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Pulmonary Diagnostics and Respiratory Therapy Services



Chapter 1 : Respiratory Therapy

Section 000 : Introduction

001 : Introduction and signatures

002 : Use of AARC Clinical Practice Guidelines

Section 100 : Administrative

101 : Pulmonary Diagnostics and Respiratory Therapy Services Organizational Chart

102 : Scope of Service

103 : Respiratory Therapy Practice Committee

104 : Medical Director for Respiratory Therapy Services

105 : Scheduling Rules

106 : Allocating RT Staff and Prioritizing Workload

107 : New Employee Onboarding Guide

110 : Charge Therapist Responsibilities

111 : Attendance

Section 200 : Airway

201 : Cuff Pressure Measurement and Cuff Care

202 : Extubation Guidelines

203 : Intubation Assist

204 : Intubation Confirmation

205 : Setting Up Manual Ventilation Devices

206 : Speaking Valve Placement

207 : Tracheostomy Tube Change

208 : Tracheostomy Tube Weaning

209 : Intubation in the NICU

210 : Orotracheal Intubation Competency

211 : Securing Endotracheal Tube in the Children's Hospital

212 : Percutaneous Tracheostomy Assist

213 : Pressure Ulcer Prevention (PUP), Recognition and Intervention

Section 300 : Diagnostic Procedures

301 : ABG Sampling

302 : Analyzing, Troubleshooting, and Documenting Parameters

303 : ABG PRN Guideline

304 : ECG Performance

305 : Oxygen Saturation Trending Using the Nonin PalmSAT 2500 and nVision Software

306 : Quantitive Sputum Collection

307 : Sputum Induction for AFB (Adult)

308 : Arterial Catheter Placement and Competency

310 : Spontaneous Mechanics

Section 400 : Documentation

402 : Respiratory Therapy Chart Documentation

403 : Documentation Guidelines for Respiratory Therapy Monitoring Flowsheet Used for Downtime

403.1 : Monitoring Flowsheet Form

404 : Respiratory Therapy Physician Orders

405 : Shift Report

Section 500 : Emergency Response

501 : Code 12 and Trauma Alerts

502 : Medical Gas Emergency

Section 600 : Medication Administration/Therapeutic Intervention

601 : Assessment for Lung Hyperinflation Therapy

602 : Airway Clearance Guidelines

602.1 : Airway Clearance for CF Adult Patients

603 : Continuous Nebulization

604 : Heliox

605 : Cough Assist Devices

607 : Flolan

608 : Pentamidine Nebulized

609 : High Flow, Heated Oxygen Therapy

610 : Asthma Guidelines for the CH

611 : Respiratory Therapy IMU/Acute Care Protocol

611.1 : Treatment Appendix

612 : Nitric Oxide Therapy

613 : Oxyhood

614 : Oxygen Equipment Change Schedules

615 : Subambient Oxygen Therapy

616 : Esophagogastric Tube Insertion

617 : Aerosolized Ribavirin Administration

617.1 : Aerosolized Ribavirin Administration Competency

Section 700 : Ventilation

702.0 : Cleaning and Calibrating Ventilators

702.1 : Readiness Checksheet

702.2 : Equipment Malfunction Reporting Form

704 : Initial Ventilator Management Guidelines for the Heart and Vascular Center

705 : ICU Ventilators in the Operating Room

706 : Intra-facility Transport of the Mechanically Ventilated Adult Patient

708 : Transpulmonary Pressure Manometry

709 : Conventional Lung Protective Mechanical Ventilation Strategy for ARDS

710 : Ventilator Alarm Settings for Adult Patients

711 : Ventilator Alarm Settings for Pediatric Patients

712 : Patient Use of Non-Medical Center Owned Equipment

713 : Mechanical Ventilation in the MRI Environment

714 : PICU Extubation Readiness Test

715 : Lung Protective Ventilation Guideline for Pediatric ARDS

Section 800 : Related Medical Center Clinical Practice Guidelines and Protocols

1.001 Airway Management Emergency Protocol Adult

1.021a Declaration of Death by Neurologic Criteria (Brain Death)

