Emergency Procedures Fact Sheet

Applicable Accreditation Standards

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

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

Emergency policies must include policies and procedures for the following:

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

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

The facility must instruct the patient to call emergency services (911) in the event of an emergency during a HSAT.

Facilities must conduct and document drills of their emergency procedures on an annual basis. At a minimum, the facility conducts and documents annual drills of their response to cardio-pulmonary emergencies.

Facilities must have appropriate equipment to address possible emergencies. At a minimum, all facilities must have either an automated external defibrillator (AED) or access to an on-site medical emergency response team. The facility maintains and documents the maintenance of all emergency equipment according to manufacturers’ recommendations. The facility maintains and documents training of personnel on emergency equipment.

Purpose of the Emergency Plan

Emergency procedures are necessary to ensure safety of all patients and staff during situations of medical and non-medical emergencies. Every medical and technical staff member share in providing safety to all. The detailed medical emergency procedures provide step by step written instructions, so all staff members are prepared to implement basic first aid measures until other medical emergency assistance arrive.

The Written Emergency Plan Requirements:

  • Describe the mechanism(s) and specific phone contact information for emergency personnel, facility director and other sleep facility staff.
    1. It should describe the location of any special phones, alarms, call buttons, and/remote door access information.
  • Provide and outline specific responsibilities for medical and each technical staff member:
    1. Indicate the step by step basic first aid measures that is to occur during the emergency.
    2. When more than one technician is scheduled, indicate the role of each technician.
    3. If only one technician is present, define how ER personnel gain access to the facility remotely to prevent staff from leaving the patient.


  • Written Medical and Non-medical emergency plan(s).
  • Hospital-based emergency procedures if required to implement code team procedures.
  • Policy addressing Emergency equipment used, access, use and maintenance of Automated External Defibrillator, (AED) or access to Emergency Response Team.
  • Policy addressing conducting and documenting emergency drills annually; minimally a cardiopulmonary drill within the sleep lab.

Types of Emergencies

Cardiopulmonary emergencies may include the following:

  • Cardiac arrest
  • Ventricular Tachycardia > than 10 seconds
  • Ventricular Fibrillation
  • Apnea greater than 2 minutes
  • Changes in cardiac rhythm
    • Persistent bigeminy or trigemini
    • Atrial Flutter or fibrillation
    • Tachycardia or bradycardia

Neurological Emergencies may include the following:

  • Specifically, seizures,
  • Other examples of neurological emergencies include:
    1. loss of consciousness, changes in speech, weakness in limbs or face, severe or unrelenting headache (signs of cerebrovascular event (CVA)—stroke).

Psychiatric emergencies may include the following:

  • Specifically, suicide ideation,
  • Other examples may include homicidal ideation, hallucinations, acute psychosis, acute mania, any life-threatening behavior directed to harm self or others.

Environmental-Non-medical emergencies may include the following:

  • Fire,
  • Local weather threats, (earthquakes, floods, hurricanes, tornadoes),
  • Bomb threats,
  • Workplace or any threat of violence (potential for assault or inappropriate behavior during testing—for discussion) and;
  • Belligerent patient.

Emergency Equipment

All necessary emergency equipment as required by the facility’s emergency plan is to be accessible and properly functioning. A policy is required addressing the maintenance, use and training of emergency equipment.

  • Automated External Defibrillator

HSAT Emergency

  • Medical emergency while on HSAT –instruction to call for emergency assistance (i.e. 911)

Key Things to Keep In Mind

  • If facility has access to Hospital code teams and are required to use the Hospital wide Emergency code procedures, please include/upload in the application.
  • Describe specific step by step basic first aid measures for each facility staff members to implement until arrival of ER personnel or ERT.
  • Specific contact information for medical and other facility staff is to be documented in the emergency policy.
  • Describe how emergency personnel (911) are to access the sleep facility during an emergency (e.g. lock box, access through hospital entrance etc) to ensure non-interrupted emergency care is provided to the patient. Scenarios would include when there is only 1 staff on site during testing hours.
  • Indicate where the emergency equipment (AED) is located.
  • Describe the medical procedure for instructing patients in contacting emergency assistance while on HSAT (call 911).
  • Evidence of CPR Drill must be documented.
  • Reference the Accreditation Reference Manual for specifics on what the emergency policies should include.