Overview of Critical Access Hospital Respiratory Services Operations

Rural hospitals are those hospitals not located within a metropolitan area as defined by the US Office of Management and Budget and the US Census Bureau.[1] Critical Access Hospitals (CAH) are a subset of Rural Hospitals that have a special designation from the Centers of Medicare and Medicaid (CMS) that meet regulatory requirements, including:

  • Be located either more than 35 miles from the nearest hospital or CAH or more than 15 miles in areas with mountainous terrain or only secondary roads.
  • Maintain no more than 25 inpatient beds that can be used for either inpatient or swing bed services.
  • Maintain an average annual length of stay of 96 hours or less per patient for acute inpatient care. (Swing beds excluded)
  • Furnish 24/7 emergency care services 7 days a week[2]

Medicare reimburses CAHs for most inpatient and outpatient services at 101% of reasonable cost, which is different than the prospective payment system (i.e. DRG, APC) CMS uses for other short term acute care hospitals..[3]  Medicaid and private insurers do not necessarily follow Medicare’s reimbursement approach.  In the following video, Dave Passetti, Executive Vice President and Clinical Operations Director for a Northeastern Pennsylvania Critical Access Hospital provides an overview of CAH reimbursement and operations.

CAHs must be prepared to receive and initially treat patients in acute respiratory distress.  In order to better understand these hospitals’ capability to treat these patients, we conducted a survey of CAH administrators and respiratory leaders about their respiratory service operations.  34 hospitals participated. Highlights of the survey follow:

  • All of the respondents said their hospitals have wall oxygen, 96% having wall oxygen available in every room.
  • Wall air is less prevalent, with only 25% having wall air available in every room and 25% having no air at all.
  • Over 90% of the respondents’ hospitals have invasive mechanical ventilators, non-invasive ventilators and heated humidified high flow nasal cannula devices.
  • 82% of respondents’ hospitals require patients that are mechanically ventilated be transferred to a tertiary care only facility.  Only 6% and 3% require transfer when the patient is on non-invasive ventilation or heated humidified high flow therapy respectively.
  • All respondents’ hospitals employ respiratory therapists; 15% for day shift during the weekdays only, 25% for day shift during the weekdays and weekend and 60% 24 hours 7 days a week.
  • 56% of the respondents’ hospitals do not track the productivity of their respiratory staff.  32% of those that track productivity only include activities that have CPT codes.  The remaining 12% track CPT code and non-CPT code activities using time-based standards.
  • The most common primary evaluation criteria for respiratory therapists are patient satisfaction scores (31%) and patient outcomes (28%).

To see more detailed survey responses, download the PDF slide deck here:

[1] Fast Facts: US Rural Hospital Infographics (AHA website
[2] CMS.gov website
[3] Critical Access Hospital MLN Booklet, page 5.