Transcript top 10 most frequently scored standards

Lessons Learned from
Recent TJC Surveys
Kurt Patton, MS, RPh
Jennifer Cowel, RN, MBA
John R. Rosing, MHA, FACHE
Patton Healthcare Consulting
1
Medication Orders
• Preprocedure medications/IVs and testing
nurse-initiated protocols are now permitted
– Caveats: (create a policy) “Standing Orders”
• Must be approved by the medical staff, nursing (to
affirm the practice is within the scope of license) and
pharmacy (with respect to medications)
• Must be based on nationally recognized and evidence
based guidelines and recommendations
• Include regular PI review to look for problems or
improvement opportunities
• Date, time, and authenticate per state regulation
2
CPOE and the Pre-OP/Post-OP Order
• CPOE signing of post-operative anesthesia or surgical
orders pre-operatively now requires a risk assessment
and policy to avoid a finding
• Got away with it on paper; could fudge or omit the time
and not be noticed
• CPOE captures the time, so an easy observation
• The LIP must either pend or plan the orders and log back
in and sign/ release/initiate the orders post-OP, OR
• Sign orders pre-OP and justify via risk assessment and
policy having the RN reassess the patient and
release/initiate the order based on the very nature of
conditional/PRN orders
3
CPOE Pre/Post-Op Orders
• Physicians and staff seek ways to expedite
patient flow by writing post procedure orders
before the procedure starts (sometimes hours,
days, weeks). This is noble!
• EHR/CPOE systems allow organizations to build
standard order sets or pre-printed orders to
reduce/eliminate redundant work and expedite
care. Also noble!
4
CPOE Pre/Post-Op Orders
• The organization must decide whether it will allowing
practitioners to write post-procedure orders prior to the
procedure; if yes, then…
• Construct a risk assessment and policy that defends a
process where conditional orders (i.e., if this, then
that/PRN orders) may be entered/written ahead of time
by the LIP and then allow licensed/competent PACU RN to
review the order post-OP AND match the order to the
assessed needs of the patient
• The RN then initiates or activates the order or consults
with the ordering LIP if patient condition
warrants/changes
5
Medication Orders
• Intraprocedure verbal orders for meds
administered by a nurse need to be
countersigned by LIP
• On paper – sign the OR flow sheet/ MAR
• eFlow Sheet or eMAR and goes to LIP
inbox for electronic signature
6
Pharmacy Review of Orders
• Applies in PACU!
• Prior to administration a pharmacist must review all
medication orders for contraindication, allergies,
proper dosing
• Long felt to be a “physician controlled environment” no longer
• CPOE and standardized order sets facilitates prompt
review and profiling for ready retrieval from ADM
• May still override ADM for urgent needs so long as
retrospective review and evaluation occurs
7
Medication/Fluid Integrity
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IV bag fluids and Irrigation bottle fluids
Pharmacy should establish and oversee ongoing
Cannot exceed 104 degrees F, check manufacturer
Wise to record a daily temp reading
IV bag in outer pouch: 14 days,
– label with new, “do not use beyond” date
• All are single use (i.e., no opened bottles)
8
Label All Medications
(NPSG.03.04.01)
Label all meds on and off the sterile field.
• All products, including sterile water/saline,
disinfectants in a basin must be labeled.
• The safety goal includes bedside procedures
as well as IR, cath lab, out patient
• Its an A element of performance
Prelabeling??? OK if your policy permits it
9
Sentinel Event Alert #49
Safe Opioid Use - Risk Factors
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Hx of sleep apnea or snoring
Smoker
Morbid obesity
Older age (>80 has almost 9X > risk)
No recent opioid use///opioid habituation
Concomitant use of benzodiazepines, antihistamines,
sedatives or other CNS depressants
• Post surgical, notably abdominal///thoracic
• Longer anesthesia times
• Pre-existing pulmonary or cardiac disease
10
Safe Opioid Use
• State Board of Medicine – Massachusetts
– 27 incident reports since 2007
– 77% concomitant morphine or lorazepam
– 23% of patients were obese
– 19% had sleep apnea
– 15% asthma
– 15% some other chronic respiratory condition
– > age 60, female, most likely on night shift
11
Safe Opioid Use – Actions Taken
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Eliminate range orders for dose and time
Lower dose hydromorphone purchased
Eliminate Pyxis override for hydromorphone
Educate staff on 8:1 dose conversion between
morphine and hydromorphone
• Specific privileging for hydromorphone ordering
• Discourage hydromorphone use for outpatients
• Closely monitor patients with known risk factors
12
Safe Opioid Use - Key Recommendations
• Use conversion support systems when
converting from one opioid to another or
one route of administration to another.
