Guidelines &

Standards

The American Association for Respiratory Care

11030 Ables Lane Dallas, Texas 75229

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Guidelines & Statements

Administrative Standards for Respiratory Care Services and Personnel

An Official Statement from the American Association for Respiratory Care

In assuming the traditional responsibility of a professional society, the American Association for Respiratory Care, through its Board of Directors, has approved the following standards, defmitions, philosophies, and statements. The specific purpose of this document is to promote delivery of an optimal level of respiratory care to the consumer.

Definitions

Standards: Guidelines established by a recognized authority for the measurement of the level of quality, quantity, value, and appropriateness of methods and resources (human and material) used to meet a goal.

Respiratory Therapy: A health care specialty under medical direction for the assessment, treatment, management, diagnostic evaluation, and care of patients with deficiencies, abnormalities, and diseases of the cardiopulmonary system.

The American Association for Respiratory Care (AARC): A national society of health care professionals dedicated to maintaining the highest standards of practice in respiratory care. The AARC is sponsored by the American Society of Anesthesiologists, The American College of Chest Physicians, and the American Thoracic Society. In addition to providing extensive educational opportunities through publications, continuing education programs, and seminars, the AARC works to promote governmental understanding and support for the profession and sponsors national and community programs to help improve public education and awareness. A Board of Medical Advisors serves in an advisory capacity to the Board of Directors of the AARC. This twenty-member advisory body consists of the sponsoring organizations previously mentioned and representatives from the American Academy of Pediatrics, the American College of Allergists, the Society for Critical Care Medicine, and the Society for Thoracic Surgeons.

The National Board for Respiratory Care (NBRC): The official credentialing board of the profession. The NBRC sets standards for entry into the credentialing process, develops and administers examinations for respiratory therapy practitioners, and ensures the integrity of the examination process.

The Joint Review Committee for Respiratory Therapy Education (JRCRTE): The official accrediting agency for respiratory therapy educational programs. Programs are reviewed on a regular basis for compliance with standards adopted by the Council on Medical Education (CME) of the American Medical Association (AMA).

Registered Respiratory Therapist (RRT): One who has been registered by the National Board for Respiratory Care (NBRC).

Graduate Respiratory Therapist: One who is a graduate of a JRCRTE-approved respiratory therapy training program.

Certified Respiratory Therapy Technician (CRTT): One who has been certified by the National Board for Respiratory Care (NBRC).

Graduate Respiratory Therapy Technician: One who is a graduate of a JRCRTE-approved respiratory therapy technician program.

Respiratory Therapy Assistant: One who has received on-the-job training in respiratory therapy.

Respiratory Therapy Student: One who is enrolled in a JRCRTE-approved respiratory therapy training program.

Respiratory Therapy Trainee: One who is employed by a Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-approved medical ·facility in the Respiratory Therapy Service while receiving on-the-job training as a Respiratory Therapy Assistant.

Scope

This document includes requirements and rationale for the appropriate structure and organization of a respiratory care service, staffmg, physical facility, requests for service, quality assurance, maintenance of diagnostic and therapeutic equipment, safety, continuing education, invasive assessment, diagnostic procedures, infection control, and records and reports.

No requirements are included for the delineation of roles and responsibilities of personnel, hiring practices, or employee relations. Nor does this document include requirements for formal educational programs or structured practicums such as formal internships.

Guidelines & Statements

to maintain the quality and the quantity of the services provided. The Service should incorporate management tools which assess quantity of work and productivity, such as the AARC's Respiratory Therapy Uniform Reporting Program.

The Directors of the Respiratory Care Service must maintain current documentation of services provided. In cases where needed service is not available, or cannot be provided in an optimal fashion, a plan must exist for the transfer of patients to a facility where such care is available. Institutions providing 24-hour respiratory care to patients must assure adequate coverage of all shifts by qualified practitioners.

Physical Facilities and Equipment The Respiratory Care Service shall be provided with sufficient facilities and equipment to safely and effectively accomplish its assigned tasks. These facilities should be situated within the hospital in a location that minimizes the movement of personnel and the transportation of apparatus.

