California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 1 - General Acute Care Hospitals
Article 6 - Supplemental Services
Section 70433 - Cardiovascular Surgery Service General Requirements

Universal Citation: 22 CA Code of Regs 70433

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate. These policies and procedures shall include provision for at least:

(1) Definitions of qualifications of physicians for privileges to perform cardiovascular laboratory catheterization procedures and/or surgery.

(2) Regular review of case management, both preoperatively and postoperatively.

(3) Collection, processing and retrieval of data on all patients to include at least: diagnosis, procedure performed, pathophysiologic, angiographic, morbidity and mortality data.

(4) Recommendations regarding equipment used, procedures performed and staffing patterns in the catheterization laboratory and cardiovascular surgery units.

(b) The responsibility and the accountability of the service to the medical staff and administration shall be defined.

(1) 260 cardiac catheterizations per year.

(2) 150 cardiovascular procedures requiring extra corporeal bypass per year.

(d) The cardiovascular surgical service shall be available at all times for emergencies.

(e) Supportive diagnostic services with trained personnel shall be available and include, where appropriate, electrocardiography, vectorcardiography, exercise stress testing, cardiac pacemaker station, echocardiography, phonocardiography and pulse tracings.

(f) An intensive care service with respiratory care capabilities shall be provided by the hospital.

(g) An animal laboratory is recommended as support for the cardiovascular surgery service.

(h) A cardiac rehabilitation program should be integrated with the cardiovascular surgery service for early identification of the patient who can profit thereby.

(i) All persons operating or supervising the operation of X-ray machines shall comply with the requirements of the Radiologic Technology Regulations, Subchapter 4.5, Chapter 5, Title 17, California Administrative Code.

(j) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.

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