reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.16 - Disaster planning

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital shall have a written,
				comprehensive disaster plan. The disaster plan, and any updates or changes to it,
				shall be submitted to the Inspection Service Program within the Department and shall
				include the following:
1. Identification of
				potential hazards that could necessitate an evacuation, including internal and
				external disasters such as a natural disaster, labor work stoppage, or industrial or
				nuclear accidents;
2. Emergency
				procedures for evacuation of the hospital;
3. Comprehensive measures for receiving and
				managing care for a large influx of emergency patients. These measures shall include
				the roles of, at least, the emergency department, surgical suite, and patient care
				units;
4. Comprehensive plans for
				receiving patients who are being relocated from another facility due to a disaster.
				This plan shall include at least an estimate of the number and type of patients the
				facility would accommodate;
5.
				Procedures in the case of interruption of utilities services in a way that affects
				the health and safety of patients;
6.
				Identification of the facility and an alternate facility to which evacuated patients
				would be relocated;
7. The estimated
				number of patients and staff who would require relocation in the event of an
				evacuation;
8. The system or procedure
				to ensure that medical charts accompany patients in the event of patient evacuation,
				and that supplies, equipment, records, and medications would be transported as part
				of an evacuation; and
9. The roles and
				responsibilities of staff members in implementing the disaster plan.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.18 - Blood bank

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The governing board
				shall designate the pathologist or other qualified physician as physician-in-charge
				of the blood service.
(b) The hospital
				shall maintain an emergency supply of blood and shall have access to additional
				supplies as needed.
(c) The hospital
				shall maintain a current list of potential blood donors of all principal blood types
				and groups who are available in emergencies or it shall establish a stable source of
				blood supply, either through an integrated blood operation or by arrangement with an
				outside blood service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.19 - Clinical and pathological laboratories

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The laboratories
				shall be under the direction of a pathologist on a full or part time
				basis.
(b) A qualified member of the
				medical staff may be appointed by the governing authority to assume a portion of the
				responsibilities involved, with a pathologist as a consultant.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.20 - Electrocardiogram laboratory

Current through Register Vol. 56, No. 14, July 15, 2024
The hospital shall provide at least one room designated for
				  electrocardiography. Sufficient space shall be provided for the maintenance of
				  essential records and such office space as may be required.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.21 - Out-patient and preventive services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All hospitals shall
				provide, on a regular and continuing basis, out-patient and preventive services,
				including clinic services for medically indigent patients, in those services
				provided on an in-patient basis.
(b) In
				no instance shall a hospital provide less than out-patient services in medicine and
				surgery.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.22 - General hospital governing body training

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In addition to any
				general orientation, a general hospital shall ensure that all members of the
				hospital's governing body complete a trustee training program as set forth in (b)
				below conducted by an approved training provider within six months of the member's
				appointment.
(b) The trustee training
				program shall consist of at least seven hours of instruction and address each of the
				following subjects:
1. The ethical and fiduciary
				responsibilities of a member of a hospital governing body;
2. The role of the governing body in improving
				health care quality and the mechanisms available for doing so;
3. Hospital financial management and understanding
				the financial statements of healthcare institutions and reimbursement and finance
				payment systems;
4. Hospital
				organization and governance; and
5.
				Legal and regulatory compliance issues.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 5 - HOSPITAL ADMINISTRATION AND GENERAL HOSPITAL-WIDE POLICIES › Section 8:43G-5.23 - Approved training providers; requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with
				26:2H-12.3 4b, the Department approves
				the following as trustee training providers:
1.
				Accredited academic institutions that do not have a direct interest, corporate
				relationship, or primary mission in the support or development of the hospital
				offering the trustee training program;
2. Non-profit hospital trade associations and/or
				their affiliates;
3. Non-profit
				healthcare foundations that do not have a direct interest, corporate relationship,
				or primary mission in the support or development of the hospital offering the
				trustee training program;
4. Providers
				of board development and/or governance leadership training programs for hospitals
				and/or healthcare providers, such as, but not limited to, the Governance Institute,
				the American Hospital Association's Center for Healthcare Governance or Estes Park
				Institute;
5. Non-profit providers of
				professional legal and/or medical continuing education with expertise in trustee
				education training; and
6. Any provider
				of continuing education training with expertise in trustee education training
				authorized by the International Association for Continuing Education and
				Training.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.2 - Anesthesia services, policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Anesthesia services
				shall be administered in accordance with written policies and procedures that are
				reviewed at least annually, and revised as needed to ensure the safety of patients
				during the administration and conduct of, and emergence from, anesthesia and shall
				include at least the following:
1. Monitoring of
				patients in the postanesthesia care unit, including availability of monitoring
				equipment, and discharge from the postanesthesia care unit;
2. Monitoring of patients in any special procedure
				rooms where patients receive anesthesia;
3. Reporting of morbidity and mortality, and any
				unusual or untoward occurrences in compliance with
				8:43G-6.10(c);
				and
4. Preanesthesia evaluation, patient
				preparation and intraoperative management.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.3 - Anesthesia staff: qualifications for administering anesthesia

