Page 1 of 13. Document Title: All HAAD Licensed Healthcare facilities. Classification: Public

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1 Document Title: HAAD Standard for Minimum Preparedness for Common Medical Emergencies In Inpatient Care Setting, Outpatient Care Setting, Ambulance Services and Interfacility Patient Transfer Document Ref. Number: HAAD/EMS/SD/0.9 Version 0.9 Approval Date: 23/12/2015 Effective Date: 23/12/2015 Document Owner: Applies to: Classification: Health Regulation Department All HAAD Licensed Healthcare facilities Public 1. Purpose 1.1 The purpose of this Standard is to set out: The requirements for HAAD Licensed Healthcare Facilities as defined by HAAD ( to manage emergency patients in response to patient needs until the patient recovers, the patient is stabalised, transferred/referred to the appropriate healthcare facility or until a specialised team assumes responsibility; The required minimum medications and equipment to manage an emergency response for inpatient settings, outpatient settings and ambulance service providers; The requirements for healthcare professionals employed at a HAAD licensed healthcare facility The emergency vehicle requirements for the ambulance transfer of stable and unstable patients Establish the minimum requirements to provide safe, efficient and timely support and transportation for elective and emergency patients to a HAAD licensed healthcare facility, licensed by a UAE competent authority, healthcare facility in other international jurisdictions licensed by the country specific competent authority. 2. Scope 2.1. This standard applies to all HAAD licensed inpatient and outpatient healthcare facilities and ambulance service providers as per HAAD Facility Licensing definitions. Page 1 of 13

2 2.2. All HAAD licensed healthcare facilities and professionals involved with the purpose of providing emergency services and ambulance services including events transfer, interfacility patient transfer, emergency transfer from site of accident or emergency transfer from the patients home Transfer of patients must be in accordance with HAAD licensure, scope of service, the privileges granted by the healthcare facility and in compliance with the UAE legal requirements This Standard only applies to ambulance vehicles used for emergency patient transfer, as set out in section Ambulance Service Providers shall be given an eighteen (18) month grace period to meet the vehicle requirements set out in this Standard during which evidence and/or action plans to meet the requirements set out in this Standard shall be submitted to HAAD upon licensure. 2.4 This Standard does not include the requirements for emergency transfer of patients exposed to Chemical Biological Radiological and Nuclear Explosives (CBRNE). 3. Definitions and abbreviations: 3.1 Emergency Medical Dispatch (EMD) System: Is the principle link between the Public caller requesting emergency medical assistance and the emergency medical service (EMS) resource delivery system. 3.2 Ambulance: An emergency vehicle, whether privately or publicly owned which is designed, constructed and equipped to the level of service provisions or duly modified for the sole transport of sick, disabled or injured individuals. 3.3 Ambulance service: the business of transporting sick, disabled or injured individuals by ambulance to or from facilities or institutions providing health services. 3.4 Ambulance Service Provider: a healthcare provider engaged in the business of transporting injured, sick or disabled individuals by ambulance to or from healthcare facilities providing health services or from non-health institutions to a healthcare facility. 3.5 CEN 1789: is the European Union Standard for ambulance vehicles and medical transportation vehicles. 3.6 Emergency response: Response is an effort to mitigate the impact of an incident on the public and the environment that would otherwise threaten public safety, health and welfare of an individual or a group of people. 3.7 Medical Oversight: Includes active day-to-day role in the function and management of the service as it relates to patient care needs. Medical oversight may be prospective (planning), indirect and offline (i.e. not directly engaged during the emergency process) such as developing policies and procedures and protocols for emergency and ambulance response, transfer and transport; concurrent, direct and online such as giving verbal orders in person or via radio (i.e. directly involved in the transfer and transport on site); retrospective, indirect and offline such as quality management (i.e. after the event of transfer conducting evaluation of the transfer system) and clinical audit Medical oversight shall include having in place a protocol for issuance of drugs (including narcotic and controlled substances) and training of their use by authorised staff only; Page 2 of 13