Rationale: The size and nature of the physical facilities and equipment necessary to provide safe and effective care will vary in direct proportion to the scope of the services provided. Existing codes and regulations should serve as a baseline standard. Beyond this point, the Directors of the Respiratory Care Service must utilize their own experience and draw on the assistance of experts from other fields to determine the appropriate resolution of present and potential requirements. For example, the assistance of a facilities engineer is essential in establishing adequate heating, ventilation, and air conditioning requirements when heat producing apparatus such as computers or sterilization equipment are to be housed in the respiratory care facility . Similar cooperation is necessary if sterile goods are to be maintained in the respiratory care facility with an optimum shelf life. The Directors of the Respiratory Care Service must provide an effective liaison with those responsible for the design and maintenance of the physical plant

Locating the Respiratory Care Service in close proximity to the patient care areas most frequently served is desirable.

Medical Gas Systems The Directors of the Respiratory Care Service shall assure the safe function of the bulk oxygen and compressed air system used for patient breathing mixtures. A plan shall exist to provide patient support in the event of failure in either system, and regular drills shall be conducted by the Service to assure a rapid response in the event of system failure. Records of such drills shall be kept by the Directors of the Respiratory Care Service.

Primary alarm systems* shall be tested on at least a quarterly basis, and a record of testing and calibration shall be kept in the Respiratory Care Service' s records. Other alarms that indicate pipeline pressure locally (such as in an intensive care unit) should also be calibrated on a regular basis, and records of these calibrations should also be kept. *"Primary alarm systems" refers to the audiovisual indicator which indicates main pipeline pressure, and which is located in an area where 24-hour monitoring of the alarm is provided. (See NFPA 56F-1983, Non-Flammable Medical Gas Piping Systems, Chapter 3.)

Rationale: Although the day-to-day operation of the medical gas system is often managed by departments other than the Respiratory Care Service or managed as a shared responsibility between departments, the ultimate responsibility for safe respiratory care rests with the Directors of the Respiratory Care Service. The development of a multidisciplinary approach to gas system management that involves respiratory care practitioners, plant engineers, and administrative personnel is recommended. The shutdown of any portion of the medical gas piping system for maintenance or repair should be coordinated by the Directors of the Respiratory Care Service if patient care is to be safely maintained.

Maintenance of Diagnostic and Therapeutic Equipment

All diagnostic and therapeutic equipment in current use shall be included in a documented preventive maintenance program. All equipment not in current use and not included in such a program shall be clearly marked as such, and should be stored in an area separate from regularly used equipment. All permanent equipment shall be included in an inventory which is checked at least annually. Where applicable, specific lot or serial numbers of this permanent equipment shall be a part of the inventory records. The complete operating and maintenance instructions as supplied by the manufacturer shall be kept as a part of the Respiratory Care Service's records. The location of these instructions must be available to all who use the equipment. Maintenance schedules should be equal to or in excess of the manufacturer's recommended practices unless written documentation justifying practices to the contrary is kept as part of the Service's record for equipment.

Rationale: "Current use" is intended to refer to equipment prepared · for use in accordance with the Service's written procedures, and tested and inspected in accordance with appropriate hospital (e.g., electrical safety) procedures. Equipment that is not maintained for current use must be clearly marked to avoid possible inclusion with tested and maintained devices. An inventory of permanent equipment

Guidelines & Statements

Safety The Directors of the Respiratory Care Service shall assure that all patients receive the safe delivery of respiratory care, and shall also be responsible for the provision of a safe working environment for personnel in the Respiratory Care Service.

Rationale: The traditional aspects of operator and patient safety are addressed in standards such as UL 544 , Medical and Dental Equipment , AAMI Safe Current Limits, and the · NFPA Life Safety Code. Changing roles within the Respiratory Care Service and the rapid advance of . technology in the field may often create safety problems that are not specifically addressed in existing standards. In these instances the Directors of the Respiratory Care Service may be forced to rely on personal experience in order to develop appropriate safety requirements. Often the institution's Safety Officer may be helpftJI in this regard. Specific procedures must also be developed to implement safety standards within the Service. Without such procedures, standards will be subject to individual interpretation by practitioners, which may or may not be appropriate for the circumstances involved. The scope of the services provided will directly affect the amount of effort that must be expended in order to assure a safe therapeutic and working environment. For example, if the Service uses ethylene oxide gas to sterilize its equipment, both the residual gas in sterilized equipment and employee exposure to exhaust and residual gases must be addressed in the policies and procedures of the Respiratory Care Service.

