Medical Direction for Respiratory Care Services Provided Outside of the Hospital

Home care agencies, durable medical equipment (DME) companies, and skilled care nursing facilities which provide respiratory care services outside of the hospital have no less responsibility for the provision of quality care than do hospital-based respiratory care departments. Medical direction for respiratory care services provided in the hospital is required by JCAHO for accreditation and by Medicare as a condition for participation. Qualified medical direction is an essential component to help assure quality care, both in the hospital and at alternate community sites. The definition of a medical director of respiratory care which has been officially adopted by the American College of Chest Physicians (ACCP), the National Association of Medical Directors of Respiratory Care (NAMDRC), and the Board of Medical Advisors (BOMA) of the American Association for Respiratory Care (AARC) clearly recognizes the need for medical direction of both inpatient and outpatient services and reads as follows:

“The medical director of any inpatient or outpatient respiratory care service, department, or home care agency shall be a licensed physician who has special interest and knowledge in the diagnosis and treatment of respiratory problems. Whenever possible, the medical director should be qualified by special training and/or experience in the management of acute and chronic respiratory disorders. This physician should be responsible for the quality, safety, and appropriateness of the respiratory services provided and require that respiratory care be ordered by a physician who has medical responsibility for the patient. The medical director should be readily accessible to the respiratory care practitioners and should assure their competency.”

Since respiratory care services (and particularly mechanical ventilation) usually comprise the most complex medical services administered outside of the hospital, it is essential that those companies, agencies, and facilities which choose to provide these services do so with qualified medical direction. As in the hospital, many physicians prescribing these services are not experts in respiratory care technology. They must depend on the medical director to provide knowledgeable input for quality assurance of the respiratory care being given.

In many cases, appropriate medical direction, ideally through a formal relationship, can be provided by a qualified physician serving in an advisory capacity. The extent of involvement by the medical director should be commensurate with the complexity of the respiratory care services being offered by the provider agency, company, or facility. In accordance with the definition of a medical director, specific duties relative to the provision of home care should include, but are not limited to:

  1. Provision of a knowledgeable medical perspective of good practices in respiratory care.
  2. Assistance in the initiation of new practices in respiratory care.
  3. Assistance in the development of procedure manuals and treatment protocols.
  4. Assistance in establishing standards to assure that the individuals providing respiratory care services are qualified.
  5. Serving as an education resource for respiratory care practitioners, other members of the health care team, the public, and third party payers.
  6. Establishment of standards to assure that physicians’ orders are appropriate; discussion of problem orders with the responsible physicians when necessary; and provision of consultation concerning the most appropriate care when requested.
  7. Monitoring of methods being used for patient assessment, including physical examinations and physiologic measurements which are done outside of the hospital.
  8. Assistance in the development and review of policies related to selection, maintenance, repair and cleaning of equipment use in respiratory care.
  9. Assistance in assuring compliance with state and federal regulations regarding provision of respiratory care services.
  10. Being readily accessible to the respiratory care practitioners.

Effective 12/89