Current through September 2, 2024
If appropriate for the hospital, these units may be established for patients requiring extraordinary care.
01.Policies and Procedures. If the hospital has critical care units then written policies and procedures shall be developed and implemented by the medical staff, appropriate nursing staff, and administration. The physician or committee responsible for the overall medical direction of the unit, shall also participate in the development of the written policies and procedures and approve them. Policies and procedures shall include at least the following:
a. A policy statement regarding the responsibility of the units to the medical staff including the working relationship between the unit director and the patient's physician; and
b. Admission criteria, priorities, discharge and transfer policies and procedures; and
c. Staffing requirements including training and experience; and
d. Emergency procedures; and
e. Infection control procedure including isolation procedures; and
f. Policies and procedures including standing orders for medical emergencies when a physician is not present. These shall include the procedure for the use of drugs and equipment, and specify who can do the procedure.
02.
Critical Care Staff. The staff of a hospital critical care unit shall be composed of the following:
a. A physician shall have overall medical direction and responsibility for the unit. The physician, with concurrence from the medical staff and administration, shall provide direction for:
i. Implementation of policies and procedures involving critical care service; and
ii. Determination of qualifications of all other personnel serving the unit; and
iii. Development of a system to assure physician coverage; and
iv. Criteria for admission and discharge; and
v. Assuring continuing education for medical and nursing staff.
b. There shall be sufficient licensed registered nurses with training and experience in critical care on duty on a twenty-four (24) hour basis for nursing care and nursing management.
c. Licensed registered nurses who work in the unit must have training or experience in that type of nursing care.
d. If there is only one (1) patient in the critical care unit there shall be one (1) licensed registered nurse who shall be available to observe the patient. If there are two (2) or more patients in the unit, a licensed registered nurse shall be present in the unit at all times.
03.
Equipment and Supplies. There shall be sufficient equipment and supplies to meet the needs of the patients treated; and
a. There shall be a call signal at each bed to a continuously staffed station; and
b. There shall be an alarm system or other method of calling assistance for special teams.
04.
Area Requirements. Critical care unit requirements are as follows:
a. There shall not be more than twelve (12) patient beds in each unit.
b. Each bed area shall be one hundred thirty-two (132) square feet.
c. There shall be a minimum of eight (8) feet between beds with at least four (4) feet at the foot and sides of the bed.
05.
Maintenance Program. There shall be a regularly scheduled preventive maintenance program with emphasis on electrical safety, and there shall be written evidence of such a program (refer to Subsection 510.03, Electrical Safety).
Effective March 17, 2022
