Emergency Procedures Fact Sheet

Applicable Accreditation Standards

Emergency policies must include policies and procedures for the following:

  1. Cardio-pulmonary emergencies with equipment required in Standard S-7 
  2. Neurologic emergencies, particularly seizures and strokes 
  3. Psychiatric emergencies, particularly suicidal ideation 
  4. Environmental emergencies including fire, weather, belligerent patients, and bomb threats 

Each service location must conduct and document drills of their emergency procedures on an annual basis. At a minimum, each service location should conduct and document annual drills of their response to cardio-pulmonary emergencies.

Each service location must have appropriate equipment to address possible emergencies. At a minimum, all service locations must have immediate access to either an automated external defibrillator (AED) or access to an on-site medical emergency response team. Each service location should maintain and document the maintenance of all emergency equipment according to manufacturers’ recommendations. The service location should also maintain and document training of personnel on emergency equipment.

An emergency plan must be accessible in paper or electronic format delineating the following:

  1. Mechanism and specific details for contacting emergency personnel. 
  2. The lab personnel to be contacted in an emergency. 
  3. Specific responsibilities of the medical and technical staff. 

Labs using hospital code teams may use hospital-based policies for medical emergencies 

Purpose of the Emergency Plan

Emergency procedures are essential to ensure the safety of all patients and staff during medical and non-medical emergencies. Every medical and technical staff member is responsible for contributing to overall safety. Detailed procedures include step-by-step written instructions to prepare staff to administer basic first aid until additional medical assistance arrives. 

Emergency Plan Requirements:

  • Provide and outline specific responsibilities for medical and technical staff:
    1. Indicate the–step–by–step basic first aid measures to be followed during an emergency.
    2. When more than one technician is scheduled, specify the role of each technician.
    3. If only one technician is present, define how emergency personnel will gain remote access to the facility to prevent staff from leaving the patient. 
  • Describe the mechanism(s) and specific contact information for emergency personnel, network or site director and other sleep staff.
    1. Include the location of special phones, alarms, call buttons, and remote door access information. 
  • Define the types of medical emergencies, such as cardiovascular and neurological emergencies.

Submit

  • Written Medical and Non-medical emergency plan(s).
  • Hospital-based emergency procedures, if required to implement code team protocols. 
  • Policy outlining the use, access, and maintenance of emergency equipment, including Automated External Defibrillators (AED) or access to the Emergency Response Team. 
  • Policy addressing the annual conduct and documentation of emergency drills, including at least one cardiopulmonary drill within the sleep lab.

Types of Emergencies

  • Cardiopulmonary emergencies: cardiac arrest, ventricular tachycardia, Apnea>2min
  • Neurological Emergencies: seizure and stroke
  • Psychiatric emergencies: suicide ideation

Environmental Non-medical Emergencies

  • Fire
  • Local weather threats (earthquakes, floods, hurricanes, tornadoes)
  • Bomb threats
  • Belligerent patient

Emergency Equipment

All necessary emergency equipment, as outlined in the emergency plan, must be accessible and in proper working order. A policy must be in place addressing the maintenance, use, and training for emergency equipment, including the Automated External Defibrillator (AED). 

Key Things to Keep In Mind

  • If the facility has access to an Internal Response Team or is required to follow hospital-wide emergency code procedures, include this information in the application.
  • Describe step-by-step basic first aid measures for each staff member to implement until the arrival of emergency personnel or the Emergency Response Team (ERT).
  • Document specific contact information for medical and other facility staff in the emergency policy.
  • Outline how emergency personnel (911) can access the sleep facility during an emergency (e.g., lock box, access through hospital entrance, etc.) to ensure uninterrupted emergency care, especially when only one staff member is on-site during testing hours.
  • Indicate the location of emergency equipment, such as the Automated External Defibrillator (AED).
  • Describe the procedure for instructing patients on how to contact emergency assistance while on HSAT (e.g., calling 911).
  • Document evidence of a CPR drill.