3 This must be undertaken by a qualified physician with internationally recognised qualifications and experience in Emergency Services; Assigning responsible manager (authorised for decision making) to oversee, monitor and report service performance Ensuring appropriate and effective mechanisms to facilitate consultation with treating physicians and specialty care physicians (specialists/consultants) Ensuring availability of appropriate mix of multidisciplinary team, its members possessing the requisite levels of knowledge and skills in accordance with the service needs Tracking, monitoring, case review and quality management of a quality management system 3.8 Interfacility Transfer: Any pre-arranged emergency or non-emergency transfer including use of a retrieval service for patients, after initial assessment and stabilisation, from one healthcare facility to another for reasons including but not limited to the following: The need for specialised treatment and care not available at the referring facility; for example (professionals, equipment and requisite treatment); Lack of bed capacity for the patient at the referring facility; Patient eligibility of care and treatment in the referring facility in accordance with their health insurance product except for emergency cases. Patients must not be denied emergency care and management on the basis of their health insurance product; as this breaches Federal and Abu Dhabi Laws (Appendix 1) 3.9 Referring facility: A HAAD licensed healthcare facility referring and/or requesting the transfer of patient care to another HAAD licensed facility Receiving facility: A HAAD licensed healthcare facility accepting the request for transfer and admitting the patient referred by and/or transferred from another HAAD licensed facility Transfer Coordinator Referring (TCRF): A designated individual from a HAAD licensed healthcare facility who has been given the responsibility to coordinate the transfer of a patient to another HAAD licensed receiving facility and who is responsible to ensure all documentation requirements are completed as per the requirements set out in this Standard Transfer Coordinator Receiving (TCRC): A designated individual from a HAAD licensed receiving healthcare facility who has been given the responsibility to coordinate the reception of a patient from another HAAD licensed healthcare facility (transferring) and ensure all documentation requirements are completed as per the requirements set out in this Standard 3.13 Patient preference: Individual's expression of desirability or value of one course of action, outcome, or selection in contrast to others Transfer agreement: A written agreement between a HAAD licensed healthcare facility and an interfacility transport service that has been licensed by HAAD with specified scope of service. Page 3 of 13

4 4.0 Duties for Healthcare Facilities 4.1 HAAD licensed healthcare facilities are required to manage emergency response in an inpatient setting, outpatient setting, ambulance service setting and when patient transfer is needed to an appropriate healthcare facility. Healthcare Facilities and Professionals shall comply with the following duties: Have policies and procedures in place and the appropriate level of resources (professionals, medical needs and supplies and access to ambulance services) to provide high quality safe management and care of patients in accordance to the requirements set out in this Standard; Comply with all policies and standards for medication management, supply and control of their use and ensure: Sufficient stocks of required medications and medical equipment are available as per the healthcare providers license and scope of services and minimum requirements set out in this Standard All Medications and Medical devices are compliant with the Ministry of Health, UAE, Administrative Circulars 27 of 2005, 41 of 2008 and 001 of 2009; Ensure Medical devices are maintained and quality tested according to manufacturer s specifications; Ensure the secure management of narcotics, controlled and semi-controlled medication; Cooperate with HAAD authorised auditors, as and when requested for inspections and audits by HAAD; and Comply with HAAD requirements for managing patient medical records, maintaining confidentiality, privacy and security of patient information and educating patients and fulfilling the requirements of patient consent and patients rights and responsibilities charter Undertake and document the outcomes of assessment of the patient s condition to ensure: that patients are stabilised prior to transfer; that potential risks of deterioration during transfer are evaluated against the potential benefits; and the most suitable receiving healthcare facility has been identified for the management of the patient s needs (specialised expertise and equipment shall also be considered) and condition (urgency for definitive management); Document the outcome of the transfer and evaluate the process to demonstrate the effectiveness of the referral and transfer system; Cooperate with and endeavour to accept transferred patients and assist with coordination and identification of bed availability prior to transfer, and subsequently be accountable for fulfilling all duties necessary to receive the patient, once bed availability is confirmed Page 4 of 13