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director of anesthesia services who is a diplomate of either the American
				Board of Anesthesiology or the American Osteopathic Board of Anesthesiology, or who
				was made a fellow of the American College of Anesthesiology before 1982.
(b) The physician director of anesthesia services
				shall participate in the credentialing process and delineation of privileges of all
				personnel who administer anesthetic agents. Criteria for hospital-wide anesthesia
				credentialing shall include at least:
1. Objective
				measures of training and experience in anesthesia care against which all candidates
				are evaluated; and
2. A requirement for
				continuing education in anesthesia care.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.4 - Anesthesiologist availability

Current through Register Vol. 56, No. 14, July 15, 2024
At all times, an anesthesiologist shall be on-site or on-call and
				  available to reach the hospital within 30 minutes under normal transportation
				  conditions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.5 - Anesthesia patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A preanesthesia
				note, reflecting evaluation of the patient and review of the patient record prior to
				administration of anesthesia, shall be made or certified by the APN/anesthesia or
				the physician administering or supervising, as applicable, the administration of
				anesthesia and entered into the medical record of each patient receiving anesthesia
				at any anesthetizing location.
(b) A
				record of anesthesia that conforms with policies and procedures developed by the
				medical staff shall be made for each patient receiving sedation or anesthesia at any
				anesthetizing location.
(c) Upon arrival
				in the postanesthesia care unit a postanesthesia note shall be entered into the
				patient's anesthesia record by a member of the hospital's anesthesia team.
(d) An anesthesia team member shall make a
				postoperative discharge note for inpatients prior to the patient leaving the
				postanesthesia care unit and at the time of discharge for outpatients.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.6 - Anesthesia supplies and equipment; safety systems

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Diameter index
				safety systems or equivalent shall be used on all large cylinders of medical gases
				and wall and ceiling outlets of medical gases.
(b) Pin index safety systems with a single washer
				shall be used on all small cylinders to prevent interchangeability of medical gas
				cylinders.
(c) All medical gas hoses and
				adapters shall be color-coded and labeled according to current national standards
				set forth in the following publication: Compressed Gas Association Publication.
				"Characteristics of Safe Handling of Medical Gases," P-1; Ed. 10; November 2013;
				1-26, which is incorporated herein by reference, as amended and supplemented and
				which is available from the Compressed Gas Association , Inc., 14501 George Carter
				Way, Suite 103, Chantilly, VA 20151. Phone: (703) 788-2700. Fax: (703) 961-1831.
				Website:
http://www.cganet.com
. E-mail:
				cga@cganet.com.
(d) An oxygen
				failure-protection device ("fail-safe" system) shall be used on all anesthesia
				machines to announce a reduction in oxygen pressure, and, at lower levels of oxygen
				pressure, to discontinue other gases when the pressure of supply oxygen is
				reduced.
(e) A vaporizer exclusion
				("interlock") system shall be used to assure that only one vaporizer, and therefore
				only a single agent, can be actuated on any anesthesia machine at one
				time.
(f) To prevent delivery of excess
				anesthesia during an oxygen flush, no vaporizer shall be placed in the circuit
				downstream of the oxygen flush valve.
(g) All anesthesia vaporizers shall be
				pressure-compensated in order to administer a constant non-pulsatile
				output.
(h) Accurate flow meters and
				controllers shall be used to prevent the delivery to a patient of an inadequate
				concentration of oxygen relative to the amount of nitrous oxide or other medical
				gas.
(i) Alarm systems shall be in place
				for high (disconnect), low (subatmospheric), and minimum ventilatory pressures in
				the breathing circuit for each patient under general anesthesia.
(j) There shall be a written protocol to assure
				that surgery does not proceed when there are disabled alarms, depleted batteries and
				inactive sensors in oxygen monitors or carbon dioxide monitors, improperly
				positioned breathing-circuit sensors, or other insufficiencies.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.7 - Anesthesia supplies and equipment; maintenance and inspections

