange transfers (consistent with applicable law) to other hospitals or appropriate care settings for those patients whose needs cannot appropriately be met at the hospital.


1.Admission Criteria

A patient shall be admitted to the hospital only by a member of the medical staff. All practitioners shall be governed by the official admitting policy of the hospital. The admitting policy shall include admission criteria for each level of care/service provided. Such criteria shall be used to determine appropriateness of patient placement. The patient shall be seen by the attending physician within 24 hours following admission to an acute care setting, unless there are extenuating circumstances.

2.Admission Status

The Admitting Department will admit patients to the following status:

Emergency: Intended for use by patients for the treatment of life-threatening health care problems that require medical intervention within 24 hours or urgent health problems that require medical treatment within 48-72 hours to prevent a life-threatening situation.

Inpatient: Intended for use by physicians for patients in need of medical treatment in an acute care setting. Services needed for medical treatment will likely require an overnight stay.

Ambulatory Surgery: Intended for use by physicians for patients having a surgical procedure that will be performed in an ambulatory setting. It is planned that the patient will be discharged from the hospital the same day as the procedure.

Outpatient: Intended for use by physicians for patients of whom a diagnostic and/or medical treatment is planned. Services will be provided in an outpatient setting, and it is planned that the patient will be discharged from the outpatient setting following the procedure.

Observation: Intended for use by physicians for services furnished in the hospital in which the patient receives periodic monitoring by the nursing staff and others to evaluate an outpatient’s condition or to determine the need for a possible inpatient admission.


The attending practitioner is responsible for obtaining the required pre-certification for services planned for the patient as outlined in the patient's third party payor policies.

4.Admission Diagnosis

Except in an emergency, no patient shall be admitted for hospital services until a provisional diagnosis or valid reason for admission has been stated. In the case of an emergency, such statement shall be recorded as soon as possible.

5.Admission to ICU

Any physician may admit to the Intensive Care Unit; however, all General Practitioners admitting to ICU must have a consult from an Internist for patients who remain on a ventilator for greater than 72 hours and as for management of thrombolytics.

If any questions as to the validity of admission to or discharge from the ICU should arise, the decision is to be made through consultation with the chairman of the Critical Care Committee.

6.Admission Documentation Requirements

All practitioners shall be governed by the official documentation policy of the Medical Records department when admitting patients to any of the hospital’s services.

The attending practitioner is required to document in the patient's clinical record the medical necessity of services requested, unless there are extenuating circumstances.

Documentation must also describe the chief complaint, medical status and plan for treatment in order for certification requirements to be met.

Following determination of medical necessity for inpatient services utilizing the approved third party payor criteria/guidelines, an expected length of stay will be assigned according to the diagnostic related category. If the patient requires further health care in the hospital, the attending physician will justify the medical necessity in the progress notes on a daily basis and the length of stay shall be adjusted according to third party payor guidelines. Failure to comply with this policy will be brought to the attention of the Physician Advisor. The Physician Advisor will evaluate the need for continued stay or possible continued stay termination, as stated in the hospital's Utilization Management Plan approved by the Executive Committee of the Medical Staff, the CEO and the Board.

7.Emergency Admissions

Emergency services will be provided according to the COBRA/EMTALA guidelines as outlined in the Emergency Department policy.

8.Tuberculosis Admissions

Patients with active tuberculosis ordinarily are not admitted to the hospital for tuberculosis treatment; they are treated at home. However, there is no regulation that prohibits admitting a patient who has tuberculosis but needs hospital admission for a diagnosis other than tuberculosis. Management of patients with tuberculosis shall be governed by Infection Control policies and procedures.


1.From Emergency services:

When seeking medical treatment for conditions of which needed services are not provided by the hospital, patients will be stabilized and transferred to an appropriate facility following COBRA/EMTALA guidelines. Those conditions include, but are not limited to, psychiatric care, alcoholism, drug abuse, and obstetrics.

2.Prioritizing Transfers:

All transfers will comply with COBRA/EMTALA guidelines. Subject to those requirements, priority of patient transfers shall be as follows:

  • Emergency patients to appropriate facility/patient bed.
  • Patients from ICU to acute care unit. Patients temporarily placed in a geographical or a clinical service area because of bed overflow to the appropriate area for that patient. No patient will be transferred without such transfer being approved by the responsible practitioner.


1.Discharge Criteria

Patients shall be discharged only on a written order of the attending practitioner. Should a patient leave the hospital against the advice of the attending practitioner or without proper discharge, a notation of the incident shall be made in the patient's medical record.

2.Appropriateness for discharge

Appropriateness for discharge shall be determined by discharge criteria established for each level of care/service as outlined in the Provision of Care Plan.