5 and transfer is accepted, and provide appropriate, safe and high quality care; Ensure that when a patient is identified as requiring transfer to another facility, that the responsible treating physician supported by a multidisciplinary team assesses the patient s needs so as to: determine whether the admitting facility is able to provide the required level and type of service and care needed; or identify a facility that can offer the requisite scope of services and care needed, has the mix of specialised staff, resources and equipment that are appropriate to meet patient needs; Develop, implement and monitor an emergency response system for patients and include the following: Set out in writing the details of the system in a policy and standard operating procedures for emergency response, the staffing requirements and documentation for emergency response, audit and training, the coordination and transfer of patients (including the requirement to have in place transfer agreements with respective healthcare providers), monitoring the outcome of patient transfers, identifying issues, and risks associated with transfers and process for rectifying identified issues, managing risk; A medical oversight mechanism shall be in place to oversee, manage and monitor the effectiveness of the emergency system and to affect corrective actions and continuous improvements where necessary; Where the responsible healthcare provider decides to transfer the patient as determined by the patient s case assessment, they must ensure that all triaging and initial assessment of findings are documented at the time of referral and an appropriate ambulance with appropriate staff are made available as per the patient needs In cases where a patient receives specialised treatment at a receiving facility, and is to be transferred back to the referring facility, the referring and receiving facilities must continue to coordinate to ensure this takes place in a seamless manner to meet the patient s needs are met; Provide emergency services and care in accordance with the requirements of this Standard and with relevant HAAD Clinical Care Standards, as applicable, and ensure their practices are consistent with internationally recognised evidence based clinical care practices; Comply with HAAD requirements on adverse events management and reporting, managing patient medical records, including developing effective recording systems, maintaining patient records including consent, protecting the confidentiality, privacy and security of patient information and educating patients and fulfilling the requirements of patients rights and responsibilities charter; and Comply with HAAD requests to inspect and audit records and cooperate with HAAD authorised auditors. Page 5 of 13

6 5. Role of HAAD 5.1 To set and define the required Standards, including but not limited to: laying out the parameters and service specifications for emergency preparedness, emergency service requirements, professional requirements, coordination and communication requirements and reporting requirements; 5.2 Audit and inspect providers and monitor compliance with the requirements of this Standard and other relavant HAAD Policies and Standards; 5.3 Request improvement actions from healthcare providers in cases where non-compliance with this Standard is identified; 5.4 Where risks to patient safety and quality are identified impose sanctions for breaches to HAAD regulations; 5.4 Analyse data reported on interfacility transfer and emergency transfer cases and their management, identify trends and improvement needs, disseminate and publish reports; and 5.5 Request, at its discretion, through the HAAD Operations Centre, service information such as information on bed availability, patient acuity (and during transfer), staff and vehicle capacity to facilitate the safe and effective transfer of patients. 6. Enforcement and Sanctions 6.1 HAAD licensed healthcare providers must comply with the requirements of this Standard, the HAAD Standard Provider Contract and the HAAD Data Standards. HAAD may impose sanctions in relation to any breach of requirements under this standard in accordance with Chapter IX, HAAD Policy on Complaints, Investigations, Regulatory Action, and Sanctions, The Healthcare Regulator Policy Manual. 7. Standard 1. Requirements for All Healthcare Facilities 7.1 Resources, equipment, medications and professional requirements HAAD licensed healthcare facilities shall as a minimum: Adhere to the minimum requirements as listed in Appendix 2 and 3 for inpatient setting and Appendix 4 for outpatient setting Adhere to the minimum requirements as listed in Appendices 5-13 for the provision of ambulance services and Interfacility transfer; Adhere to the following: A list and description of all medications and their review date; Appropriate adult and paediatric dosing references (drug product leaflet); Expiry dates of the medications; List of staff who fulfil basic or advanced emergency response Other than the oxygen, all emergency medications, equipment and supplies must be safely and securely stored together in a purposedesigned, storage unit and/or portable emergency kit; Page 6 of 13

