§ 133.31. Policies and procedures.

 (a)  Because of the intensity of care given within the special care unit and of the critical nature of the illnesses of patients cared for in it, written policies and procedures additional to basic hospital policies shall be developed to guide personnel in the management of the unique situations which may occur within the unit. These policies and procedures shall be developed by the medical staff, the nursing staff, other appropriate hospital departments and services and the chief executive officer and shall be approved by the appropriate committee of the medical staff. They shall be reviewed and revised as necessary.

 (b)  Policies and procedures established in accordance with subsection (a) of this section should give special attention to the following:

   (1)  Functions and authority of the unit director, with special emphasis on the working relationships that exist between the attending physicians and the director.

   (2)  Admission and discharge criteria, including priority determinations.

   (3)  Staff responsibility for special procedures and specifications as to which procedures are to be done, by whom, under what circumstances, and under what degree of supervision. Special procedures, as used in this paragraph, may include cardiopulmonary resuscitation, tracheotomy, ordering of medications, administration of parenteral fluids and other medications, and obtaining of blood and other laboratory specimens.

   (4)  The assignment of responsibility for a preventive and corrective maintenance program, including procedures to follow in the event of breakdown of essential equipment.

   (5)  The use and location of special equipment and supplies.

   (6)  Respiratory care, including assisted ventilation and humidification.

   (7)  Infection control and isolation procedures.

   (8)  Procedures for priority orders for laboratory tests.

   (9)  Standing orders, if any.

   (10)  Regulations governing visitors and traffic control.


   The provisions of this §  133.31 issued under 67 Pa.C.S. § §  6101—6104.


   The provisions of this §  133.31 adopted December 9, 1977, effective December 10, 1977, 7 Pa.B. 3631; amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37889).

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