1. (1)(a) Each licensee shall self-evaluate and classify to show capability in providing emergency care. Type I, II, or III categories represent acute care hospitals and critical access hospitals, and Type IV category represents specialty hospitals.

   1. (b) A Type I acute or critical access hospital licensee shall provide in-hospital support by members of the medical staff for:

      1. (i) anesthesia services;
      2. (ii) medical;
      3. (iii) obstetric;
      4. (iv) orthopedic;
      5. (v) pediatric; and
      6. (vi) surgical.
   2. (c) The licensee shall ensure specialty consultation is available within 30 minutes, or two-way voice communication is available for the initial consultation.
   3. (d) A Type III licensee shall ensure that specialty consultation is available by request of the attending medical staff member by transfer to a Type I or Type II hospital where care can be provided.

   4. (e) A general hospital licensee operating a satellite emergency department in a county of first or second class shall:

      1. (i) comply with Section 26B-2-203;
      2. (ii) submit to the department any initial and renewal application and applicable fee; and

      3. (iii) have the capability to conduct the following clinical laboratory tests and analyses available on-site during hours of operation:

         1. (A) core blood panels;
         2. (B) critical care and cardiac marker tests;
         3. (C) point-of-care tests (POCTs); and
         4. (D) specialized emergency analyses.
   5. (f) The licensee shall ensure clinical laboratory services are immediately available to meet the emergency diagnostic and stabilizing needs of any patient presenting to the satellite emergency department in a county of first or second class.

   6. (g) The licensee shall develop, implement, and maintain a written policy, approved by the medical staff and governing body, that identifies the specific laboratory tests and analyses to be performed at the satellite emergency department in a county of first or second class, including:

      1. (i) a list of emergency laboratory tests available at the facility;
      2. (ii) the required turnaround time for any critical laboratory result; and
      3. (iii) any protocol for obtaining an emergency test not performed on-site.

2. (2)(a) The licensee shall organize and staff the emergency service with qualified individuals based on the defined capability of the hospital.

   1. (b) An individual appointed and authorized by the hospital administrator shall direct the emergency services.

   2. (c)(i) One or more members of the medical staff shall define in writing and provide medical direction of emergency services.

      1. (ii) The medical staff shall provide back-up and on-call coverage for emergency services and as needed for emergency specialty services.

   3. (d) A licensed practitioner is responsible for the evaluation and treatment of a patient who goes to or is brought to the emergency care area including:

      1. (i) an appropriate medical screening examination;
      2. (ii) if necessary for definitive treatment, an appropriate transfer to another medical facility that has agreed to accept the patient for care; and
      3. (iii) stabilizing treatment.
   4. (e) Trained personnel using guidelines by the emergency room director and approved by the medical staff may determine the priority that a physician sees a person seeking emergency care.
   5. (f) The licensee shall post rosters designating medical staff members on duty or on-call for primary coverage and specialty consultation in the emergency care area.

   6. (g) A designated registered nurse who is qualified by relevant training, experience, and current competence in emergency care shall supervise the care provided by nursing service personnel in the department, including that:

      1. (i) the emergency nurse supervisor shall ensure that there is enough nursing service personnel for the types and volume of patients served;
      2. (ii) the emergency nurse supervisor shall participate in internal committee activities concerned with the emergency service; and
      3. (iii) Type I and II emergency department licensees shall have at least one registered nurse with advanced cardiac life support certification, and enough other nursing staff assigned and on duty within the emergency care area.

   7. (h) The licensee shall ensure that the emergency service is integrated with other departments in the hospital.

      1. (i) The licensee shall provide clinical laboratory services with the capability of performing any routine studies and standard analyses of blood, urine, and other body fluids.
   8. (j) The licensee shall ensure that a supply of blood is available 24 hours a day.

   9. (k) The licensee shall ensure that diagnostic radiology services is available 24 hours a day.

      1. (l) The licensee shall define, in writing, the duties and responsibilities of personnel, including physicians and nurses, providing care within the emergency service area.

3. (3)(a) Each licensee shall define the scope of emergency services in writing and implement a plan for emergency care, based on community needs and on the capabilities of the hospital.

   1. (b) Each licensee shall comply with federal anti-dumping regulations as defined in 19 CFR 351.101 (1998).
   2. (c) The licensee shall define the role of the emergency service in the hospital's disaster plans.
   3. (d) Each licensee shall have a communication system that permits instant contact with law enforcement agencies, rescue squads, ambulance services, and other emergency services within the community.

   4. (e) The licensee shall have emergency department policies and protocols that address:

      1. (i) the care, security, and control of incarcerated individuals or people to be detained for police or protective custody;
      2. (ii) handling of hazardous materials and contaminated patients;
      3. (iii) providing care to an unemancipated minor not accompanied by parent or guardian, or to an unaccompanied unconscious patient;
      4. (iv) reporting of persons dead-on-arrival to the proper authorities including the legal requirements for the collection and preservation of evidence; and
      5. (v) the evaluation and handling of alleged or suspected child or adult abuse cases.

   5. (f) The licensee shall develop criteria to alert emergency department and service personnel to possible child or adult abuse. The criteria shall address:

      1. (i) suspected domestic abuse of elders, spouses, partners, and children;
      2. (ii) suspected physical assault;
      3. (iii) suspected rape or sexual molestation;
      4. (iv) the collection, retention, and safeguarding of specimens, photographs, and other evidentiary materials; and
      5. (v) visual and auditory privacy during examination and consultation of patients.
   6. (g) The licensee shall make a list available in the emergency department that outlines private and public community agencies and resources that provide, arrange, evaluate, and care for the victims of abuse.
4. (4) The licensee shall make reasonable and timely efforts to contact the guardian, parents, or next of kin of any unaccompanied minor, or any unaccompanied unconscious patient admitted to the emergency department.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203