News and Views for Healthcare Accreditation Professionals

Archive for the ‘Joint Commission’ Category

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.

Deep Sedation: Can nurses administer the agents?

I get a lot of questions concerning the ability of nurses to administer agents of deep sedation.  I have put together my conclusion based on the following citations from CMS.  Be aware that some states have written into the nurse practice act that RNs may not administer agents of deep sedation, or “non-reversable” agents for sedation purposes.  My conclusion is, based on the actual CMS COP, that nurses may not administer these agents for the purpose of sedation.  Actually, based on CMS, one would wonder if RNs could even MONITOR patients.  By the way, supervision of nurses is not even addressed by CMS, so therefore the “supervision” aspect would be irrelevant.  Be aware that whether something is Deep Sedation or MAC depends on the manufacturer’s definition of the drug.

482.52 Condition of Participation: Anesthesia Services

Monitored anesthesia care (MAC): anesthesia care that includes the monitoring of the patient by a practitioner who is qualified to administer anesthesia as defined by the regulations at §482.52(a). Indications for MAC depend on the nature of the procedure, the patient’s clinical condition, and/or the potential need to convert to a general or regional anesthetic. Deep sedation/analgesia is included in MAC.

§482.52(a) Standard: Organization and Staffing

Anesthesia must be administered only by —
(1) A qualified anesthesiologist;
(2) A doctor of medicine or osteopathy (other than an anesthesiologist);
(3) A dentist, oral surgeon, or podiatrist who is qualified to administer
anesthesia under State law;
(4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c) of this
section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
(5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed.

Based on the above, it would also appear that Nurse Practitioners or Physician Assistants may also not administer deep sedation.


Privileging REQUIRED by CMS for Rehabilitation

Traditionally TJC surveyors have generally NOT looked for privileges for physicians who order therapy in outpatient rehabilitation centers.  CMS just released in the November COP release.  Note that if the hospital bills for the outpatient rehabilitation center under the hospital CCN, it is both surveyable, and CMS would expect privileges to be granted.  I have asked John Herringer if TJC surveyors will look for this.  I will update the blog when I get his response.

(Rev. 72, Issued: 11-18-11, Effective: 11-18-11, Implementation: 11-18-11)
§482.56(b) Standard: Delivery of Services
Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws.

Interpretive Guidelines §482.56(b)
Rehabilitation services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient. The practitioner must have medical staff privileges to write orders for these services.

This is the reply from John Herringer at SIG

For rehab if this is a new CMS requirement then the
practitioner will need to be privileged. We have always
required privileging for any outpatient services requiring medication
administration or blood administration as required by CMS.
It was not required for diagnostic testing and previously not
for therapy services.
The requirement would apply to any setting included in the scope
of the hospital survey.

TJC surveys AAMI standards

It has come to our attention that Joint Commission surveyors are now surveying according to AAMI standards.  It is reported that training occurred some months ago and we have seen reports containing citations for not following AAMI guidelines.  While some of these related to AAMI standards for chemical water analysis in dialysis, there may be other implications.

Pre-labeling empty syringes acceptable

TJC has backed off on the requirement to NOT pre-label containers (NPSG 3).  However, from the wording it is very clear that the policy must actually permit it and that it is not just a random and inconsistent event.

Director of Anesthesia Job Description

Just posted to is a Job Description for the Director of Anesthesia services which may or may not be the Chief of Anesthesia.

For those COP Part A hospitals that are surveyed that do not have anesthesiologists, just rewrite the qualifications to what is appropriate.

In larger hospitals, the Chief of Anesthesiology may not always be the Director of Anesthesia services especially in large academic facilities.


Writing Orders in advance of procedures/anesthesia

Prior to surgery, anesthesiology assesses the patient while in the holding room. Based on that assessment, the anesthesiologist knows that for pain relief in the recovery room he is going to prescribe, for example, Dilaudid, for the patient. The hospital uses a post-operative recovery order set, which has on it various medications for post-operative pain. If Dilaudid doesn’t work, the order set allows the anesthesiologist to choose the next med, likely Morphine Sulfate. To initiate all of this, is it acceptable for the Anesthesiologist to sign/date/time the post-operative recovery order set when he does the pre-operative assessment – which is prior to the surgery?

It is not acceptable to write and sign orders prior to performing the procedure. In the post-op note situation the practitioner might start the note prior to the procedure, leave it unsigned and after the procedure edit/update as necessary and sign, date and time it to clearly indicate completion after performance of the procedure or at the time the order is needed.

In an orders situation, there would need to be clear evidence that the order was given or activated after the procedure or at the time the order is needed by the patient. This can again be a signature, date and/or time or if your “activation” process can clearly indicate that it was activated by the physician at the appropriate time, not in advance, then an electronic signature or activation would likely be acceptable. It could be activated only by the person giving the order, i.e., the physician, dentist, etc.

In most states nurses or other non-independent practitioners under their scope of licensure cannot determine when an order is required to be activated. We see this issue with preprinted and pre-approved standing order sets. There must be a patient specific order from the physician for the use of the standing order set at the time the set is to be implemented or is determined to be needed by the patient.