6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 24

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

Part 24 - SURGICAL AND RECOVERY SERVICES

24.1 The hospital shall provide emergency surgical care commensurate with the scope and types of services provided at the hospital. The hospital may provide other surgical services.

24.2 Surgical and recovery services shall be directed by a physician qualified by education, training, competencies, and experience.

24.3 The nursing service of the surgical suite shall be supervised by a registered nurse qualified by education, training, competencies, and experience to direct operating room nursing services.

24.4 A registered nurse qualified by education, training, competencies, and experience in operating room nursing shall be present as a circulating nurse during operative procedures.

24.5 Staffing

(A) At least one (1) registered nurse shall be on duty at all times in the surgical recovery room when patients are present.

(1) Nurses shall have been instructed in the care of post-anesthetic and post-surgical patients and shall have no other duties during the time they care for such patients.

(B) Additional registered nurses and auxiliary personnel shall be available.

(C) The nursing care required by different types of patients shall be the major consideration in determining the number, quality, and category of nursing personnel that are needed in any given situation.

24.6 Surgical Privileges

(A) Surgical services shall maintain a roster of practitioners specifying the surgical privileges of each practitioner.

(B) Surgical privileges shall be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner.

(C) Surgical privileges shall be reviewed and updated at least every two (2) years.

24.7 The hospital shall develop and implement policies and procedures related to surgical and recovery services. The policies and procedures shall be based on nationally-recognized guidelines and standards of care. These policies shall address, at a minimum, the following:

(A) Admission of patients, personnel, and visitors;

(B) Authority and responsibilities of nursing personnel;

(C) Admission and length of stay of patients in the surgical recovery room;

(D) Infection prevention and control policies, including, but not limited to, the cleaning and sterilization of surgical supplies and equipment. This policy shall be reviewed by the Infection Prevention and Control Committee;

(E) Documentation requirements, including, but not limited to, informed consent for surgical procedures, when applicable; and

(F) Surgical smoke evacuation, in compliance with the requirements of Section 25-3-120, C.R.S.

24.8 The hospital shall maintain minimum life support and resuscitative equipment in the surgical suites. The minimum equipment maintained shall be based on nationally-recognized guidelines and standards of practice and be commensurate with the scope of services offered by the hospital.

6 CCR 1011-1 Chapter 04, pt. 24