7 7.1.3 The emergency medications must be readily accessible, in a visible location, and where a storage unit is utilised, be in a container secured with a break-away lock or as an emergency kit that is secure; The contents of the emergency storage unit and/or portable emergency kit may only be serviced with medication and equipment by appropriately licensed and privileged healthcare professionals based on the specific scope of service provided at the facility and the expectation of emergency patient needs; The contents of the emergency storage unit and/or portable emergency kit must be: Inspected and/or tested at least once a month and after each use by a licensed healthcare professional with relevant qualifications and training; An inspection log must be attached to the emergency storage unit and/or portable emergency kit with clear dates of inspections, replacements and name of the individual undertaking the inspection; and Replenished, maintained and serviced according to medications expiry and equipment service requirements as per the manufacturer s recommendations. 7.2 The HAAD licensed Healthcare Facility must ensure that they operate and have in place arrangements for access to and/or use of ambulances services to transfer patients to an appropriate level of care provided by a HAAD licensed Healthcare facility. 7.3 The HAAD licensed Healthcare facility must ensure: All healthcare professionals are licensed by HAAD; and Emergency interventions are provided by a HAAD licensed healthcare professionals with the appropriate emergency skills and training requirements; 8. Standard 2. Inpatient and Outpatient Healthcare Facility Service Requirements 8.1 All healthcare professionals employed in an inpatient healthcare facility shall be trained to Basic Life Support level (BLS) with at least one member within the department who is trained to Advanced Life Support (ALS) or Paediatric Advanced Life Support (PALS) level in accordance with an internationally recognised training programme 8.1.1Training refresher courses shall be undertaken annually; 8.2 All healthcare professionals employed at outpatient healthcare facility shall be trained to Basic Life support level (BLS) in accordance with an internationally recognised training programme Small outpatient facilities such as dental clinics or home healthcare services should undertake a Primary Survey for Respiratory Arrest (BLS) until the patient is stabalised for transfer to a suitable setting; Equipment in the portable kit shall include but not be limited to AED, Epipen (or Epi 1:1000), hydrocortisone, anti-histamine and aspirin (tablets); Training refresher courses shall be undertaken annually; 8.3 All healthcare professionals dealing with paediatric patients shall be trained to deliver Paediatric Life Support (PALS), in accordance with an Page 7 of 13

8 internationally recognised training programme; 8.3.1Training refresher courses shall be undertaken annually; 8.4 The healthcare facility must maintain records of training (including refresher training) and provide evidence of the delivery of such training when requested by HAAD Healthcare Facilities must ensure that they have the appropriate number of Basic and Advanced ambulances to meet the patient case mix, operational requirements of the clinical services provided by that facility. Where a healthcare facility sources ambulance services from a third party, it is the healthcare facilities responsibility to ensure that the appropriate level of ambulance service is provided to meet the patient needs. 8.5 A Healthcare Facility may utilise the Abu Dhabi universal emergency services where for example: they meet the HAAD requirement for provision of patient transfer capacity and capability in accordance with their license and scope of services and privileges; capacity and/or capability of their own ambulance service does not allow for emergency patient transfer; patient acuity does not permit the required professional and skill mix to transfer the patient ambulance services are en-route and/or prioritised elsewhere; 9. Standard 3. Interfacility Patient Transfer Service Requirements 9.1 Healthcare providers shall develop, implement, monitor and review their system for patients requiring interfacility transfer. The system must be designed to provide high quality and safe standards of care before, during and after transfer suited to the level of patient need. The system must comprise of medical oversight to ensure favourable patient outcomes. As a minimum, written policies and standard operating procedures/protocols must cover the following elements: Patient assessment, classification and need for transfer and care management; Identification and selection of a receiving facility that is appropriate to the patient s needs, taking into account the scope of service, including need for specialised services, capacity and capability of the receiving facility; Use of HAAD licensed ground ambulance and assignment of a transfer coordinator to manage the co-ordination of interfacility patient transfers as set out in Appendices 5-13; It is the responsibility of the Healthcare Provider to determine the category of healthcare professional to be assigned the role of the transfer coordinator Use of HAAD Licensed healthcare professionals with suitable credentials and training to form a transfer or retrieval team to manage the needs of the patient To ensure accurate and efficient communication processes between Healthcare facilities and HAAD operation Centre, Healthcare facilities shall: Assign and manage an emergency number to facilitate direct Page 8 of 13

