Defining emergency privileges

Frequently, emergency and disaster privileges are confused. Emergency privileges are those privileges that the medical staff has granted to existing members to do whatever is necessary (within the scope of each practitioner’s license) to save the life, limb, or organ of a patient. Typically, the practitioner is required to ask an appropriately privileged colleague to consult on or become involved with a case at the earliest feasible time.

“Anyone who has privileges can exceed those privileges or provide services they do not have privileges for if it is an emergency,” says Elizabeth “Libby” Snelson, JD, president of Legal Counsel for the Medical Staff, PLLC. “If you have a shooting at the hospital and a pathologist walks by, a pathologist does not have privileges to provide emergency care to a patient, but if she is standing there, she can do whatever she needs to do to save the person’s life.”

CMS and the NCQA do not use emergency privileges terminology in their requirements. The Joint Commission (TJC) does not require emergency privileges be included in governing documents, but suggests it. DNV GL and the Healthcare Facilities Accreditation Program (HFAP) both require that medical staff bylaws include a process for granting emergency privileges.

Novant Health UVA Health System Culpeper (Virginia) Medical Center, which is accredited by TJC, has both its emergency and disaster privileges defined in its medical staff bylaws. Emergency privileges are granted in three situations:

  1. For a medical staff member to exceed his or her clinical privileges to save a patient from serious harm.
  2. For any person to do whatever is reasonably possible to save a patient from serious harm.
  3. For known practitioners to provide coverage of a clinical function that is devoid of coverage. The scope and time of these privileges is determined by the medical executive committee and president.

Source: Medical Staff Briefing