News and Views for Healthcare Accreditation Professionals

Archive for February, 2013

CMS weighs in on Endoscopy Suites

Based on the information that was presented from survey and certification group in last 2012.  Here is a summary of the information:

1.  Humidity and Temperature MUST be monitored either by automated systems from a central location OR it must be logged, but not both.  There is no other way to know that the parameters are “out of bounds.”  What these bounds are depends on whether the state requires FGI guideline compliance or NFPA 99.  But if its anesthesia or deep sedation, then NFPA 99 is mandatory.
2.  Emergency power and lighting must be present in all surgical suites including endoscopy.  THIS IS A BIG ONE.. Few endoscopy rooms have back up LIGHTING.
3.  The air pressure differential, positive versus negative really depends on:
      a.  If this is an anesthetizing or deep sedation location (then POSITIVE).
      b.  State Law (California requires negative).
      c.  Hospital states decision depends on law or cited reference, or if required to comply with FGI by state.
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Single Use of Multidose Vials in ORs: CDC says

I recently browsed the CDC website and found this.  I will be recommending that multi-dose vials not be opened and used
for multiple patients inside an operating room, such as on an anesthesia cart:

  1. Can multi-dose vials be used for more than one patient?  How?
    Multi-dose vials should be dedicated to a single patient whenever possible.
    If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area.  This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients.  If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use.
  2. What are examples of the “immediate patient treatment area”?
    Examples of the immediate patient treatment area include patient rooms or bays, and operating rooms.