6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 17

Current through Register Vol. 47, No. 17, September 10, 2024

Part 17 - DIAGNOSTIC AND THERAPEUTIC IMAGING SERVICES

17.1 The hospital shall have radiological imaging, including Computed Tomography (CT), available on campus, at all times. The hospital may provide other diagnostic or therapeutic imaging services either on campus or made available off-site.

(A) The hospital shall develop a policy to be implemented in the event radiology equipment, including CT, is unavailable.

(B) The policy shall include procedures for notification of EMS providers and agencies and any other impacted facilities or providers.

17.2 Imaging services shall be directed by a qualified physician.

17.3 Radiology services shall be under the supervision of a qualified, full-time or consulting radiologist

17.4 Radiological services involving the use of machines that produce ionizing radiation or the use of radioactive materials for diagnostic or therapeutic purposes shall comply with 6 CCR 1007-1, Rules and Regulations Pertaining to Radiation Control.

17.5 The scope and complexity of radiological services maintained or made available must be specified in writing, and demonstrate how the hospital meets the needs of its patients.

17.6 The hospital must develop and implement policies and procedures that:

(A) Provide safety for affected patients and hospital personnel;

(B) Are based on nationally recognized guidelines, such as those promulgated by the American Medical Association, American College of Radiology, and the American Society of Radiologic Technologists;

(C) Comply with all applicable federal and state laws and regulations governing radiological services; and

(D) Are reviewed periodically and updated as needed, no less than every three (3) years.

17.7 The policies and procedures shall address, at a minimum, the following:

(A) Application of the fundamental principle of As Low as Reasonably Achievable to ionizing radiation services.

(B) Ensuring procedures are routinely performed in a safe manner, utilizing parameters and specifications that are appropriate to the ordered study or procedure.

(C) Ensuring protocols are designed to minimize the amount of radiation while maximizing the yield and producing diagnostically acceptable image quality.

(D) Identification of patients at high-risk for adverse events for whom a procedure may be contraindicated (e.g. pregnant women, individuals with known allergies to contrast agents, individuals with implanted devices).

(E) Management of patients with infectious diseases, critical care patients, and patients who experience medical emergencies.

(F) Training required by personnel permitted to enter areas where radiologic services are provided.

(G) Training and, as applicable, qualifications required for personnel who perform diagnostic imaging studies or therapeutic procedures utilizing radiologic services equipment.

(H) Establishment and maintenance of safety precautions against radiation hazards, including, but not limited to:

(1) Clear and easily recognizable signage identifying hazardous radiation areas,

(2) Limitations on access to areas containing radiologic services equipment,

(3) Appropriate use of shielding, and

(4) Identification and use of appropriate containers to be used for various radioactive materials, if applicable, when stored, in transport between locations within the hospital, in use, and during or after disposal.

(I) Ensuring periodic inspections of radiology equipment are conducted, current, and that problems identified are corrected in a timely manner. Equipment must be inspected in accordance with manufacturer's instructions and Federal and State laws, regulations, and guidelines.

(J) Periodic checks for amount of radiation exposure for diagnostic imaging service personnel as well as other hospital employees who may be regularly exposed to radiation.

17.8 Diagnostic or therapeutic imaging services shall be ordered by a physician or other licensed independent practitioner. The order shall include the name of the patient, the name of the ordering individual, and the radiological procedure ordered. Services shall be provided in accordance with the order.

17.9 The performance of radiologic studies must be done on campus or at a facility off the hospital's campus when resources are not available on campus.

17.10 The interpretation of radiologic studies may be performed remotely by a teleradiology practitioner, in a timely fashion.

6 CCR 1011-1 Chapter 04, pt. 17