Policy Title: Respiratory Therapy Department: Policies and Scope of Services
Policy Number: 1-01
Effective Date: September, 2017
To define the role of the Respiratory Therapy Department within the organization and
provide a policy framework for its operation.
II. POLICY ELEMENTS
Respiratory Therapy provides respiratory technology, equipment, and staffing resources to
UWHC and AFCH patients and staff 24 hours a day. These services are guided via the medical
direction of the Respiratory Care Committee, the Medical Director and Associate Medical
Director for Respiratory Care Services. Respiratory interventions are provided by a licensed
Respiratory Care Practitioner (RCP) or a student therapist that is guided and overseen by the
onsite observation of a licensed RCP.
III. SCOPE OF SERVICES:
A. Life support modalities:
1. CPR support
2. Invasive and non-invasive ventilation with monitoring and weaning.
B. Diagnostic and monitoring services:
3. Capnography and other physiologic measurements
4. Non-bronchoscopic bronchial alveolar lavage
5. Arterial puncture (radial)
C. Medical gas administration:
D. Respiratory Therapy Treatments:
1. Volume expansion therapies
2. Airway clearance therapies
3. Aerosolized medication delivery, both continuous and scheduled.
E. Respiratory Assess and Treat Protocols
F. Patient instruction
G. Respiratory DME coordination for the home setting.
A. All Respiratory Therapy services must be ordered by a physician, advanced
practice nurse prescriber or a physician assistant acting within the scope of
his/her authorized practice at UWHC.
B. Upon receipt of an order, the RCP will assess the patient to verify the
appropriateness of treatment. C. All patient procedures performed by RCPs are
guided by written policy and procedure approved by the Medical Director of
D. Respiratory treatments are itemized by procedure and billed to the patient over and
above daily hospital bed charges. They are not intended to substitute for basic
nursing care such as routine suctioning or pulmonary hygiene measures such as
turning, coughing, and deep breathing. Rather RT is available as a central resource
for high acuity, high-risk patients, requiring specialized equipment and staff.
E. Under direction of the Medical Director of Respiratory Care and the Respiratory
Care Committee, the Department will monitor indications for therapy and outcome
of therapy and will actively seek discontinuance of non-indicated, ineffective
F. When patient care is provided via a duly approved protocol, RCPs may adjust or
discontinue therapy per protocol. RT protocols are available on U-connect from
the Workroom/Clinical Apps/Clinical Guidelines/Respiratory Therapy Protocols.
G. All patients will be appropriately monitored and come under the oversight of the
Medical Director of Respiratory Care or his/her designate.
Approved by Respiratory Care Committee September 2009
Approved by Director of Respiratory Care – Kris Ostrander
Approved by Medical Director of Respiratory Care – Dr. Michael Regan
Original copy of this Policy & Procedure is available in the Respiratory Care Office
H:/Policies/1.01 Revised by KO 9/2017
Next revision: 9/2020