§515.315. Bypass or Resource Limitation Status Review

a)         The Department shall investigate the circumstances that caused a hospital in an EMS System to go on bypass status to determine whether that hospital's decision to go on bypass status was reasonable.  (Section 3.20(c) of the Act)

 

b)         The hospital shall notify the Illinois Department of Public Health, Division of Emergency Medical Services, of any bypass/resource limitation decision, at both the time of its initiation and the time of its termination, through status change updates entered into the Illinois EMResource application, accessed at https://emresource.juvare.com/login.  The hospital shall document any inability to access EMResource by contacting IDPH Division of EMS during normal business hours.

 

c)         In determining whether a hospital's decision to go on bypass/resource limitation status was reasonable, the Department shall consider the following:

 

1)         The number of critical or monitored beds available in the hospital at the time that the decision to go on bypass status was made;

 

2)         Whether an internal disaster, including, but not limited to, a power failure, had occurred in the hospital at the time that the decision to go on bypass status was made;

 

3)         The number of staff after attempts have been made to call in additional staff, in accordance with facility policy; and

 

4)         The approved hospital protocols for peak census, surge, and bypass and diversion at the time that the decision to go on bypass status was made, provided that the Protocols include subsections (c)(1), (2) and (3).

 

5)         Bypass status may not be honored or deemed reasonable if three or more hospitals in a geographic area are on bypass status and/or transport time by an ambulance to the nearest facility is identified in the regional bypass plan to exceed 15 minutes.

 

d)         Hospital diversion should be based on a significant resource limitation and may be categorized as a System of Care (STEMI or Stroke), or other EMS transports.  The decision to go on bypass (or resource limitation) status shall be based on meeting the following two criteria, and compliance with subsection (c)(3).

 

1)         Lack of an essential resource for a given type or class of patient (i.e. Stroke, STEMI, etc.) Examples include, but are not limited to:

 

A)        No available or monitored beds within traditional patient care and surge patient care areas with appropriate monitoring for patient needs;

 

B)        Unavailability of trained staff appropriate for patient needs; and/or

 

C)        No available essential diagnostic and/or intervention equipment or facilities essential for patient needs.

 

2)         All reasonable efforts to resolve the essential resource limitations have been exhausted including, but not limited to:

 

A)        Consideration for using appropriately monitored beds in other areas of the hospital;

 

B)        Limitation or cancellation of elective patient procedures and admissions to make available surge patient care space and redeploy clinical staff to surge patients;

 

C)        Actual and substantial efforts to call in appropriately trained off-duty staff; and

 

D)        Urgent and priority efforts have been undertaken to restore existing diagnostic and/or interventional equipment or backup equipment and/or facilities to availability, including but not limited to seeking emergency repair from outside vendors if in house capability is not rapidly available.

 

3)         The hospital will do constant monitoring to determine when the bypass condition can be lifted.  Such monitoring and decision making shall include clinical and administrative personnel with adequate hospital authority.  Efforts to resolve issues in subsection (d)(1) using all available resource under subsection (d)(2) to come off bypass as soon as such patients can be safely accommodated.

 

e)         For Trauma Centers only, the following situations would constitute a reasonable decision to go on bypass status:

 

1)         All staffed operating suites are in use or fully implemented with on-call teams, and at least one or more of the procedures is an operative trauma case;

 

2)         The CAT scan is not working; or

 

3)         The general bypass criteria in subsection (c).

 

f)         During a declared local or state disaster, hospitals may only go on bypass status if they have received prior approval from IDPH. Hospitals must complete or submit the following prior to seeking approval from IDPH for bypass status:

 

1)         EMResource must reflect current bed status;

 

2)         Peak census policy must have been implemented 3 hours prior to the request of bypass;

 

3)         Hospital and staff surge plans must be implemented;

 

4)         The following hospital information shall be provided to IDPH:

 

A)        Number of hours for in-patient holds waiting for bed assignment;

 

B)        Longest number of hours wait time in Emergency Department;

 

C)        Number of patients in waiting area waiting to be seen;

 

D)        In-house open beds that are not able to be staffed;

 

E)        Percent of beds occupied by in-patient holds;

 

F)         Number of potential in-patient discharges; and

 

G)        Number of open ICU beds.

 

5)         The IDPH Regional EMS Coordinator will review the above information along with hospital status in the region and determine whether to approve bypass for 2 hours, 4 hours, or an appropriate length of time as determined by the DPH Regional EMS Coordinator, or to deny the bypass request.  A by pass request may be extended based on continued assessment of the situation, including status of surrounding hospitals, with the DPH Regional EMS Coordinator and communication with the requesting hospital.  A hospital may be denied bypass based on regional status or told to come off bypass if an additional hospital in the geographic area requests bypass.

 

g)         The Department may impose sanctions, as set forth in Section 3.140 of the Act, upon a Department determination that the hospital unreasonably went on bypass status in violation of the Act.  (Section 3.20(c) of the Act)

 

h)         Each EMS System shall develop a policy addressing response to a system-wide crisis.

 

(Source:  Amended at 46 Ill. Reg. 20898, effective December 16, 2022)