A.Anesthesia Care

Responsibility for the overall management for anesthesia lies with the Director of Anesthesia. Anesthesia types and location are as follows: general, regional, monitored anesthesia care and moderate sedation care are given in the Operating Rooms, Endoscopy Suite, Catherization Lab, ICU, 4 West, Diagnostic Imaging, Neurology Diagnostics, and Emergency Room. The Director of the Anesthesiology Service shall ensure that there is at least one member of the Anesthesiology Service on duty in the Hospital, or on call at all times, to provide routine and emergency anesthesia care. General anesthesia may only be given in the operating room, the Imaging Services departments, and the Endoscopy Suites.

B.Anesthesia Rules and Regulations:

  1. Anesthesiologists will be available to assist the Service with Staff development in organization of and participation in educational programs.
  1. Anesthesiologists will be available on request of the Medical Staff Members to perform consultations relating to the respiratory care of patients of the Medical Staff Members.
  1. Certified Registered Nurse Anesthetists shall administer anesthesia under the supervision, direction and guidance of an anesthesiologist and within their scope of service as granted by the Board of Trustees.
  1. Anesthesiologists shall actively participate in advising the nurse anesthetists on refresher courses and requiring continuous education and routine in-service programs.
  1. An anesthesiologist will perform a pre-anesthesia evaluation of the patient. He/she will note on the patient’s anesthesia record all pertinent information relative to the choice of anesthesia in relation to the surgical procedure anticipated, and any previous anesthesia history of the patient. In addition, the risks/benefits of anesthesia will be explained to the patient and noted in the medical record based upon ASA Classifications.
  1. A member of the Anesthesiology Staff or other qualified licensed, independent practitioner ordering moderate sedation will re-evaluate the patient immediately prior to the induction of anesthesia, and will document the physiological status of the patient, the readiness, availability, cleanliness, sterility where required, and working conditions of all equipment used in the administration of anesthetic agents.
  1. All reusable anesthesia equipment in direct contact with the patient shall be cleaned after each use.
  1. Following the procedure for which anesthesia was administered, the anesthesiologist or other qualified person will remain with the patient as long as deemed necessary. Personnel responsible for post anesthetic care will be advised of any specific problems presented by the patient’s condition. A member of the anesthesiology staff or other qualified person, based upon Medical Staff pre-approved PAR score criteria, will authorize the discharge of patients to other services. If sedation during surgery is minimal, the anesthesiologist may discharge the patient from the operating room if PAR scores are met and documentation of such is recorded.
  1. The anesthesiologist, anesthetist or other qualified person will record all events taking place in the induction of, maintenance of, and emergence from anesthesia. This record will include the dosage and duration of all anesthetic agents, other drugs, intravenous fluids and blood or blood products.
  1. Inpatients that stay overnight will have a second visit by anesthesia/CRNA. An anesthesiologist or CRNA in the PACU will make a post-anesthesia visit to the patient and note in the chart the presence or absence of any anesthesia-related complications and date and time the entry. A post-operative anesthesia note will be written on outpatients by an appropriate member of the anesthesia service.
  1. The type and method of anesthesia for a patient will be decided by the anesthesiologist or qualified LIP while taking into consideration any special requests or problems presented by the surgeon.
  1. Complication or unusual events occurring to a patient under anesthesia will be reviewed at the Surgical Care Committee meeting in accordance with criteria or indicators established by that Committee.
  1. The Director of Anesthesia will participate in the development of and have oversight responsibility for moderate sedation to ensure standardization of care delivered. Competency of Medical Staff for the delivery of conscious sedation will be delineated based upon credentialed privileges as set forth by the Anesthesia Service, Credentials Committee, Medical Executive Committee and approved by the Board of Trustees.
  1. Advance Directives and Do Not Resuscitate orders will be discussed with the patient by either Anesthesia or the attending physician prior to surgery to ascertain patient’s wishes as they relate to the continuance of advance directives.
  1. Anesthesia is defined as the administration (in any setting, by any route, for any purpose) of general, spinal, or major regional anesthesia or sedation with or without analgesia for which there is a reasonable expectation that, in the manner used, the sedation or analgesia will result in the loss of protective reflexes.


A.Emergency Services Physician

The purpose of the Emergency Services Physician (ESP) shall be to practice quality emergency medicine in accordance with the goals of the Medical Staff and the Hospital.

