New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 802 - RULES FOR HOSPITALS
Section He-P 802.40 - Open Heart Surgery Services

Universal Citation: NH Admin Rules He-P 802.40

Current through Register No. 40, October 3, 2024

(a) If open heart surgery services have not been provided by the hospital previously, no licensee shall offer open heart surgery services without a special health care service license.

(b) In accordance with RSA 151:2-e, all licensees shall comply with this section if they provide open heart surgery services, regardless of whether the licensee holds a special health care license.

(c) Open heart surgery services shall be available and accessible on-site 24 hours per day, 7 days per week, for emergency purposes.

(d) All licensees performing open heart surgery services shall be accredited by a recognized accrediting agency for the provision of open heart surgery services.

(e) If the licensee is newly providing open heart surgery services, the licensee shall have 3 years, from the date of receiving a special health care license, to obtain accreditation required in (d) above.

(f) Staffing for open heart surgery services shall be in accordance with the accrediting agency's accepted staffing requirements.

(g) Each open heart surgery program shall provide, at a minimum, the following:

(1) A total of 4 segregated/private beds for cardiac care in an ICU;

(2) A telemetry unit proximate to the ICU;

(3) An acute renal dialysis service;

(4) A cardiac rehabilitation service;

(5) A minimum of 2 operating rooms equipped and available as needed for open heart surgery;

(6) An in-house cardiac catheterization service; and

(7) An available and accessible supply of blood and platelets, through an in-house supply or through affiliation with an established blood bank network.

(h) The licensee shall establish and maintain:

(1) A quality assurance plan that includes:
a. An outline of utilization, or peer review and control programs, or both; and

b. An annual review of the morbidity and mortality rates and other indicators of patient outcomes, compared with regional or national averages;

(2) Protocols governing transfers, admissions, and discharges of open-heart surgery patients; and

(3) Protocols to establish, maintain, and annually review including:
a. A list of indications and contraindications to govern patient selection for open heart surgery;

b. Guidelines governing the admission of open heart surgery patients to the intensive care, coronary care and progressive care units, and discharge from these units; and

c. Mechanisms for follow-up surveillance of discharged patients.

(i) Licensee's providing open heart surgery shall subscribe, for the purpose of external quality review, to a confidential data registry.

(j) The licensee shall have the appropriate equipment to adequately perform open-heart surgery as required by the accrediting agency.

(k) Each licensee performing open heart surgery shall perform 150 open heart surgery cases on an annual basis by the end of the third year of operation. This may be demonstrated by the number of claims the licensee files in any twelve-month period.

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