Invasive Assessment or Therapeutic Procedures The Directors of the Respiratory Care Service and the institution' s governing body shall determine the nature and extent of any invasive procedures to be performed by practitioners in the Respiratory Care Service. A current record of qualified practitioners and their specific training shall be kept. The specific procedures and techniques approved for use shall be kept as a part of the Service' s records, and those practitioners who have been authorized by the Directors of the Service to practice such procedures shall also be part of the Service' s records.

Rationale: Invasive procedures include, but are not limited to, such procedures as the drawing of arterial blood gases, fiberoptic visualization of a tracheostomy or endotracheal tube to facilitate placement, or the removal and replacement of such devices.

Infection Control Written policies and procedures shall be established that clearly outline methods for minimizing potential patient cross-infection with, or personnel exposure to, pathogenic organisms. These policies and procedures shall clearly

establish appropriate isolation technique equipment handling and transport. and specific methods of decontamination and/or sterilization of individual pieces of apparatus. If these policies or procedures vary from accepted infection control guidelines, written documentation shall be provided to substantiate such variances.

Rationale: Respiratory care equipment has been cited as a potential source for pathogens causing nosocomial pneumonias, and often respiratory care is administered to patients with communicable diseases. Respiratory therapy personnel may transmit nosocomial infections if proper preventive techniques are not used. The problems that were previously traced to the improper use of respiratory care equipment in the 1960's and 1970's were largely eliminated through application of sound techniques for equipment processing and personal hygiene.

Individual circumstances within an institution may justify variations from recommended practices, either due to the treatment of particularly susceptible (e.g., immunosuppressed) patients or because it can be demonstrated conclusively by the hospital Infection Control Committee that alternative measures are as effective as the recommended practices.

Records and Reports In addition to the recording requirements specified elsewhere in this standard, all orders for respiratory care shall be recorded in the patient's permanent record, and the results of therapy shall be recorded in the permanent record. Failure to administer ordered therapy shall also be recorded. at least in the departmental records.

Rationale: Continuity of care cannot be appropriately established or maintained unless the continuity of the written record is maintained as well. Respiratory Care Service records for use within the Service do not constitute a part of the permanent patient record and should be considered to be in addition to this recording requirement.

Annual Reporting A summary of the major events of the past year, including but not limited to staffing and facilities changes, major equipment changes, and policy and procedural changes should be prepared. The projected impact of these changes on future care should also be detailed.

Rationale: Reporting of this nature is helpful in reviewing the appropriateness of past changes, and may also be of value in projecting future needs.

Guidelines & Statements

Standards for the Provision of Care to Ventilator-Assisted Patients in

an Alternative Site

In assuming the traditional responsibility of a professional organization, the American Association for Respiratory Care (AARC), through its Board of Directors, has approved the following standards, defmitions, philosophies, and statements. The specific purpose of this document is to promote delivery of an optimal level of respiratory care to the patient

Definitions

Standards: Guidelines established by a recognized authority for the measurement of the level of quality, quantity, value, and appropriateness of methods or resources (human and material) used to meet a goal.

Respiratory Care Services: A health care specialty under a Medical Director for the assessment, treatment, management, diagnostic evaluation, and care of patients with deficiencies, abnormalities, and diseases of the cardiovascular system.

The American Association for Respiratory Care (AARC): A national organization of health care professionals dedicated to maintaining the highest standards of practice in respiratory care. The AARC is sponsored by the American Society of Anesthesiologists, the American College of Chest Physicians, and the American Thoracic Society. In addition to providing extensive educational opportunities through publications, continuing education programs, and seminars, the AARC works to promote governmental understanding and support for the profession and sponsors national and community programs to help improve public education and awareness. A Board of Medical Advisors serves in an advisory capacity to the Board of Directors of the AARC. This twenty-member advisory body consists of physicians appointed by the sponsoring organizations previously mentioned plus representatives from the American Academy of Pediatrics, the American College of Allergists, and the Society for Critical Care Medicine.

Program: An organized system of patient selection, education, and resource coordination necessary to establish and maintain the ventilator-assisted patient in an alternative site.

Alternative Site: Any identifiable location outside the acute care hospital setting - such as the home, convalescent center, nursing facility, or retirement center- where ventilator-assisted patients receive care.

Participant: Anyone, including the patient, involved with the specific program.

Patient: The person requiring mechanical ventilation, either continuously or for predetermined periods of time during each day and/or night.

Provider: That professional, or group of professionals, responsible for the overall care of the patient receiving mechanical ventilation.