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A record shall be
				maintained of all service and maintenance performed on all anesthesia machines,
				ventilators, and vaporizers. The record shall include machine identification; name
				of servicing agent; work performed; and date of work. This maintenance shall conform
				with maintenance requirements established by the machine manufacturer. Credentials
				of each servicing agent shall be approved by the machine manufacturer or be
				determined by the hospital's physician director as equivalent to the credentials of
				manufacturers' servicing agents.
(b) All
				anesthesia equipment shall be inspected fully at the beginning of each day of use. A
				record of each such inspection shall be maintained for each machine. The inspection
				shall conform with a checklist that is supplied by the manufacturer of the machine;
				issued by the Federal Food and Drug Administration; or, alternatively, developed by
				the hospital's anesthesia services and approved by the hospital's physician director
				of anesthesia services.
(c) All
				anesthesia equipment shall be inspected before each use. A record of each inspection
				shall be indicated on the patient's anesthesia record. Each record may consist of a
				checklist or a single phrase explanation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.9 - Anesthesia staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the anesthesia education program shall be as set
				  forth in 8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 6 - ANESTHESIA › Section 8:43G-6.10 - Anesthesia continuous quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The hospital's
				quality improvement program shall include a systematic review and evaluation of
				patient care, anesthesia practices and anesthesia techniques. The surgical staff
				shall identify problem-prone processes which manifest undesirable patterns. The
				hospital shall develop a plan by which to collect and analyze data in order to
				evaluate outcomes or performance of the problem-prone processes. Data analysis shall
				focus on recommendations for implementing corrective actions and improving
				performance.
(b) The continuous quality
				improvement program shall include morbidity and mortality conferences.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.2 - Cardiac surgery policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) At least 350
				open-heart operations shall be performed at each licensed cardiac surgical center by
				the end of the third year of operation and annually thereafter as referenced at
				8:33E-2.3(a)1  and
				2.
(b) The hospital shall have in effect
				policies and procedures which ensure that priority laboratory services will be
				available to cardiovascular patients if medically indicated.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.3 - Cardiac surgery staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				director of the cardiac surgery service who is board certified in thoracic
				surgery.
(b) The primary surgeon shall
				be board certified in thoracic surgery, or shall meet current requirements to be
				examined and shall be examined within two years of eligibility.
(c) The surgeon in charge of a cardiac operation
				shall be assisted by a physician board certified in thoracic surgery, a thoracic
				surgery resident or a physician with privileges to assist in the specific procedure
				and with prior approval from the physician director of the cardiac surgery
				service.
(d) The cardiovascular surgical
				intensive care service or recovery room shall have a physician director, who may be
				the director of cardiac surgery.
(e) The
				cardiac perfusionist for each cardiac surgical procedure shall have graduated from
				an educational program for perfusionists accredited by the Council on Allied Health
				Education Administration (CAHEA) and be certified by the American Board of
				Cardiovascular Perfusion or shall meet current requirements to be examined and shall
				be examined within two years of eligibility; or during each of the past two years
				shall have performed at least 75 cardiac perfusions.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.5 - Cardiac surgery staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be at
				least a ratio of one registered professional nurse to one patient during the
				patient's stay in the cardiovascular surgical intensive care service or recovery
				room until the patient is stabilized.
(b) For patients who remain in the cardiovascular
				surgical intensive care service or recovery room beyond the initial period of
				stabilization, there shall be at least a ratio of two registered professional nurses
				to three such patients.
(c) Following
				reclassification or transfer of the patient to an intermediate level of care, nurse
				staffing shall be in accordance with
				8:43G-9.20(a)6.
(d) An anesthesiologist responsible for providing
				anesthesia care during cardiac surgery shall meet one of the following
				qualifications:
1. Is board certified in
				anesthesiology, and has completed additional training in providing anesthesia care
				during cardiac surgery; or
2. Is board
				eligible in anesthesiology, has completed additional training in providing
				anesthesia care during cardiac surgery, and is examined for certification within two
				years of initial anesthesia board eligibility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.7 - Cardiac surgery patient services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reports of
				diagnostic and operative procedures performed by cardiac services shall be dictated
				for inclusion in the medical record not later than 48 hours after completion of the
