New York Department of Health Guidance Document for Hospitals - Hospital Obligations & Responsibilities

Hospitals must meet the needs of the communities they serve on an ongoing basis. It is the responsibility of the hospital's Governing Body and Senior Management personnel to review the following guidelines and to implement, as appropriate.

  • Emergency preparedness and readiness is not an episodic response, but is an ongoing commitment to maintaining a hospital's capacity and capabilities to respond to emergencies. Emergency Departments need to remain open and fully operational to ensure that each hospital is able to maintain the capacity to respond, not only to episodic events, but to long term or seasonal periods of overcrowding.
  • Maintaining admitted patients within the emergency department is not acceptable. Hospital administration must be proactive in identifying and utilizing inpatient beds for admissions from the emergency department. All hospital beds and inpatient areas should be identified and considered in determining bed assignments. During peak periods of overcrowding, as a temporary emergency measure, the use of beds in solariums and hallways near nursing stations should be utilized consistent with a facility -wide plan to alleviate hospital overcrowding.
  • Ambulance diversion is an emergency response to overcrowding that is to be used sparingly and only upon the direction of the hospital's key administrative staff. Hospital administration is responsible to document and monitor all diversion practices and decisions. As hospitals proceed with emergency preparedness planning, all trauma centers, hospitals, counties, and Regional Emergency Medical Advisory Committees, are advised to meet and collectively establish and/or assess the effectiveness of countywide or system wide diversion policies and practices.
  • Hospitals are expected to have in place effective monitoring protocols to track and identify length of stay patterns and deviations, both for inpatients and for patients in the emergency department. Priority attention should be given to initiating inpatient and emergency department discharge planning activities to ensure the prompt and safe discharge of patients. Efforts to coordinate with community resources, nursing homes and other patient support services should be in place and functioning at all times.
  • Ambulances and EMS personnel should not be detained in the emergency department and should be placed promptly back into service. To ensure that patient care needs are met by hospital staff, ambulance patients must be transferred promptly to emergency department staff.
  • Hospitals should evaluate staffing levels on a hospital-wide basis. Cross training and coordination among programs and services is necessary to ensure adequate staffing levels during peak periods of need.
  • Hospitals must assume responsibility for the quality and appropriateness of all patient care services. Regardless of location within the facility, staffing, services, privacy, infection control and confidentiality protections must be consistently in place.
  • Hospitals must make available to ED staff the ancillary services which permit the prompt disposition of patient care needs. The 24-hour availability of transport services is necessary to meet patient needs and to allow for the timely transfer of admitted patients. 


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