Caregiver: Credentialed or noncredentialed patient care attendants trained to manage routine and recurrent respiratory and general medical problems encountered in the alternative site.

Standard I

The provision of care to a ventilator-assisted patient located in an alternative site shall be defmed and guided by established written policies and procedures accepted by both the discharging institution and the alternative care site.

Required Characteristics: 1.1 There are written policies and procedures, approved by the responsible authority, specifying the scope and conduct of patient care to be rendered in the provision of services.

1.2 The written policies and procedures relate to at least the following:

1.2.1 Criteria for patient selection; 1.2.2 Mechanisms for resource evaluation; 1.2.3 Coordination of human and material resources; 1.2.4 Education and training of program participants; 1.2.5 Equipment selection, support and maintenance; 1.2.6 Documentation and reporting of program activities; and 1.2.7 Quality assurance activities

Standard II

The services provided to ventilator-assisted patients shall be dispensed in accordance with a prescription written by the physician responsible for the care of that particular patient

Guidelines & Statements

Guidelines for Respiratory Care Services in Skilled Nursing Facilities

An Official Joint Statement From the American Association for Respiratory Care and the American Health Care Association

The American Association for Respiratory Care and the American Health Care Association, assuming the responsibility of professional organizations and being concerned with high quality health care, through their respective governing bodies, have approved the following definitions, standards, philosophies, and statements. The specific purpose of this document is to promote delivery of an optimal level of respiratory care in skilled nursing facilities in a cost-efficient manner.

Definitions

Standards: Guidelines established by a recognized authority for the measurement of the level of quality, quantity, value, and appropriateness of methods and resources (human, financial, and material) used to meet a goal.

Respiratory Care: A health care specialty, performed under a qualified medical director for the assessment, treatment, management, diagnostic evaluation, and care of patients with deficiencies, abnormalities, and diseases of the cardiopulmonary system.

The American Association for Respiratory Care (AARC): A national society of health care professionals dedicated to maintaining the highest standards of practice in respiratory care. The AARC is sponsored by the American Society of Anesthesiologists, the American College of Chest Physicians, and the American Thoracic Society. In addition to providing extensive educational opportunities through publications, continuing education programs, and seminars, the AARC works to promote governmental understanding and support for the profession and sponsors community and national programs to help improve public education and awareness. A Board of Medical Advisors (BOMA) serves in an advisory capacity to the Board of Directors of the AARC. BOMA consists of representatives from the sponsoring organizations previously mentioned and from the American Academy of Pediatrics, the American College of Allergists, and the Society of Critical Care Medicine.

The American Health Care Association (AHCA): A non-profit federation of state associations serving 8,500 licensed nursing homes and allied facilities. Members of AHCA provide long-term health care to over 800,000 elderly, convalescent, and chronically ill individuals.

AHCA was founded in 1949 to promote standards for professionals in long-term health care delivery and quality care for patients and residents in a safe environment and at fair payment for services and care.

The National Board for Respiratory Care (NBRC): The official credentialing board of the respiratory care profession. The NBRC sets standards for entry into the credentialing process, develops and administers examinations for respiratory care providers, and ensures the integrity of the examination process.

Qualified Respiratory Care Provider: The AARC officially recognizes the personnel described below as qualified providers of respiratory care.

Registered Respiratory Therapist (RRT): One who has been registered by the National Board for Respiratory Care (NBRC).

Graduate Respiratory Therapist: One who is a graduate of an AMA- approved respiratory therapist training program and is eligible to sit for the NBRC registered respiratory therapy examination.

Certified Respiratory Therapy Technician (CRTT): One who has been certified by the National Board for Respiratory Care (NBRC).

Graduate Respiratory Therapy Technician: One who is a graduate of an AMA-approved respiratory therapy technician training program and is eligible to sit for the NBRC entry level examination.

Respiratory Therapy Assistant: One who has received on-the-job training in respiratory therapy.

With additional training and experience, others, such as Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Licensed Practical Nurses (LPN), may perform respiratory care procedures in skilled nursing facilities .

Joint Review Committee for Respiratory Therapy Education (JRCRTE): The official accrediting agency for respiratory therapy education programs. Programs are reviewed on a regular basis for compliance with standards adopted by the Council on Medical Education (CME) of the American Medical Association (AMA).

Skilled Nursing Facility (SNF): Under Medicare and Medicaid an institution that provides skilled nursing care and related services for patients who require medical, nursing, and/or rehabilitation services.