				procedure.
(b) A note by the physician
				performing the procedure shall be included in the patient's medical record
				immediately after completion of the cardiac procedure.
(c) Counseling by trained and experienced
				professionals shall be available to assist pre/post operative cardiac
				patients/families to cope with the crisis of illness, adjustment to hospitalization,
				plans for patient's care post-discharge, or bereavement and loss.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.8 - Cardiac surgery space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be a cardiac surgical intensive care service or
				  recovery room dedicated specifically to patients from the cardiac surgical
				  service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.9 - Cardiac surgery supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The cardiac surgical
				intensive care service or recovery room shall have equipment and staff for the
				following:
1. Hemodynamic and electrocardiogram
				monitoring;
2. Pacemaker
				usage;
3. Cardiopulmonary
				resuscitation;
4. Arrhythmia detection
				and treatment; and
5. Intra-aortic
				balloon-assisted circulation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.12 - Cardiac surgery continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of continuous quality improvement for all cardiac services that is
				integrated into the hospital quality continuous improvement program and includes
				regularly collecting and analyzing data to help identify health-service problems and
				their extent, and recommending, implementing, and monitoring corrective actions on
				the basis of these data.
(b) The
				continuous quality improvement program for cardiac surgery, percutaneous
				transluminal coronary angioplasty (PTCA), and electrophysiology studies (EPS) shall
				include at least:
1. Monitoring the volume of each
				service provided;
2. Infection and
				complication rates;
3. The incidence of
				mortality, morbidity, and other adverse occurrences in each service;
4. Patient factors that affect risk of
				complications in each service; and
5.
				Retrospective evaluation of emergency procedures in each service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.14 - Cardiac catheterization policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Cardiac
				catheterization services shall be promptly accessible in a hospital setting, either
				on-site or by immediate transfer, in which case there shall be a written transfer
				agreement.
(b) The cardiac
				catheterization laboratory shall perform a minimum of 500 catheterizations, per year
				excluding the first three years following initiation of services as referenced at
				8:33E-1.4(b)1.
(c) The cardiac catheterization laboratory shall
				have written policies and procedures that are reviewed at least once every three
				years, revised more frequently as needed, and followed. They shall include at least
				policies and procedures that assure aseptic practices and radiologic
				safety.
(d) For all procedures in the
				cardiac catheterization laboratory a postcatheterization report shall be entered in
				the patient's medical record immediately after the procedure. This report shall
				include at least:
1. A description of the
				procedure, by the physician;
2.
				Preliminary presentation of the results, by the physician;
3. The patient's condition upon discharge from the
				laboratory by the physician;
4.
				Postcatheterization orders, by the physician;
5. Complications, if applicable, by the
				physician;
6. Medications and anesthesia
				given;
7. The patient's condition upon
				discharge; and
8. Palpation of
				pulses.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.15 - Cardiac catheterization staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				director of cardiac catheterization who is board certified in internal medicine in
				the subspecialty of cardio-vascular disease, and who has completed at least one year
				of additional training in cardiac catheterization and has performed at least 200
				cardiac procedures as the primary operator.
(b) Any physician performing cardiac
				catheterization as primary operator in the cardiac catheterization laboratory shall
				meet one of the following qualifications:
1. Is
				board certified in internal medicine and the subspecialty of cardiovascular disease
				and has completed the current training and experience requirement in cardiac
				catheterization, including twelve months experience in the cardiac catheterization
				laboratory, as required by the American Board of Internal Medicine; or
2. Is board eligible in the subspecialty of
				cardiovascular disease, has completed the current training and experience
				requirement in cardiac catheterization, including 12 months experience in the
				cardiac catheterization laboratory, as required by the American Board of Internal
				Medicine, and is examined for certification within two years of initial cardiac
				board eligibility.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.16 - Cardiac catheterization staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following staff
				shall be present for all cardiac catheterization procedures:
1. A physician who meets the requirements in
				8:43G-7.15(b);
2. A registered professional nurse, trained and
				experienced in assisting in cardiac catheterization procedures, who acts as the
				circulating nurse; and
3. One of the
				following:
i. A scrub nurse, who is either a
				registered professional nurse or a licensed practical nurse; or
ii. A technician, who has been trained in
				assisting in cardiac catheterization procedures.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.17 - Cardiac catheterization patient services