  1. The Emergency Services Physicians shall be members of the Hospital Medical Staff. They shall have all the rights, privileges, and responsibilities of staff membership, except that of admitting patients to the hospital.
  1. Emergency Services Physicians shall arrange their schedule to provide emergency patient care twenty-four (24) hours per day, seven (7) days per week. Emergency Services Physicians shall also have a Director who is Board Certified for Emergency Medicine and a specialty deemed appropriate by the Chief of the Department of Medicine. The Director shall be responsible for augmenting the physician staff in situations of increased patient volumes or acuity.
  1. Services provided by the Emergency Services Physician shall include, but shall not be limited to the following:
  1. Providing initial emergency health services 24 hours a day to patients of all ages, ensuring the availability of follow-up care, in or out of the hospital as may be required;
  1. Evaluating patient’s emergency health needs, stabilizing insofar as possible those patients with life-threatening conditions, and providing such services as are immediately indicated;
  1. Undertaking the responsibility of establishing the necessary training programs for emergency department and community personnel in order to provide them with the basic skills required to intervene in life-threatening situations;
  1. Managing the ER team in the care of patients with life-threatening illnesses and injuries, as well as the efficient handling of those patients with more routine problems;
  1. Ensuring that the layout, equipment and supplies are available to meet both emergency and routine demands;
  1. Responding to emergency situations arising in the Intensive Care Units or on the floor, provided that theses situations do not interfere with the Emergency Room (ER) activity and coverage; and
  1. Pronouncing patients’ expirations in the hospital at the request of the attending physician.
  1. The Emergency Services Physician on duty will be physically present in the Hospital at all times. The professional and ethical conduct of the Emergency Services Physician shall be under the auspices of the Department of Medicine and the Medical Executive Committee. It shall be incumbent upon the Emergency Services Physician to perform in the best interest of the patient first, and secondly, of the Hospital and Medical Staff.
  1. Patients are classified as urgent, emergent or non-emergent according to established criteria and conditions, which are approved by the Medical Staff and Emergency Services Physician. The guidelines are used by physicians to establish the priority of care.

B.Emergency Department Rules and Regulations:

  1. Clinical privileges shall be delineated for all practitioners rendering emergency care in accordance with Staff and Hospital policies and procedures.
  1. The Medical Staff shall adopt a method of providing medical coverage in the Emergency Room. Each clinical department shall establish and maintain their own specific rules and regulations governing their call schedules for each clinical service. Each member of the medical staff shall agree and serve as on call physician for emergency department coverage as required. Physicians who fail to comply with such schedules shall be subject to continued disciplinary action as defined by the Medical Staff Bylaws, up to and including termination of privileges. The call schedules established herein shall be in compliance with all applicable requirements of law, including COBRA/EMTALA, and may be altered by the Executive Committee and/or Board if the call schedules established do not appear to meet any requirements of law.
  1. Staff physicians shall be entitled to the traditional right of treating their patients in the emergency room based upon the individual privileges. Staff physicians may order treatment in writing or by telephone and in so doing, retain responsibility for their patients. Telephone orders by staff physicians shall comply with the policies and procedures of the emergency room.
  1. If requested by an emergency room patient, and if determined appropriate in the judgement of the Emergency Services Physician, the patient’s private physician shall be notified in accordance with the emergency room policies and procedures. The Staff Physician may refer his patient to another member of the Staff, including the Emergency Services Physician, who then shall accept the responsibility for diagnosis and treatment rendered in the emergency room, and refer the patient back to his own physician for follow-up care.
  1. If in the judgment of the emergency services physician a patient needs to be admitted to the Hospital as an inpatient, either for observation or for furthers treatment, the patient shall be admitted in the name of the attending physician. Upon transfer from the Emergency Department to a patient unit, the patient becomes the responsibility of the attending physician.

C. Emergency Room Records:

An appropriate emergency room medical record shall be kept for every patient receiving emergency service and shall be incorporated into the patient’s medical record, if such exists.

  1. The emergency room medical record shall accompany patients being admitted as an inpatient.
  1. The emergency room medical record shall include the following:
  1. Pertinent history of the injury or illness including details relative to first aid or emergency care given to the patient prior to his arrival at the Hospital;
  1. History of allergies;
  1. Description of significant clinical, laboratory, and X-ray findings. In cases where the X-ray interpretation of the radiologist is different from that initially made by the emergency services physician, copies of the radiologist’s report shall be made available and brought to the attention of the emergency services physician. The physician or licensed staff will notify the patient and instructions are documented on the original encounter documentation form;
  1. Diagnosis including condition of the patient;
  1. Treatment given and plans for management;
  1. Condition of the patient on discharge or transfer;
  1. Final disposition, including instruction given to the patient and/or family for necessary follow-up care;
  1. Signature by the physician in attendance who is responsible clinical accuracy of the emergency room medical record; and
  1. Discharge instructions given to patient/family with clear understand
  2. Along with warnings as to applicable food and drug interactions.

D.Patients Screening and Transfers:

  1. Every patient presenting to the Emergency Department for treatment or screening shall be screen in accordance with the requirements of good medical procedure and COBRA/EMTALA. Patient shall be triaged based upon condition; the triage shall not be in lieu of, but may be in conjunction with, an appropriate medical screening.
  1. Medical screenings in the Emergency Department may be delegated by the Medical Staff to include the following categories of LIP:, Physician or Physician Extenders, i.e., Physician Assistant and/or Advanced Practice Registered Nurse (APN/FNP)
  1. Patients with conditions whose definitive care is beyond the capabilities of this hospital shall be referred to the appropriate facility, when in the judgement of the attending physician or emergency services physician, the patient’s condition permits such a transfer. The Emergency Department shall comply with COBRA/EMTALA guidelines in the transfer of all patients.