9 communication between hospital transfer coordinators; and Assign a dedicated (non-personal address) for the allocated transfer coordinator to facilitate direct communication between hospital transfer coordinators and with HAAD All healthcare professionals involved in the provision of care during interfacility patient transfer must have Transport knowledge and skills comprising of: Radio and communication technology; Safety operations; Transport equipment; Documentation including patient care records (manual/electronic) Transport logistics; Facility transfer standard operating procedures/protocols; Physician verbal orders, patient positioning during transport for safety and accessibility; Relevant emergency training according to basic or advanced transfer as per HAAD requirements including but not limited to: BLS, ACLS, ATLS and PALS All healthcare professionals involved in the provision of basic transfer shall have the knowledge and skills and meet the minimum requirements including but not limited to: intravenous insertion, monitoring and maintenance, all forms of medication administration, airway management, ECG monitoring, defibrillation, cardio-version, transcutaneous pacing and offer basic intervention as needed All healthcare professionals involved in the provision of advanced transfer shall have the knowledge and skills and meet the minimum requirements including but not limited to: ACLS, ATLS, PLS, advanced airway management, ventilator management, all forms of medication management, circulatory management and support and have the ability to continuously monitor and assess the patient s condition and intervene as needed. 9.2 It is the responsibility of management and staff of the referring healthcare facility to ensure and check that the ambulance is well equipped and all equipment are functional to respond to medical emergencies during the patient transfer; The referring healthcare facility management will be responsible for any delay in transporting the patient to the receiving healthcare facility once the approval from the receiving facility is obtained; After each patient transfer by ambulance it is the responsibility of the ambulance service provider to dispose of all used disposable and contaminated items and replace them with new items. All other items including emergency medicines should be replaced or refurbished accordingly and in compliance with regulation; Page 9 of 13

10 9.3 Documentation related to transfers must be recorded including expected timeframes between referring and receiving facility in addition to the following: Transfer requests from requesting provider; Acceptance from receiving providers (at least specialist level physician) prior to patient transfer; Discussion with patient and/or relatives and consent for transfer. Where a patient and/or their family reject the transfer, a form including Left Against Medical Advice (LAMA) section must be signed by the patient or his/her legally authorised guardian/family member; Discussion with and instructions given to the escorting healthcare professionals; Evidence of agreement between hospitals regarding the transferring of the patient back to the referring hospital upon fulfilling the transfer purpose; Post transfer feedback form to be sent back to referring facility within one week of patient discharge (Appendix 13); Details of any electronic records or documentation sent to the receiving facility and acknowledgements of their receipt; Documentation related to the transferred patient that is not available at the time of transfer but is to be sent within five (5) working days (e.g. laboratory results); Management and safe and secure storage of all patient related documentation and forms, including Referring facility reporting form, receiving facility reporting form, record of transfer, Post transfer feedback form and any other related forms such as consents forms, left against medical advice form The full address regarding the location of referring Healthcare facility, demographic data and condition of patient must be properly communicated to the universal emergency service staff. 10. Standard 4. Ambulance Service Requirements 10.1 Ambulance service providers will be licensed by HAAD to provide either basic and/or advanced emergency service as set out in Appendix All HAAD licensed Ambulance Service Providers must: Ensure all ambulance vehicles have passed the regulatory vehicle registration requirements of respective Abu Dhabi Government Authorities, including those of Abu Dhabi Police Vehicles and Drivers Licensing Department, road and service worthiness and safety, crash test certification and vehicle drivers have the appropriate registration and license for the use of ambulances; Ensure that ambulance vehicle drivers have the appropriate license to drive ambulances and that they have completed training in road safety rules and regulations as specified by the respective Abu Dhabi Government Authority; Page 10 of 13

11 Ensure all newly acquired ambulance vehicles comply with CEN 1789 best safety standards, meet UAE regulations, HAAD requirements for licensing and certification and have relevant and up to date documentation/certificate and registration/license to ensure vehicle and driver safety including but not limited to the following: Weight It is essential that the manufacturer s weight limit (GVW) is not exceeded when the vehicle is in full operational mode. Documentation of this requirement must be provided to HAAD Markings The base colour of the ambulance must be in line with HAAD requirements; and High visibility markings and emergency light must be in line with HAAD requirements When installing medical and/or emergency devices and equipment into an ambulance, ensure that installation is done by a licenced company/organisation that complies with this Standard and CEN1789, and that such installation does not adversely impact the operability of the ambulance or any of it equipment; Ensure ease of accessibility to installed devices and equipment for servicing, maintenance and/or replacement; Retain documentation from the original vehicle equipment manufacturer confirming the acceptability of any modifications for healthcare performed on an ambulance vehicle, including equipment devices for healthcare for at least the lifespan of the vehicle; Changes in ambulance configuration can be made as long as they remain consistent with CEN1789 Standards manufacturer s specifications Have in place and maintain a record of routine performance checks of ambulance vehicles as requested by HAAD and in accordance with the manufacturer s recommendations including but not limited to: Having user manuals and service schedules for all medical devices and equipment easily accessible to paramedics and ambulance staff; Ensuring vehicles are maintained in clean and sanitary condition, and that a detailed facility policy and procedures governing infection control the cleaning and sanitation of ambulances and equipment is developed, implemented and its implementation monitored; Ensuring appropriate medical supplies are available and replenished to ensure minimum level maintained at all times and supplies are suitable for the care provided, as per the approved scope of services; 10.3 Healthcare providers are responsible for ensuring that ambulance services (be it through facility owned and/or contracted services), deliver safe, effective and high quality services HAAD Licensed Healthcare Facilities may obtain ambulance services through third party ambulance service providers under contractual or Page 11 of 13