Current through Register Vol. 56, No. 14, July 15, 2024
Handwashing between contacts with patients shall be performed
				  using an antimicrobial agent by all personnel involved in patient care in the
				  cardiac catheterization laboratory.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.18 - Cardiac catheterization space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All persons entering
				the cardiac catheterization laboratory shall be attired in scrub suits. Limited
				access people may wear cover gowns or jumpsuits as substitutes.
(b) The procedure room in the cardiac
				catheterization laboratory shall have a minimum clear area of 400 square feet
				exclusive of fixed and movable cabinets and shelves, with a minimum dimension of 20
				feet.
(c) There shall be a control room
				in the cardiac catheterization laboratory that is at least 50 square feet and is
				large enough to contain and provide for the efficient functioning of the x-ray
				equipment and image recording equipment.
(d) The cardiac catheterization laboratory shall
				have an equipment room or enclosure large enough to contain the x-ray transformers,
				power modules, associated electronics, and electrical gear. This room or enclosure
				shall be at least 100 square feet and shall be positioned in the laboratory to
				ensure short high-voltage cables. There shall be ready access to the equipment for
				servicing.
(e) There shall be a patient
				holding area or recovery room where patients are under visual observation before and
				after the procedure.
(f) Scrub
				facilities shall be located adjacent to the entrance to the procedure room, and
				shall be arranged to minimize incidental splatter on nearby personnel, medical
				equipment, or supply carts.
(g) There
				shall be an enclosed soiled workroom within the cardiac catheterization suite. The
				workroom shall contain at least:
1. A clinical
				sink or equivalent flushing-type fixture;
2. A sink equipped for handwashing;
3. A work counter;
4. A waste receptacle; and
5. A linen receptacle.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.19 - Cardiac catheterization supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All cardiac
				catheterization laboratory linens and apparel shall be laundered in the laundry
				services provided by the hospital.
(b)
				The cardiac catheterization laboratory shall be equipped with radiological equipment
				strong enough to produce an image and in accordance with
				26:2D-1 et seq.
(c) Fluoroscopic radiological equipment shall be
				installed in such a way that either it can be easily moved around the patient or the
				patient table can be adjusted mechanically in order to get the desired
				views.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.20 - Cardiac catheterization staff education and training

