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Emergency Medical Response


In a very recent Medicare Certification/CMS inspection, it was noted by the surveyor that there was a missing Emergency Medical Response procedural plan. Upon reviewing the Medicare Conditions for Participation, it appears this can be viewed differently than what we considered it to be which was the Emergency Management Preparedness Plan. With this new interpretation of this requirement, we forged forward in the development of this procedure. It is now complete and can be edited with your surgery center name and then added to your existing policies. If you want a copy of the document, copy and paste the text below:


Emergency Medical Response Policy and Procedure

Policy Statement: It is the policy of [Surgery Center Name] to establish and maintain a comprehensive Emergency Medical Response Plan to ensure the swift and effective response to medical emergencies that may occur within the facility. This plan is designed to safeguard the well-being of patients and provide immediate, appropriate care in the event of a medical crisis.

Scope: This policy applies to all personnel, including clinical staff, medical providers, and support staff, within [Surgery Center Name].


1. Emergency Medical Response Team: a. [Surgery Center Name] shall establish an Emergency Medical Response Team (EMRT) consisting of trained medical personnel responsible for responding to medical emergencies within the facility. b. The EMRT shall include, at a minimum, a designated leader and members with expertise in emergency medicine, CPR, and advanced life support.

2. Emergency Notification: a. In the event of a medical emergency such as a patient experiencing cardiac arrest or respiratory distress, any staff member who identifies the emergency shall immediately: - Call 911 or activate the facility's emergency response system. - Notify the EMRT leader or a designated staff member responsible for coordinating the emergency response.

3. Initial Assessment: a. The EMRT leader or designated staff member shall promptly assess the patient's condition. b. If the patient is not breathing or has no pulse, immediate CPR shall be initiated. c. If the patient is unconscious but breathing, appropriate first aid measures shall be taken as needed.

4. Equipment and Medications: a. The EMRT shall have access to necessary emergency equipment and medications, including but not limited to: - Automated External Defibrillator (AED) - Oxygen - Emergency medications b. Equipment shall be regularly inspected, maintained, and kept in a readily accessible location.

5. Coordination with External Services: a. When 911 has been called, the EMRT leader or designated staff member shall provide essential information to the emergency dispatcher and coordinate with arriving emergency medical services. b. Facility staff shall assist emergency personnel in locating the patient and providing relevant medical history.

6. Documentation: a. All actions taken during the emergency medical response, including assessments, interventions, and medications administered, shall be accurately and promptly documented. b. The patient's medical record shall be updated with the details of the emergency and the response provided.

7. Post-Emergency Debriefing: a. After the medical emergency has been resolved, a debriefing session shall be conducted with the EMRT and involved staff members to review the response, identify areas for improvement, and discuss any necessary follow-up care for the patient.

8. Training and Drills: a. All clinical staff shall receive regular training on emergency medical response procedures, including CPR and the use of emergency equipment. b. Drills and simulations shall be conducted periodically to maintain staff readiness.

9. Compliance: a. All clinical personnel are required to adhere to this policy and the associated procedures. b. Non-compliance may result in disciplinary action.

This Emergency Medical Response Policy and Procedure shall be readily accessible to all clinical personnel and reviewed with new staff during their orientation. The EMRT shall be well-trained and prepared to respond effectively to medical emergencies within the surgery center.


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