12 partnership arrangements that stipulate the type of practice, privilege and patient acuity to be transported; and The Healthcare Provider must have in place a written contract/agreement with a third party service provider to manage emergency transfer where it does not have ambulance services. This contract/agreement must be presented during facility licensure Ambulance Service Providers must ensure the following requirements are in place: Governance: necessary formal arrangements to govern and ensure quality improvement, assurance and safety and performance of ambulance service provision is suitable for the range and type of services provided by the healthcare facility Staffing: All healthcare professionals must adhere to their approved privileges in accordance with the HAAD Clinical Privileging framework, their respective professional scope of practice and scope of service Service Provision: Service provision will be determined by HAAD licensure, service scope of practice and privileges granted by the healthcare provider Ambulance Service Provider shall ensure they have in place and make use of information management systems including but not limited to: Telecommunications, Emirates Medical Radio Communication Systems (Tetra), Electronic Patient Care Reporting (EPCR) system and have the technological ability to communicate at different frequencies as required Ambulance Service Provider shall ensure: They have in place an Emergency Medical Dispatch (EMD) system that is functioning with sufficient Telecommunication equipment (wireless radio) for communication and a means for receiving calls for the service They are equipped with a Mobile Tracking Device (MTD) system for emergency management and tracking Response: Healthcare facilities must utilise their own ambulances in the first instance (see section 8.5) and where necessary ensure they respond major incident as part of a system wide response as directed by HAAD emergency operation centre Monitoring: Ambulance service providers must ensure they are able to assess and monitor the patient s condition with an integrated monitoring system capable of four lead ECG, SpO2, PetCO2 and NIBP with 12 lead ECG capability, if ALS is present Clinical Supplies and Staffing: It is the responsibility of the Healthcare Provider to ensure adequate staffing, equipment and medical supplies are functional for all medical emergency transfer Restocking of the Ambulance: Ambulance Service Providers must ensure they dispose all used disposable and contaminated items and replace them to a minimal level once transfer has been completed. All other items including emergency medicines should be replaced or refurbished as per best practice and UAE regulations. This includes updating medication stock and medication management and administration of Page 12 of 13

13 controlled/narcotic medications as per HAAD requirements. The Ambulance Service Provider must: Ensure disposable medical waste is managed in accordance with HAAD Policies and Standards governing medical products and medical waste disposal and EHSMS; and Ensure that all medical equipment where possible shall be disposable or single patient use in accordance with international best practice for infection control Adhere to the latest JRCALC (UK Ambulance Clinical Practice Guidelines) or equivalent internationally recognised ambulance Clinical Practice Guidelines. 11. Standard 5. Ambulance Service Performance 11.1 HAAD requires ambulance service providers to maintain a record of Key Performance Indicators (KPIs) as noted in Appendix Healthcare Facilities must monitor and analyse the performance of ambulance services and ensure actions are taken to improve service performance, quality, patient safety and patient outcomes; Healthcare Facilities must report the number of Ambulances they have, their classification and Type (CEN 1789 B or C) to HAAD on a quarterly basis to opcenter@haad.ae Healthcare facilities must submit monthly reports to HAAD all interfacility patient transfers to emergency.review@haad.ae Healthcare facilities must submit Jawda performance metrics for ambulance service performance on a quarterly basis to quality@haad.ae Page 13 of 13