Current through Register Vol. 56, No. 14, July 15, 2024
Requirements for the cardiac catheterization staff education
				  program shall be as provided at
				  8:43G-5.9.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.21 - Cardiac catheterization quality assurance methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The quality
				assurance program for cardiac catheterization shall include at least:
1. Monitoring the volume of procedures;
2. Infection and complication rates;
3. The incidence of mortality, morbidity, and
				other adverse occurrences;
4. Patient
				factors that affect risk of complications in each service; and
5. Retrospective evaluation of emergency
				procedures.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.22 - Scope of pilot catheterization program

Current through Register Vol. 56, No. 14, July 15, 2024
In addition to meeting all applicable standards in
				  8:43G-7.1 through 7.21, a pilot
				  catheterization program established in accordance with N.J.A.C. 8:33E shall comply
				  with all standards in
				  8:43G-7.23 through 7.27.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.23 - Requirements for licensure

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Initial licenses
				granted to pilot catheterization program facilities shall be valid for a period not
				to exceed 30 months from the month in which the facility initiates low risk invasive
				cardiac diagnostic services under the program and shall expire automatically without
				the need for further notification or other action by the Department.
(b) Licenses that have expired at accordance with
				(a) above shall be renewed only upon demonstration of full compliance with all
				applicable standards and criteria for low risk invasive cardiac diagnostic pilot
				catheterization programs.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.24 - Pilot catheterization program policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
The pilot catheterization program shall perform a minimum of 350
				  left-heart catheterizations annually by the end of the second year of operation. In
				  accordance with 8:33E-1.14, the program shall
				  demonstrate and verify its ability to provide at least this level of service in
				  order to obtain renewal of its license.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.25 - Pilot catheterization program staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				physician director of the program who is board certified in internal medicine in the
				subspecialty of cardiovascular disease. The director shall have completed at least
				one year of additional training and performed at least 200 cardiac procedures as the
				primary operator.
(b) The director shall
				perform at least 150 left-heart catheterization procedures per year, at least 100 of
				which shall be performed at the pilot program laboratory.
(c) Any physician performing invasive cardiac
				procedures in the pilot catheterization program shall meet the qualifications at
				8:43G-7.15(b) and
				(c).
(d) Each physician with privileges in the pilot
				program laboratory shall perform at least 50 left-heart catheterization per
				year.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.26 - Pilot catheterization program staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be at
				least one physician trained and experienced in cardiac catheterization present in
				the room during all catheterization and angiographic procedures.
(b) There shall be at least one registered
				professional nurse with appropriate training and experience, in accordance with
				8:33E-1.5(b)4, present
				in the room during each procedure.
(c)
				There shall be at least one trained and experienced technician qualified in
				accordance with 8:33E-1.5(b)5  through
				8 present in the room during each procedure.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.27 - Pilot catheterization program quality improvement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The pilot
				catheterization program shall include at least the following quality improvement
				indicators:
1. Low-risk patient mortality and
				morbidity rate;
2. Physician-specific
				and overall pilot laboratory percentage of normal studies (not to exceed 25 percent
				of total annual cases);
3. Increase in
				the number of normal studies during any reporting period (not to exceed 50 percent,
				with a plan for corrective action to be submitted to the Department within 60 days
				should the increase reach 50 percent or more);
4. Percentage of all patients undergoing
				diagnostic cardiac catheterization in the pilot program who subsequently undergo a
				therapeutic interventional cardiac procedure as a direct result of the findings of
				the initial diagnostic procedure; and
5.
				Clinical appropriateness of the performance of catheterization procedures other than
				left-heart procedures (that is, right-heart procedures).
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.28 - Percutaneous transluminal coronary angioplasty policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Elective
				percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary
				interventions (PCI) shall be performed only in cardiac surgical centers approved by
				the Department unless a certificate of need has been granted in accordance with
				N.J.A.C.
				8:33-3.11.
(b) Primary (that is, emergent during acute
				myocardial infarction) PCI procedures shall be performed only in a hospital-based
				facility where cardiac surgery services are immediately available on site, unless a
				certificate of need has been granted in accordance with
				8:33E-2.16.
(c) There shall be at least 200 PTCA procedures
				performed in the hospital per year excluding the first three years following
				initiation of services as referenced at
				8:33E-2.3(d)1.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.29 - PTCA staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any physician
				performing PTCA as primary operator shall meet one of the following qualifications:
1. Is board certified in both internal medicine
				and the subspecialty of cardiovascular disease, or is board eligible in the
				subspecialty of cardiovascular disease and shall be examined within two years of
				initial cardiac eligibility. Physicians meeting either of these qualifications must
				additionally complete the training and experience requirement in cardiac
				catheterization including 24 months in the cardiac catheterization laboratory during
				which time the individual actively participated in at least 200 PTCA's under the
				supervision of primary operators provided by no more than two separate institutions;
				or
2. Is board certified in internal
				medicine and the subspecialty of cardiovascular disease as of July 1, 1990 and has
				performed at least 50 PTCA's per year as the primary operator for each of the past
				two years.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.30 - PTCA staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following staff
				shall be present for all PTCA procedures:
1. A
				physician who meets the requirements in
				8:43G-7.23(a);
2. A registered professional nurse certified in
				basic cardiac life support, and trained and experienced in cardiac catheterization
				and PTCA who acts as the circulating nurse; and
3. One of the following individuals:
i. A scrub nurse who is either a registered
				professional nurse or a licensed practical nurse; or
ii. A technician who has been trained in assisting
				with cardiac catheterization and PTCA.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.31 - PTCA space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
There shall be an operating room available for immediate use
				  on-site that complies with criteria established in the hospital's surgery policies
				  and procedures and meets the minimal physical requirements of
				  5:23-3.2(b), any time a
				  PTCA procedure is performed on an elective basis.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.32 - Electrophysiology studies staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The physician
				performing electrophysiology studies (EPS) as primary operator shall meet at least
				one of the following qualifications:
1. Fulfills
				the criteria of being a catheterizing physician as defined in
				8:43G-7.15(b)1  or 2;
				or
2. Is board eligible in the
				subspecialty of cardiovascular disease and has performed 25 complex cases per year
				as primary operator for each of the past five years.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.33 - EPS staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following staff
				shall be present during all EPS procedures:
1. A
				physician who meets the requirements in
				8:43G-7.26(a) and
				(b);
2. A registered professional nurse certified in
				basic cardiac life support and trained and experienced in cardiac catheterization
				and EPS who acts as the circulating nurse; and
3. One of the following individuals:
i. A scrub nurse who is either a registered
				professional nurse or a licensed practical nurse; or
ii. A technician who has been trained in assisting
				with cardiac catheterization and EPS.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.34 - Board eligibility status

