1. (1) Medical Services.

   1. (a) A Basic Pediatric Emergency Facility shall have an on-call physician who shall be promptly available and provide direction for the emergency department nursing staff. The physician and associated mid-level practitioner(s) providing care in the emergency department shall be currently PALS certified and competent in the care of pediatric emergencies including the recognition and management of shock and respiratory failure, the stabilization of pediatric trauma patients, advanced airway skills, vascular access skills, and be able to perform a screening neurologic assessment and to interpret diagnostic tests, laboratory values, physical signs and vital signs appropriate for the patient’s age. ATLS certification is strongly encouraged. A system shall be developed for access to physicians who have advanced airway and vascular access skills as well as for general surgery and pediatric specialty consultation. A back-up system must be in place for additional registered nurse staffing for emergencies. ATLS certification is strongly encouraged.
   2. (b) A Primary Pediatric Emergency Facility shall have an emergency physician in-house twenty-four (24) hours per day, seven (7) days per week. The emergency department physician shall be currently PALS certified and competent in the care of pediatric emergencies including the recognition and management of shock and respiratory failure, the stabilization of pediatric trauma patients, advanced airway skills, vascular access skills, and be able to perform a screening neurologic assessment and to interpret diagnostic tests, laboratory values, physical signs and vital signs appropriate for the patient’s age. A pediatrician or family practitioner, general surgeon with trauma experience, anesthetist/anesthesiologist, and radiologist shall be promptly available twenty-four (24) hours per day. ATLS certification is strongly encouraged.
   3. (c) A General Pediatric Emergency Facility shall have a board certified or board eligible emergency physician or pediatrician in the emergency department twenty-four (24) hours per day, seven (7) days per week. The emergency department physician shall be currently PALS certified and competent in the care of pediatric emergencies including the recognition and management of shock and respiratory failure, the stabilization of pediatric trauma patients, advanced airway skills, vascular access skills, and be able to perform a screening neurologic assessment and to interpret diagnostic tests, laboratory values, physical signs and vital signs appropriate for the patient’s age. A General Pediatric Emergency Facility shall have an emergency department medical director who is board certified or board eligible/admissible in pediatrics or emergency medicine. A record of the appointment and acceptance shall be in writing. The physician director shall work with administration to assure physician coverage that is highly skilled in pediatric emergencies. ATLS certification is strongly encouraged.
   4. (d) A CRPC and a PTC shall have an emergency department medical director who is board certified or board eligible in pediatric emergency medicine. A record of the appointment and acceptance shall be in writing.
   5. (e) A CRPC and a PTC shall have twenty-four (24) hours ED coverage by physicians who are board eligible or board certified and meet the requirements of maintenance of certification in pediatric emergency medicine, or who were credentialed pediatric emergency medicine providers in Tennessee prior to the promulgation of these rules. The medical director shall work with administration to assure highly skilled pediatric emergency physician coverage. All physicians in pediatric emergency medicine shall participate on at least an annual basis, in continuing medical education activities relevant to pediatric emergency care and shall have successfully completed the ATLS course at least once. Maintenance of current ATLS certification status is strongly encouraged.
   6. (f) A CRPC and a General Facility with a PICU shall have an appointed medical director of the pediatric intensive care unit. A record of the appointment and acceptance shall be in writing. The medical director of the pediatric intensive care unit shall have a minimum of three (3) years experience as an attending in pediatric critical care and shall be board certified and meet the requirements of maintenance of certification in pediatric critical care medicine or have been an existing medical director of a PICU prior to the promulgation of these rules.
   7. (g) In a CRPC and General Facility with a PICU, PICU physicians shall be credentialed by the facility to practice pediatric critical care medicine and be board eligible or board certified and meet the requirements of maintenance of certification in pediatric critical care medicine or have been a credentialed pediatric critical care provider in Tennessee prior to the promulgation of these rules.
   8. (h) In a CRPC and General Facility with a PICU, the pediatric intensive care unit and ED medical director shall participate in developing and reviewing their respective unit policies, promote policy implementation, participate in budget preparation, help coordinate staff education, maintain a database which describes unit experience and performance, supervise resuscitation techniques, lead quality improvement activities and coordinate research.
   9. (i) In a CRPC and General Facility with a PICU, the pediatric intensive care unit medical director shall name qualified substitutes to fulfill his or her duties during absences. The pediatric intensive care unit medical director or designated substitute shall have the institutional authority to consult on the care of all pediatric intensive care unit patients when indicated. He or she may serve as the attending physician on all, some or none of the patients in the unit.
   10. (j) The CRPC and General Facility with a PICU shall have at least one pediatric critical care physician promptly available to the PICU twenty-four (24) hours per day, and as well as an in-house physician with a minimum of post graduate year level 3 training with current PALS certification and is approvedal by the PICU medical director and/or a mid-level practitioner credentialed by the institution to provide pediatric critical care services, who is PALS trained, and is approved by the PICU medical director. All providers in pediatric critical care shall participate in continuing medical education activities as per facility policies relevant to pediatric intensive care medicine.
   11. (k) The CRPC shall have pediatric subspecialty trained surgical and medical providers who are board eligible or board certified and meeting the requirements of maintenance of certification in their subspecialty or who were credentialed providers in their subspecialty in Tennessee prior to the promulgation of these rules in their respective subspecialty as listed in Table 1.