• Use a sedation monitoring scale such as
RASS, Pasero POSS or University of MI.
• As with any SEA, have paper trail showing
consideration of recommendations and
actions taken, plus subsequent QAPI
13
Laryngoscope Blades
• Clean and (at least) high level disinfect them per
manufacturer instructions for use
• Store in manner that prevents recontamination
• One blade per Zip-Lock bag if HLD, or
• Peal pouch if steam
• Consistent practice throughout the hospital
• Look everywhere!!!
• Testing light source?
– Hand hygiene and/or use gloves
– Place back into Zip-lock bag or peal pouch
– Battery expiration dates!
14
ET Tubes/Stylets
• Video-assisted laryngoscope (e.g. GlideScope)
re-usable stylets must be sterilized and
packaged per manufacturer instruction
– Often found unwrapped on cart ready for re-use
– Check the ED and non-OR anesthetizing locations
15
Disposable ET Tube and Stylet
• Often found in/on an anesthesia cart ready
for next case where the factory package is
opened and stylet is inserted to save time in
a STAT induction; package is not dated or
timed with new expiration date/time.
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High Level Disinfection - Scopes
• Follow manufacture recommendations
• E.g., glutaraldehyde or OPA test strips
– Date bottle of strips when opened – 90 days
– QC run on a positive and negative solution
– Requires 6 strips right from the start
– Document the strip QC
– Testing prior to each load, document QC
18
Separation of Clean/Dirty
• Scrutiny of scope cleaning room to
determine if flow/practice prevents crosscontamination
• Key: remove HLD scopes from sterilizer only
when no other dirty scopes are in the room
• Flawless QC and load record documentation
• Proper PPE, eyewash station
• GUS unit if ventilation is inadequate
19
Scope Storage
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Hang in a positive pressure vented cabinet
Avoid tip dragging on base
Avoid towels or other absorbent on base
Avoid cross-contamination (adjacent sink??)
10-14 day shelf life? (August/2011 OR Manager)
Never store in foam mold in hard case
20
Consistent Practice
• How many TEE probes exist in the hospital?
• How many nasogastric scopes? Where???
• In each area – are decontamination, testing,
QC, HLD processing, load record-keeping
steps performed consistently???
• Exact concentrations, soak times, handling?
• Inventoried by Biomed/Clinical Engineering?
21
Sterile Processing Tour
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Attire: donned at the hospital, changed daily
Red line – no one enters without proper attire
No artificial nails, nail polish, jewelry, watches
Head AND facial hair covered at all times
In Decontamination: liquid-resistant garb,
heavy-duty gloves, eye protections
• WASH HANDS WHEN FINISHED
• Eyewash station
22
Immediate Use Sterilization
• Important that staff can speak to the process without
using the term “flash”
• Follow manufacturer recommendations for sterilizer,
pack, instruments, CI, BI
• Covered, rigid containers even in sub-sterile
• No pre-cleaning/decontamination in sub-sterile!
• “A sterilized item intended for immediate use is not stored for
future use, nor held from one case to another.”
• “Instrument inventories should be sufficient to meet anticipated
surgical volume and permit the time to complete all critical
elements of reprocessing.”
• Submit data to PI Committee /leadership to justify purchase
23
SPD Facility
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Easily cleaned walls, floors and ceiling
Daily housekeeping
No exposed pipes, etc. that collect dust
Maintain neg/pos pressure by keeping doors and
windows closed; test pressures monthly
• Sinks available for hand washing
• Eye wash within 10 second travel time; single action
lever, tepid water temperature to allow 15 minute
flush time
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HVAC Temperature, Humidity, Storage
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Monitor and record daily
Temp 68-73 in clean area of department
Temp 60-65 in decontamination
Humidity 20-60% in work areas
Proper # of Air Exchanges (>10, 2 fresh)
Pos/Neg pressure relationships
Humidity not > than 70% in sterile storage
18 inch, 6 inch, 2 inch, solid lower shelf
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Relative Humidity to 20%
• CMS finally agreed to lower the minimum
acceptable humidity level from 30% to 20%
• Requires an “internal” waiver
• You need not submit a waiver request to
CMS or TJC, but simply discuss at a
committee of record (e.g., EOC, IC, OR
Operations, etc.) and conclude and
memorialize in minutes that you have
adopted the 20% minimum acceptable
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Reduce Risk of Infection
• Surveyors will observe staff as they process dirty
equipment
• Surveyors will check manufacturer instructions
for use (IFU) for three things: the
device/instrument, the sterilizer itself, and the
packaging (i.e., blue wrap or flash pan.)