Current through Register Vol. 56, No. 14, July 15, 2024
Board eligibility status in the subspecialty of cardiovascular
				  disease shall be of limited duration as defined by the American Board of Internal
				  Medicine.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.35 - Pediatric cardiac services standards; scope

Current through Register Vol. 56, No. 14, July 15, 2024
In addition to the standards in
				  8:43G-7.1 through 7.34 for adult cardiac
				  services, the following standards in
				  8:43G-7.36 through 7.46 shall apply to
				  separate, designated units or services for pediatric cardiac diagnostic services and
				  pediatric surgical centers.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.36 - Pediatric cardiac surgery policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) At least 150 open
				and closed heart operations shall be performed in the hospital per year with at
				least 75 open heart operations performed per year, excluding the first three years
				following initiation of services as referenced at
				8:33E-2.3(b)1.
(b) The hospital shall have in effect policies and
				procedures which ensure that priority lab services will be available to pediatric
				cardiovascular patients if medically indicated.
(c) All medical and nursing staff who provide
				services to pediatric cardiac patients shall have training and experience in
				pediatrics.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.37 - Pediatric cardiac surgery staff qualifications

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				director of the pediatric cardiac surgery service who is board certified in thoracic
				surgery and has five years prior experience in pediatric cardiac surgery.
(b) Effective July 1, 1990, the surgeon in charge
				of a pediatric cardiac operation shall be board certified in thoracic surgery, or
				shall meet current requirements to be examined and shall be examined within two
				years of eligibility.
(c) The cardiac
				perfusionist for each pediatric cardiac surgical procedure shall have graduated from
				an educational program for perfusionists accredited by the Council on Allied Health
				Education Administration (CAHEA) and be certified by the American Board of
				Cardiovascular Perfusion; or during each of the past two years, shall have performed
				at least 30 perfusions as primary operator.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.38 - Pediatric cardiac surgery staff time and availability