2. (2) Nursing Services.

   1. (a) Emergency staff in all facilities shall be able to provide information on patient encounters to the patient’s medical home through telephone contact with the primary care provider at the time of encounter, by faxing or by electronic means. Follow-up visits shall be arranged or recommended with the primary care provider whenever necessary.
   2. (b) In all Pediatric Emergency Facilities at least one RN shall be physically present 24 hours per day, 7 days per week, and capable of recognizing and managing pediatric shock and respiratory failure and stabilizing pediatric patients, including early recognition and stabilization of problems that may lead to shock and respiratory failure. At least one emergency room nurse per shift must be PALS certified. Certification in ENPC and TNCC is strongly encouraged.
   3. (c) A Pediatric General Emergency Facility shall have an emergency department nursing director/manager and at least one nurse per shift with pediatric emergency nursing experience. Nursing administration shall assure adequate staffing for data collection and performance monitoring as well as a registered nurse responsible for ongoing coordination of education in pediatric emergency care.
   4. (d) In a Comprehensive Regional Pediatric Center, administration shall provide a nursing director/manager dedicated to the pediatric emergency department. The nurse director/manager shall have specific training and experience in pediatric emergency care and shall participate in the development of written policies and procedures for the pediatric emergency department, coordination of staff education, coordination of research, patient and family centered care, QI, and budget preparation in collaboration with the pediatric emergency department medical director. The nurse director/manager shall name qualified substitutes to fulfill the nurse director/manager’s duties during absences.
   5. (e) In a Comprehensive Regional Pediatric Center, nursing administration shall provide nursing staff experienced in pediatric emergency and trauma nursing care and a registered nurse trained in pediatric specific education/competencies responsible for ongoing staff education.
   6. (f) In a Comprehensive Regional Pediatric Center, or a General Facility with a PICU, administration shall provide a nurse director/manager dedicated to the pediatric intensive care unit. The nurse director/manager shall have specific training and experience in pediatric critical care and shall participate in the development of written policies and procedures for the pediatric intensive care unit, coordination of staff education, coordination or research, patient and family centered care, QI and budget preparation in collaboration with the PICU medical director. The nurse director/manager shall name qualified substitutes to fulfill the nurse director/manager’s duties during absences.
   7. (g) In a Comprehensive Regional Pediatric Center, or a General Facility with a PICU, administration shall provide a pediatric nurse educator for pediatric emergency care and pediatric critical care education.
   8. (h) In a Comprehensive Regional Pediatric Center, or a General Facility with a PICU, administration shall provide an orientation to the pediatric emergency department and the pediatric intensive care unit staff and specialized nursing staff shall be Pediatric Advanced Life Support certified. Administration shall assure staff competency in pediatric emergency care and intensive care.