• Check your policy, check staff understand and
follow both. Create a recipe book or OneSource
• Will observe proper use of PPE
27
Eye Wash
• Study MSDS: Corrosive? Irreversible Tissue
damage? Immediate 15 minute rinse?
• An eyewash is likely needed – risk assess
• Within 10 seconds (50 feet)
• In the same room
• Single action lever
• Tepid water – 60-100 degrees F
• Consider wall mount/self contained system
28
Loaner Equipment
• Clear policy and procedure, penalties for
noncompliance; ripe for short-cuts
• Mandate 48 hour lead-time???
• Follow manufacture recommendations
• Staff should blow whistle if uncertain
• Don’t be bullied
29
New Topic: 2011 ASA IP Guidelines
• Recommendations for Infection Control
for the Practice of Anesthesiology (Third
Edition)
– Great Explanation of Hand hygiene
– Ditto Safe Injection Practices
– Expiration Dating of Medications
• (Propofol = 6 hours)
– Catheter Insertion
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Tissue Management TS.03.01.01
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EP 1 Assign responsibility for tissue
EP 2 Policy for acquisition, receipt, storage, issuance
EP 3 Confirm FDA registration, have current paperwork
EP 4 Spread process throughout hospital
EP 5 Use manufacturer instructions for transporting,
handling, storing and using tissue (verify that vendor
keeps records per lot # in event of RCA)
– EP 6 document receipt of tissue(TS.03.02.01 EPs 3 &6)
– EP 7 at receipt, package integrity and temp control is
verified (TS.03.02.01 EP 6)
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TS.03.01.01 Continued
– EP 8 Daily record of temperature for ambient,
refrigerated, frozen, or liquid nitrogen (TS.03.02.01 EP 5)
– EP 9 Continuous monitoring for refrigerated, frozen, or
liquid nitrogen
– EP 10 Functional 24/7 alarm for refrigerated, frozen, or
liquid nitrogen
– EP 11 If you are a tissue supplier, you need FDA
registration.
• “If a hospital sends tissue for use at another physical location or building
that is not on the same campus, even if under the same management,
that establishment is considered a distributor and must register.”
•
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=1271.3
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TS.03.02.01
– EP 1 Bi-directional tracing including discarded (FAQ ‘10)
– EP 2 Written materials/instructions to prepare or
process (FAQ TJC)
– EP 3 date/time/name of staff involved at receipt/
acceptance, preparation, and issuance.
“During tracer activities, it was found that the organization had not been
recording times at the following points: 1. Receipt at the warehouse which
was located off site; 2. Receipt by the surgical personnel upon arrival to OR; 3.
Time placed in refrigerator or freezer, and 4. Time removed from the
refrigerator or freezer.”
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Preparation
“While doing a surgical tracer in the main operating room staff
was asked how tissue receipt, storage and use documentation
would be done if the patient needed a tissue transplant. Staff
said that reconstitution diluents or fluids such as normal saline
that were used to reconstitute the tissue would not have the
diluents’ lot number recorded. Further discussion revealed
that the form used to track tissue transplants had all the
required prompts for information except one for lot numbers
of the fluid used to reconstitute tissue. During the survey staff
updated the form to include a field for lot numbers, and when
the form is implemented this standard will be met.”
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TS.03.02.01 (con’t)
• EP 4 document in MR tissue type and unique identifier
• EP 5 retain records on temperatures, outdated
procedures, manuals, and publications for 10 years
(TS.03.01.01 EP 2 & 8)
• EP 6 records on distribution, transplantation,
disposition, or expiration for 10 years
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Name of supplier
Original numeric/alphanumeric donor and lot
Name of recipient and final disposition
The expiration dates of all tissue (TS.03.01.01 EP 6&7)
• EP 7 complete tissue cards and return to supplier
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TS.03.03.01 (all are “A” EPs)
– EP 1 written procedure to investigate adverse
events, disease transmission or complication
– EP 2 conduct investigation
– EP 3 report to supplier ASAP
– EP 4 sequester compromised tissue or tissue
implicated by a supplier
– EP 5 inform patients
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H&P and Update
• An H&P is done no more than 30 days prior to
admission or within 24 hours of admission.
