N.J. Admin. Code § 8:43G-14.9

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43G-14.9 - Sepsis protocols

(a) A hospital shall establish, implement, and periodically update, evidence-based protocols for the early identification and treatment of patients with sepsis and septic shock (sepsis protocols).

(b) The sepsis protocols shall address, at a minimum:

1. Screening patients for, and early recognition in patients of, healthcare-acquired and community-acquired sepsis and septic shock;

2. Identification of patients for whom treatment, using the sepsis protocols, is appropriate, and for whom treatment would be inappropriate based on patient-specific clinical and/or bioethical considerations, and documentation of these patient identification activities;

3. Treatment guidelines;

4. Components that are population-specific as clinically indicated in accordance with evidence-based best practices, such as perinatal, neonatal, pediatric, and adult variations that may exist in the identification and treatment of sepsis, with corresponding development and use of clinical staff training materials and practice tools that distinctly identify these population-specific variations; and

5. Training of clinical staff in the sepsis protocols and providing updated training upon substantive revision thereof.

(c) Clinical staff who are to receive training include:

1. Clinical practitioners;

2. Registered professional nurses;

3. Licensed practical nurses; and

4. Other licensed health care professionals.

(d) A hospital shall ensure that clinical staff receive training in the sepsis protocols:

1. By July 16, 2018, with respect to existing clinical staff;

2. With respect to a person who becomes a member of a hospital's clinical staff after January 16, 2018, within six months of the first day on which that person becomes a member of the hospital's clinical staff; and

3. With respect to all clinical staff, annually thereafter following initial training.

(e) A hospital shall establish, maintain, and make available upon request to the Department, a record that identifies:

1. The name and position of each member of the hospital's clinical staff who is to receive training pursuant to (d) above; and

2. The date on which each clinical staff member receives training pursuant to (d) above.

(f) The Department suggests that hospitals consider basing their sepsis protocols on guidelines issued by the following entities, as amended and supplemented:

1. The Surviving Sepsis Campaign, available at http://www.survivingsepsis.org;

2. The Hospital Improvement Innovation Network of the Health Research and Educational Trust, available at http://www.hret-hiin.org; and

3. The National Quality Forum, available at http://www.qualityforum.org.

N.J. Admin. Code § 8:43G-14.9

Adopted by 50 N.J.R. 531(a), effective 1/16/2018