3. (3) Other Personnel.

   1. (a) In a Comprehensive Regional Pediatric Center, or a General Facility with a PICU, the respiratory therapy department shall have a supervisor responsible for performance and pediatric training of staff, maintaining equipment and monitoring QI and review. Under the supervisor’s direction, respiratory therapy staff assigned primarily to the pediatric intensive care unit and the emergency department shall be in-house twenty- four (24) hours per day and shall be PALS certified and maintain ongoing competencies.
   2. (b) In a Comprehensive Regional Pediatric Center, or a General Facility with a PICU, biomedical technicians shall be available within one (1) hour. Unit secretaries or trained designees shall be available to the pediatric intensive care unit and emergency department twenty-four (24) hours per day. A radiology technician and pharmacist with pediatric training must be in-house 24 hours per day. In addition, social workers, case managers, physical therapists, occupational therapists, speech therapists, child life specialists, clergy and nutritionists/registered dieticians must be available.
   3. (c) In all PECF, the radiology department shall have guidelines for reducing radiation exposure that are age and size specific in accordance with ALARA or current American College of Radiology guidelines.

4. (4) Facility Structure and Equipment.

   1. (a) Equipment for communication with EMS mobile units is essential if there is no higher- level facility capable of receiving ambulances or there are no resources for providing medical control to the pre-hospital system.
   2. (b) An emergency cart or other systems to organize supplies including resuscitation equipment, drugs, printed pediatric drug doses and pediatric reference materials must be readily available. Equipment, supplies, trays, and medications shall be easily accessible, labeled and logically organized. Antidotes necessary for a specific geographic area should be determined through consultation with a poison control center. If the listed medications are not kept in the emergency department, they should be kept well organized and together in a location easily accessible and proximate to the emergency department.
   3. (c) A Comprehensive Regional Pediatric Center emergency department must have geographically separate and distinct pediatric medical/trauma areas that have all the staff, equipment and skills necessary for comprehensive pediatric emergency care. Separate fully equipped pediatric resuscitation rooms must be available and capable of supporting at least two simultaneous resuscitations.

5. (5) Infection Control. A Pediatric Emergency Care Facility shall have an annual influenza vaccination program which shall include at least:

   1. (a) The offer of influenza vaccination to all staff and independent practitioners at no cost to the person or acceptance of documented evidence of vaccination from another vaccine source or facility. The Pediatric Emergency Care Facility will encourage all staff and independent practitioners to obtain an influenza vaccination;
   2. (b) A signed declination statement on record from all who refuse the influenza vaccination for reasons other than medical contraindications (a sample form is available at http://tennessee.gov/health/topic/hcf-provider);

   3. (c) Education of all employees about the following:

      1. 1. Flu vaccination,
      2. 2. Non-vaccine control measures, and
      3. 3. The diagnosis, transmission, and potential impact of influenza;
   4. (d) An annual evaluation of the influenza vaccination program and reasons for non- participation; and
   5. (e) A statement that the requirements to complete vaccinations or declination statements shall be suspended by the administrator in the event of a vaccine shortage as declared by the Commissioner or the Commissioner’s designee.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-206, 68-11-209, and 68-11-251. Administrative History: Original rule filed November 30, 1999; effective February 6, 2000. Amendment filed October 15, 2002; effective December 29, 2002. Amendment filed December 4, 2007; effective February 17, 2008. Amendments filed July 18, 2016; effective October 16, 2016. Transferred from chapter 1200-08-30 pursuant to Public Chapter 1119 of 2022 effective July 1, 2022. Amendments filed July 10, 2025; effective October 8, 2025.