NAC449.389. Respiratory care services.

A hospital shall meet the needs relating to respiratory care of its patients in accordance with nationally recognized standards of practice. If the hospital has a unit to provide respiratory care services:

     1. The director of the unit must be a doctor of medicine or osteopathy who has the knowledge, experience and capabilities to supervise and administer the respiratory care services properly. The director may serve on a full-time or part-time basis.

     2. The hospital shall ensure that there are an adequate number of respiratory therapists, respiratory therapy technicians and other personnel who meet the qualifications, which must be consistent with state law, specified by the medical staff to provide respiratory care services.

     3. Personnel qualified to perform specific procedures relating to the provision of respiratory care services and the amount of supervision required for such personnel to carry out specific procedures must be designated in writing.

     4. If blood gases or other clinical laboratory tests are performed in the respiratory care unit, the unit must meet the requirements for clinical laboratories with respect to management, adequacy of facilities, proficiency testing and quality control.

     5. Respiratory care services must be provided only upon and in accordance with the orders of a doctor of medicine or osteopathy.

     6. Diagnostic studies and treatment modalities relating to respiratory care must be recorded in the patient’s medical record, including, without limitation:

     (a) The type of diagnostic or therapeutic procedures used;

     (b) The dates and times of the use of such procedures; and

     (c) The effects of such procedures, including adverse reactions.

     7. The unit shall have sufficient types and quantities of equipment to provide for the appropriate inhalation of the several gases, aerosols and such other modalities required for the anticipated nature and variety of procedures that will be performed in the unit. Equipment must be calibrated in accordance with the manufacturer’s instructions and records of such calibrations must be maintained.

     8. The unit shall have sufficient space for:

     (a) The storage of necessary equipment;

     (b) Work areas for:

          (1) Cleaning, sterilizing and repairing equipment; and

          (2) Performing studies of pulmonary function and blood analyses, if such studies and analyses are performed in the unit; and

     (c) Office space for the personnel of the unit.

     9. The unit shall establish and carry out procedures for the safe handling and storage of medical gas cylinders. Only certified persons and persons trained by the hospital may transfer gas from one cylinder to another. Such a transfer must be completed in accordance with safety protocols.

     (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)