Hospital Disaster Physician Privileging
Revised and approved by the ACEP Board of Directors titled, "Hospital Disaster Physician Privileging," January 2010
Originally approved by the ACEP Board of Directors February 2003 titled, "Hospital Disaster Privileging."
The American College of Emergency Physicians (ACEP) believes that all hospitals should have a process in place which allows emergency privileging of additional physician staff in the event of activation of the hospital disaster (emergency preparedness) plan. Should it be necessary to activate the disaster plan, additional physician support may be needed immediately to supplement the existing medical staff. A Hazard Vulnerability Assessment (HVA) or other similar evaluation should be undertaken to proactively identify potential emergencies, including any circumstances unique to the particular hospital that could suddenly affect physician demand or supply. It should also include the hospital’s role in the community and the potential of displacing the medical staff in the event of hospital evacuation to an alternate site or hospital through community and mutual aid agreements.
Physicians who request disaster credentialing must be currently licensed practitioners who maintain equivalent privileges at another facility. Privileges requested should be consistent with those currently in place in the appropriate department and specialty at the physician's "home" hospital. Hospitals and physicians should ensure that physician possesses professional liability coverage for services provided while assisting during the disaster.
Hospital medical staff rules and regulations or bylaws that address disaster credentialing should conform to local, state, and federal regulations, laws and accreditation standards and specify identification requirements for those physicians requesting disaster privileging. Such identification should include government-issued photo identification (eg, driver’s license or passport), plus one or more of the following:
- A current picture hospital/health organization identification card.
- A current license to practice medicine and/or surgery.
- Identification indicating that the individual has been granted authority to render patient care in disaster circumstances, such authority having been granted by a federal, state, or municipal entity.
- Presentation by current hospital or medical staff member(s) with personal knowledge regarding the practitioner's identity.
Immediate disaster privileges may be granted in accordance with medical staff rules and regulations or bylaws. The role for the individual(s) responsible for granting such privileges must be delineated in writing in the medical staff bylaws and/or rules and regulations, and referenced in the hospital's disaster (emergency preparedness) plan. The rules and regulations or bylaws should specify that this individual is not required to grant privileges to any requestor and is expected to make such decisions on a case-by-case basis at his or her discretion. The privileges should be effective immediately and continue through the completion of the patient care needs or until the orderly transfer of the patient's care to another properly credentialed physician can be accomplished.
Following disaster credentialing, the physician should be provided and maintain on his or her person written verification of said privileges. The medical staff bylaws, rules and regulations should require that his or her notations in the medical record reflect that the physician is working under disaster privileges. For quality review purposes, a list of all patient encounters should be kept, if practical.
As soon as practical, primary source verification of the disaster credentialed physician should be undertaken. This verification should include:
- Current and unencumbered medical licensure verification, and
- DEA and state narcotics registration verification.
If required by the hospital's policy for granting temporary privileges, one or more of the following may be verified:
- National Practitioner Data Bank discovery
- Health and Human Services/Office of Inspector General (HHS/OIG) List of Parties Excluded from Federal Programs; and
- One current active hospital affiliation.