1.110 Medical Emergency Team (MET) Rapid Response Activation for Adult Inpatients

1.111 Medical Emergency Response Protocol Neonatal NERT

1.120 Non-urgent Oxygen Delivery Protocol By Nasal Cannula Adult Acute

1.127 Pronation Therapy for the patient with severe acute respiratory distress

1.180 Ventilated Patient Transport Protocol At Discharge Adult (posted 2012)

2.050 COPD Evaluation and Management Guideline (posted 2012)

2.080 Elimination of Life-sustaining Measures - Guidelines, Adult Critical Care

2.140 Hypothermia, Therapeutic After Cardiac Arrest - Adult Guideline and Timeline

2.154a Levels of Care Guidelines - Inpatient Adults and Children

2.160 Non-Invasive Positive Pressure Ventilation Guideline (posted Oct 2012)

2.165 Obstructive Sleep Apnea (OSA) - Screening and Treatment Guides (Adult Surgical) (posted 2012)

2.181 Evaluation, Management, and Prevention of Ventilator Associated Pneumonia (VAP) in Adult Patients

2.230 Tracheostomy Care Guideline - Adult

2.240 Trauma Center Handbook

2.270 Ventilator Weaning Guideline - Adult (posted 2012)

Section 900 : Standard Work

9.200 : Adult ETT Management

9.201 : Adult Initial Secure and Dressings Perc Trachs

9.203 : CH ETT Stabilization Neofit

9.204 : CH ETT Stabilization Smith Stabilizer

9.205 : CH PICU ETT Repositioning

9.206 : CH Tracheostomy Inpatient Care

9.300 : Bronch: 1 Color Coded Pre-Cleaning

9.301 : Bronch: Bronchoscope Precleaning

9.302 : Bronch: Obtain Clean Scope – MICU Olympus

9.303 : Bronch: Obtain Clean Scope – RT Supervisor

9.600 : Adult Oxygen Saturation Monitoring – Troubleshooting

9.720 : Pronation Therapy – Proning Critically Ill Patients

9.721 : Pronation Therapy – Maintenance Positioning

9.730 : CH Kangaroo Care for Ventilated Infants

9.740 : Pressure Ulcer Prevention

Chapter 2 : Pulmonary Function Testing Center

Section 000 : Introduction and Signatures

001 : Introduction and signatures

Section 100 : Adminstrative

101 : Organizational Chart

102 : Scope of Service

103 : Services Offered

104 : Orders for Patient Care

105 : Service Refusal

106 : Laboratory Charge Initiation

107 : Quality of Care Reporting Forms

108 : New Employee Orientation

109 : Staffing Plan

110 : Attendance Addendum

111 : CPR Training/Re-Training

112 : Continuing Education

113 : Medical Director For Pulmonary Function Center

114 : Pulmonary Function Testing Center Practice Committee

Section 200 : Quality Control

202 : PFT Equipment Quality Control Program

203 : Continuous Quality Improvement Program

Section 300 : Arterial Blood Gases

301 : ABG Sampling Procedure and Certification

302.1 : Gas Tension Calculation

302.3 : Qs/Qt (% Shunt) Calculation

302.4 : Preflight Evaluation (Regression Formula)

303 : Identification of Patients and Lab Specimens

304 : ABG Critical Value

305 : Sending ABG Specimens to the Clinical Laboratory

306 : Sending Isolation ABG Specimens to the Clinical Lab

Section 400 : Procedures

402 : Pulmonary Function Testing Routine

403.1 : Lung Volumes, FRC, RV via Plethysmography

403.2 : Procedure for FRC Measurement Via He Dilution

403.3 : Lung Volumes Via N2 Washout

404 : Airway Resistance

405 : Spirometry Flow Volume Loop

406 : Panic Values For Spirometry

407 : Diffusing Capacity

408 : Bronchoprovocation

409 : Maximum Static Mouth Pressures

410 : Oximetry

411 : Peak Flow Meter Training

412 : Adverse Reaction to Pulmonary Function Testing

413 : Charting

414 : Delivery of Aerosolized Bronchodilator

415 : Storage, Security, and Distribution of All Administered Medications

416 : Infection Control

417 : Patients Having or Suspected of Having a Communicable Disease

418 : Disinfection of Non-disposable Pulmonary Function Items

419 : Cardio-pulmonary Stress Testing

420 : Procedure for Spirometry Portable

421 : MVV Testing

422 : Hypertonic Saline Nebulization

423 : Aerosolized Pentamidine

425 : Sputum Induction/Oral Wash

426 : Medication preparation/mix in designated clean area.