• If the H&P is done anytime in the 30 days prior to
admission you must update it within 24 hours of
admission, or prior to an invasive procedure on the
day of the procedure, whichever comes first.
– Must document: the patient was examined, and the H&P
was reviewed, changes___ or no changes. CMS mandate
– In EMR – use a SmartText: e.g., .no changes or .changes
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HISTORY AND PHYSICAL
• MS.03.01.01, EP 6, A,D – “The organized medical
staff specifies the minimal content of medical
histories and physicals, which may vary by setting,
level of care, tx and services”.
• Problem: a long form, short form or “ad hoc”
form is spotted which doesn’t meet your
requirements
• CMS now prohibits anything but a
“comprehensive H&P” for ASC; Hospitals?
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HISTORY AND PHYSICAL
• EP 7, A – “The medical staff monitors the
quality of H+P’s”.
• Surveyors score failure to obtain within
24 hours of admission or prior to surgery,
then look for actions taken by MEC to
improve.
• If quality data indicates that indeed
sometimes there are performance gaps,
what do the minutes show for actions?
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Sample H&P Bylaw Language
A medical history and physical examination be completed and
documented for each patient by a hospital practitioner with
appropriate privileges no more than 30 days before or 24 hours after
admission or registration, but prior to surgery or a procedure requiring
anesthesia services. An updated examination of the patient, including
any changes in the patient's condition, be completed and documented
within 24 hours after admission or registration, but prior to surgery or
a procedure requiring anesthesia services, when the medical history
and physical examination are completed within 30 days before
admission or registration.
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Informed Consent
• Physician responsibility
• Paper form needs date and time for all signatures
• CMS requires patient to sign, date, time
• May need to have them re-initial, date, time on day of surgery
• Form may include potential use of blood
• Process includes discussion of likelihood of desired outcome
• Anesthesia consent is usually in anesthesia record
• Sedation consent is on presedation assessment
• RN confirms patient understanding, advocate
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Document Operative & High Risk Procedures
(RC.02.01.03)
 H&P in record before procedure (EP 3)
 Post op/post procedure report is written or
dictated before transfer to next level (EP 5)

(Unless a post op/post procedure note is
entered immediately [see EP 7], if so, report
may be written or dictated per policy)
 The post operative/procedure report
includes: name of LIPs, procedure name
and description, findings, EBL, specimens,
post op diagnosis (EP 6 - Top Scorer)
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Document Operative & High Risk Procedures
(RC.02.01.03)
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If report is delayed, an immediate post
procedure note is entered and includes LIP,
assistants, procedure(s) performed and
finding(s), ANY EBL, ANY specimens, Post op
diagnosis (EP 7 top scorer). Check your policy.
No premature Post-OP notes!!!
Medical record includes the LIP release order or
approved DC criteria (EP 9)
Medical record includes the use of DC criteria/pt
readiness (EP10)
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CMS/TJC Anesthesia 1/11 Changes
• Post-Anesthesia assessment must occur (and
be documented) within 48 hours of recovery.
• No premature Post-Anesthesia Evals!!!
• May be based on data collected by a nurse (as
in the case of SDS where discharge is by RN
using criteria approved by the medical staff.)
• No requirement for an LIP post-sedation
assessment.
• All entries to medical record are dated/timed
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Elements of Post Anesthesia Eval
• Remember required elements should
conform to current standards of
anesthesia care including respiratory
function, rate, airway patency and O2
sat, CV function including pulse and BP,
mental status, temp, pain, N+V, postoperative hydration.
Telemedicine MS.13.01.01 - 3 Options
1. Originating site fully credentials and privileges the LIP.
2. Originating site privileges the LIP using the credentialing
information from a TJC accredited organization. The LIP
needs a license in the originating hospital’s state.
3. Originating site uses the credentialing and privileging
decision of the distant site if:
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The distant site is TJC accredited
The LIP has the privilege(s) at the distant site
The distant site must share the full list of LIP privileges
The originating site collects FPPE/OPPE data and shares with
distant site (including adverse outcomes and complaints)
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Telemedicine LD.04.03.09
• If either Option 2 or 3 is chosen, there must be a
written agreement and EP 4 and 23 apply
– EP 4 Leaders monitor performance expectations
– EP 23 the agreement must
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Label the distant site as a contractor
Specify that distant site will follow MS.06.01.01 – 06.01.13
Specify that distant site complies with CMS CoP
Note that originating site governing body grants privileges
based on originating site medical staff recommendation based
on information provided by the distant site
• Also, the medical staff bylaws must include a provision
permitting such reliance on the distant site.
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