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All staff providing
				clinical services to the pediatric cardiac surgical patient shall be trained and
				experienced in pediatric cardiac surgical care.
(b) There shall be at least a ratio of one
				registered nurse to one patient at all times during the first 24 hours of the
				patient's stay in the pediatric cardiovascular surgical intensive care
				service.
(c) For patients who remain in
				the pediatric cardiovascular surgical intensive care service after 24 hours, there
				shall be at least a ratio of one registered professional nurse to two such patients
				with capability to adjust staff levels based on acuity level of patient
				illness.
(d) An anesthesiologist who is
				board certified in anesthesia, with additional training in pediatric anesthesiology
				and experience in pediatric cardiac surgery, shall be responsible for anesthetic
				management of each pediatric cardiac surgical procedure.
(e) A pediatric cardiologist shall be available in
				the hospital whenever pediatric cardiovascular surgery is scheduled.
(f) There shall be a physician in the hospital at
				all times who is able to manage pediatric cardiac emergencies. This physician shall
				not be assigned to the emergency department at the same time.
(g) Counseling by trained and experienced
				professionals shall be available to assist pre/post operative pediatric cardiac
				patients/families to cope with the crisis of illness, adjustment to hospitalization,
				plans for patient's care post-discharge, or bereavement and loss.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.39 - Pediatric cardiac surgery space and environment

Current through Register Vol. 56, No. 14, July 15, 2024
The hospital shall designate beds in the cardiac surgical
				  intensive care service, the pediatric surgical intensive care service or the
				  pediatric medical intensive care service for patients from the pediatric cardiac
				  surgical service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.40 - Pediatric cardiac surgery supplies and equipment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be
				monitoring and treatment equipment available that is appropriate for the pediatric
				cardiac surgical patient.
(b) The
				pediatric cardiac surgical intensive care service shall have equipment and staff for
				at least the following:
1. Hemodynamic and
				electrocardiogram monitoring;
2.
				Pacemaker usage;
3. Cardiopulmonary
				resuscitation;
4. Arrhythmia detection
				and treatment; and
5. Intra-aortic
				balloon-assisted circulation.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.41 - Pediatric cardiac surgery continuous quality improvement methods

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There shall be a
				program of quality continuous improvement for all services that is integrated into
				the hospital continuous improvement program and includes regularly collecting and
				analyzing data to help identify health-service problems and their extent, and
				recommending, implementing, and monitoring corrective actions on the basis of these
				data.
(b) The continuous quality
				improvement program for surgery shall include at least:
1. Monitoring the volume of each service
				provided;
2. Infection and complication
				rates;
3. The incidence of mortality,
				morbidity, and other adverse occurrences in each service;
4. Patient factors that affect risk of
				complications in each service; and
5.
				Retrospective evaluation of emergency procedures in each service.
New Jersey Administrative Code › Title 8 - HEALTH › Chapter 43G - HOSPITAL LICENSING STANDARDS › Subchapter 7 - CARDIAC › Section 8:43G-7.43 - Pediatric cardiac catheterization policies and procedures

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pediatric invasive
				cardiac diagnostic procedures shall be performed only at pediatric cardiac surgery
				centers.
(b) The pediatric cardiac
				catheterization service may share the catheterization laboratory with the adult
				cardiac catheterization program. However, the staff who participates in the
				pediatric catheterization shall be trained and experienced in the care of the
				pediatric cardiac patient and the equipment used shall be appropriate to meet the
				needs of the pediatric patient.
(c) The
				pediatric cardiac catheterization laboratory shall perform a minimum of 150
				pediatric cardiac catheterizations per year, excluding the first three years
				following initiation of services as referenced at
				8:33E-1.11(d).