Section 500 : Exercise Testing

501 : Hallway Oximetry

502 : Six Minute Walk

503 : Exercise Oximetry

504 : Exercise Spirometry

506 : Cardiopulmonary Exercise Stress Testing (CPET)

Section 600 : Addendums

Chapter 3 : Sleep Disorders Center

Section 000 : Introduction and Signatures

001 : Introduction and Signatures

002 : Use of AASM Practice Guidelines

003 : Scope of Service

Section 100 : Administrative Policies

101 : Mission Statement

102 : Organizational Chart

103 : Medical Director Job Description

104 : Appointment and Requirements of Sleep Staff Physicians

105 : PSG Interpretation Privileges

106 : Patient Acceptance Criteria

107 : Storage of Patient Charts

108 : PSG Ordering Privileges

109 : Methods for Coordination of Care, Treatment, and Services

110 : Staffing and Scheduling Policy

111 : Attendance Policy

112 : Telephone Policy

113 : New Employee Onboarding Guideline

114 : Continuing Education Policy

Section 200 : Office Procedures

201 : Handling of Inquiries to the Center

202 : Handling Referrals for Sleep Clinic Evaluations

203 : Direct Referrals for Sleep Studies

204 : Obtaining Insurance Authorization

206 : Documentation of Initial Evaluation

207 : Follow-up and CPAP Assessment

208 : Scheduling of Sleep Studies

209 : Inpatient Referrals and Consults

210 : Release of Patient Information

211 : Retention and Storage of Files and Records

212 : Patient Selection of DME Vendor

213 : Ordering Durable Medical Equipment

Section 300 : Emergency Procedures

301 : Disaster Calling Chain

302 : Initiating Emergency Response

303 : Emergency Policy

304 : Call Escalation

305 : Background Check

306 : Patient Safety Related Significant Adverse Events Documentation

Section 400 : Infection Control and Safety Procedures

401 : Infection Control

402 : Isolation Procedure

403 : Information Security

404 : Cleaning and Maintenance of Equipment

405 : Patient Self-Administration of Medications Policy

406 : Plan for Periodic Monitoring of Patient Equipment

407 : Patients Guarded By Corrections Officer

Section 500 : Quality Assurance

501 : Quality Assurance Policy

502 : Scoring Reliability

503 : Scoring and Interpretation Timelines

504 : Patient Satisfaction Monitoring

505 : Quality Reporting

506 : Home Sleep Testing Quality Measures

508 : Process and Outcome Evaluation

Section 600 : Polysomnography Procedures

601 : Oxygen Administration

602 : Rush/Non-Rush Study Classification Scoring and Interpretation

603 : Sleep Study Montages

608 : Documentation during Sleep Studies

609 : Protocol for Polysomnography (Regular Study Protocol)

610 : Split Night Protocol

611.1 : CPAP Protocol - Adult

611.2 : BiLevel Protocol - Adult

611.3 : Protocol for Adult ASV (Adaptive Servo-ventilation) Studies

611.4 : Protocol For Auto Titrating PAP (APAP) Studies

611.5 : Hypoglossal Nerve Stimulator Titration

612.1 : CPAP Protocol - Infant Pediatric

612.2 : BiLevel Protocol - Infant Pediatric

614 : Protocol for MSLT

615 : Protocol for MWT

616 : Seizure Study Protocol

619 : Body Position Monitoring

620 : Protocol for Parasomnia Study

623 : Day Shift Technician/Technologist Duties

624 : Interpreters for Non-English Speaking Patients

625 : Urinary Drug Screen Policy

626 : Obtaining Clarification About Sleep Study Orders

627 : Actigraphy Protocol

629 : Sleep Lab Tour Talking Points

633 : Home Sleep Testing

634 : Tagging and Scoring Sleep Studies with Multiple Treatment Variables

635 : Training For Technical Staff

636.1 : CO2 Measurement End Tidal CO2

636.2 : CO2 Measurement Transcutaneous CO2

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