Private Hospitals and Day Procedure Centres Act 1988 Regulation relating to licensing standards for private hospitals providing cardiac catheterisation and emergency services (1995-94) [GG No 23 of 3.3.1995] (NSW)

1995—No. 94

PRIVATE HOSPITALS AND DAY PROCEDURE CENTRES

ACT 1988—REGULATION

(Relating to licensing standards for private hospitals providing cardiac

catheterisation and emergency services)

NEW SOUTH WALES

[Published in Gazette No. 23 of 3 Mach 1995]

HIS Excellency the Governor, with the advice of the Executive Council,

and in pursuance of the Private Hospitals and Day Procedure Centres Act

1988, has been pleased to make the Regulation set forth hereunder.

Ron Phillips

Minister for Health.

Commencement

1. This Regulation commences on 3 March 1995.

Amendments

2. The Private Hospitals Regulation 1990 is amended:

(a) by inserting in clause 4 (l), in alphabetical order, the following definitions:

“cardiac catheterisation” means the procedure of passing a catheter (or other instrument) through a major blood vessel to the heart for a diagnostic or therapeutic purpose;

“emergency service” means a service for the care of persons injured in accidents, or for those suffering from medical or other emergencies, through the provision of efficient reception, resuscitation, medical and surgical facilities and life support systems;
“primary care” means the provision of non-urgent medical care which addresses the main health problems in the community, through such promotional, preventative, curative

and rehabilitative services as are generally provided by
general practitioners;

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(b) by inserting after clause 5 (1) the following subclause:

(1A) For the purposes of section 7 of the Act, the following additional standards are prescribed:

(a)	with respect to surgical class private hospitals authorised
to provide cardiac catheterisation services—the standards specified in Part 5 of Schedule 2; and
(b)	with respect to private hospitals authorised to provide an emergency service—the standards specified in Part 6 of Schedule 2.

(c) by omitting from clause 1.5.2 (1) (a) and (2) of Schedule 1 the words “accident and” wherever occurring;

(d) by inserting in Schedule 2 after Part 4 the following Parts:

PART 5—CARDIAC CATHETERISATION

Medical advisory committee

2.5.1. The medical advisory committee of a private hospital authorised to provide cardiac catheterisation services is to include a cardiologist trained in cardiac catheterisation techniques and an anaesthetist experienced in cardiac procedures while matters relating to cardiac catheterisation are being discussed.
Planning and location

2.5.2. (1) A private hospital authorised to provide cardiac
catheterisation services must be a surgical class private hospital.

(2) Cardiac catheterisation services performed in a private

hospital must be performed in a separate unit which:

(a) is dedicated, as a cardiac catheterisation unit, to the performance of those services; and
(b) is air-conditioned and adequate in size for the services performed; and
(c) is so located as to allow quick access, when those services are performed, to a cardiac care unit or intensive care unit located in the same hospital; and
(d) has an emergency call system linked to at least one of

those units; and

(e) is close to a staff station; and

(f) includes a short-term recovery area that has

accommodation for at least 2 trolleys from each procedure

room in the unit; and

(g) has a scrub up area; and

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(h) has a clean utility room with a refrigerator for the storage of drugs; and

(i)  has access to a central sterilising supply service (unless only sterile disposable equipment is used in the unit); and

(j) has access to facilities for linen and general storage; and

(k) has ready access to facilities near the unit for film

developing and storage (and to a cinefilm viewing room, if

film is used to record services performed in the unit); and

(1) has ready access to a dirty utility room, staff change
rooms, and staff toilets, all of which are near the unit.

(3) If the cardiac catheterisation services performed are therapeutic, the hospital must have a cardiac care unit or intensive care unit from which the transfer of a patient to a theatre equipped and staffed for open heart surgery can be completed within 30 minutes (whether that theatre is in the same or in another hospital).

(4) If a private hospital where therapeutic cardiac catheterisation services are performed does not itself have a theatre equipped and staffed for open heart surgery, the hospital must have access to a readily available, suitably equipped ambulance when those services are performed.

Conduct of cardiac catheterisation unit

2.5.3. A private hospital authorised to provide cardiac catheterisation services:

(a) must have a written policy that sets out the following in relation to the hospital:

• the criteria for the admission of patients to cardiac

catheterisation;

the program of care for patients following cardiac
catheterisation;

• how many medical practitioners and nursing staff

are available, and how many are on duty for each
shift;

• the qualifications of those practitioners and staff; • the provision made for the transfer of patients to

another hospital that provides a higher level of

medical service; and

(b) must have a written policy that details the quality assurance programs established by the hospital concerning catheterisation services; and

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(c)	must have an approved number of appropriate staff, including a specialist director of cardiac catheterisation services, registered nursing staff with relevant experience and allied health staff; and
(d)	must have an in-patient orientation and education program; and
(e)	must provide, or must liaise with other bodies providing, cardiac preventative health programs and rehabilitation programs; and
(f)	if the hospital is not authorised to carry out open heart surgery, must have contingency arrangements with a nearby hospital capable of performing open heart surgery for the transfer of patients to the nearby hospital in an emergency.

Retention of clinical records

2.5.4. The films or other archival media on which a cardiac catheterisation procedure is recorded must be kept for not less than 3 years from the date when the procedure was carried out. Identification of patients

2.5.5. An identification band must be fitted around a wrist or an ankle of each cardiac catheterisation patient and on the band the patient’s name and date of birth, and the attending medical practitioner’s name, must be indelibly and legibly written.
Medical, surgical and nursing equipment

2.5.6. Each procedure room in a cardiac catheterisation unit must have its own resuscitation equipment including a defibrillator.

PART 6—EMERGENCY SERVICE

Design and construction
2.6.1. An emergency service must be provided in or from a separate unit which is dedicated to that service and which:

(a) is clearly signposted; and

(b)	has separate access, protected from the weather, for patients arriving by ambulance; and
(c)	is air-conditioned to cope with the planned maximum patient load; and
(d)	has sufficient space to cope with the planned maximum patient load; and
(e)	has a reception area with facilities for the initial assessment of patients; and

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(f) has a waiting area for the relatives and friends of patients;

and

(g)	has ready access to the hospital’s medical records service; and
(h)	has ready access to one or more operating theatres, an intensive care unit and medical imaging facilities; and

(i)    has appropriate treatment areas including resuscitation bays, treatment cubicles, examination and consulting rooms, a procedure room and a plaster room; and

(j) provides for privacy in all patient areas; and
(k) has a nurse station; and
(l) has a clean utility room; and

(m) has access to a duty utility room; and

(n)	has ready access to ancillary facilities including toilets, storage and offices; and
(o)	has appropriate communication arrangements with the Ambulance Service of New South Wales.

Conduct of emergency service
2.6.2. A private hospital approved to provide an emergency service must have:

(a) a written policy on the provision of the emergency service, covering all of the following matters:

• the co-ordination of the service with other emergency services in the same district as the hospital;

• the integration of the emergency service with the
clinical and educational activities of the hospital;

• the admission and discharge of patients and the

review of the care provided to patients;

• the provision of information and counselling to

relatives and friends of patients; and

(b) an appropriately qualified and experienced medical

practitioner appointed as director of the emergency service;
and

(c)	arrangements for appropriate specialists to be available on close call at all times; and
(d)	sufficient appropriately trained and experienced staff on duty and immediately available at all times; and

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(e)	an effective system of triage which separates patients needing emergency services from patients needing primary health care; and
(f)	arrangements for the provision of primary health care in appropriate cases; and
(g)	contingency arrangements for the transfer of patients by retrieval teams to a hospital providing a higher level of care if needed.

Clinical records

2.6.3. In addition to the requirements of clause 1.6.1, the hospital’s clinical record for each emergency patient must include:

(a) the date and time of arrival and of disposal; and

(b) a description of significant clinical, laboratory and

radiological findings; and

(c) accurate details of any treatment provided; and

(d) the identity and signature of the attending medical officer.

Medical and nursing equipment

2.6.4. In addition to the requirements of clause 1.2.4, an

emergency service must be equipped with:

(a) suitable monitors and ventilators; and

(b) resuscitation and diagnostic equipment and drugs,

adequate for the planned maximum numbers of child and adult
patients who may be undergoing examination or treatment by the

service at any one time.

(e) by inserting in Form 1 after Annexure B the following Annexure:

Annexure C

Additional information to be supplied for authorisation to

provide an emergency service

(1) The level of emergency service to be provided.
(2) The facilities to be provided for the emergency service.

(3) The support services to be provided in association with the emergency service.

(4) The arrangements to be made for the transfer, when

needed, of patients to a unit or hospital that provides a
higher level of care.

1995—No. 94

EXPLANATORY NOTE

This Regulation prescribes the licensing standards to be inserted in Schedule 2 to the Private Hospitals Regulation 1990 to cover private hospitals providing a cardiac catheterisation service or an emergency service. This Regulation also inserts appropriate definitions and references in that Regulation and changes the term “accident and emergency services” to “emergency services” in keeping with those definitions. This Regulation also amends the form of application for a private hospital licence to include a list of the materials required to accompany such an application if the hospital is to provide an emergency service.

The licensing standards cover the special equipment, personnel, arrangements and policies that must be in place if a private hospital is to provide either of those services. They are additional to the general standards already set out in Schedule 1 and elsewhere in the Private Hospitals Regulation 1990.

This Regulation is made under section 7 (Licensing standards) and section 55 (Regulations) of the Private Hospitals and Day Procedure Centres Act 1988.