Transcript Standard I - Kspan.org

ASPAN Standards and Practice
Recommendations Update
3:45 – 5:00 PM
Objectives
• Identify 4 elements needed to prove
malpractice.
• Identify the role ASPAN Standards have in
your every day practice in caring for patients
in the perianesthesia arena.
Standards of Care
• All professions have standards of care
• Minimal level of expertise that must be
delivered to the patient
• Starting point for acceptable nursing care
Standards of Care
• Set internally or externally
– Internal pertain to individual practitioner or
institution
– External pertain to nurses in all states and
territories
– Helps define scope of practice
Standards of Care
• Found in
– State nurse practice act
– Published standards of professional
organizations and specialty practice groups
(ASPAN, AORN, ANA, ENA, AACN)
– Federal agency guidelines and regulations
– Hospital policy and procedure manuals
– Individual nurse’s job description
– Manufacturer’s published materials
– Inservice films/materials
Standards of Care
• Nurses are accountable for all standards of
care as they pertain to their profession
– To maintain competence and skill
• Read professional journals
• Attend pertinent continuing nursing
education programs
Standards of Care
• Determined for the judicial system by expert
witnesses
– ‘Court sees deviations from nursing standards’
• Experts testify to the prevailing standards in the
community
– These are standards that all nurses are accountable
for matching or exceeding
– Adherence to such standards ensures that patients
receive quality, competent nursing care
Standards of Care
• In specialty practice areas
– Courts are almost universally holding health
care providers to a national standard of care
• Reasons
– All have access to same
information/educational opportunities
– Most important: all patients have the right to
quality health care regardless of where that
care is delivered - small or large, rural or urban
LAW
• Rule or standard of human
conduct
• Established and enforced
by authority, society or
custom
• Tells us what we can and
cannot do
• Statutory: Passed by
federal or state legislature
• Public: constitutional,
administrative and criminal
law; private or civil;
relationship with one
another
Tort Law
• Concerns wrongful act, damage or injury done
• Civil suit can be brought
• Malpractice falls in this category
LEGAL ISSUE DEFINITIONS
• TORT - “CIVIL WRONGDOING”
– INTENTIONAL
• Assault: Threat to do bodily harm
• Battery: Committing bodily harm
• Invasion of Privacy
• False Imprisonment
• Defamation
• Inflicting Emotional Stress
LEGAL ISSUE DEFINITIONS
• TORT - “CIVIL WRONGDOING”
– NONINTENTIONAL
• PROFESSIONAL NEGLIGENCE- Failure to do what
reasonably prudent person under similar
circumstances would do.
• MALPRACTICE - Improper or negligent treatment
resulting in damages/injury.
LEGAL ISSUE DEFINITIONS
• RESPONDEAT SUPERIOR
– “Let the Master speak” Hospital held
liable for any damages that result from
negligence of one of it’s employees.
• RES IPSA LOQUITUR
– “The thing speaks for itself” Negligence
has been done
Legal Issue considerations
• Time Out
– Verification just before procedure starts
• Right Patient
• Right site
• Right procedure
• Correct positioning
• Availability of implants or special equipment
– Documentation “Time-out” taken
• Risk Management
LIABILITY
• 4 elements of negligence for liability suit
– DUTY: Need to be professional relationship between
health care provider and health care consumer.
– BREACH of DUTY: Damages must be due to
negligence
– DAMAGE: There must be an injury (damagesphysical, mental, financial)
– CAUSES: Damages must be direct and proximate
result of negligence
PACU LIABILITY
•
•
•
•
•
•
Failure to monitor
Failure to communicate
Errors in use of equipment
Errors in medication and treatment
Patient falls
Failure to follow orders/exercise
independent judgment
• Patient Safety
Current ASPAN Standards
2010-2012 Perianesthesia
Nursing Standards and
Practice Recommendations
2012-2014 Perianesthesia
Nursing Standards, Practice
Recommendations and
Interpretive Statements
2012-2014 Standards
• This updated text contains
• standards of perianesthesia nursing
practice,
• evidence-based clinical practice guidelines,
• practice recommendations, position
statements,
• resources from partnering organizations
• interpretive statements.
ASPAN Standards Include
• Standards: generic statements which best describe the
desirable and achievable level of performance
• Guidelines: developed from systematic review of
literature and research, a prime tool for evidence
based practices, and require frequent updating as new
information becomes available
• Practice Recommendations: which best describe the
desirable and achievable level of performance
expected of perianesthesia registered nurses.
ASPAN Standards Include
• Position Statements: represent an organization’s
viewpoint on a particular issue
• Resources: recommendations for practice based
primarily on expert consensus, expertise and opinion
from partnering organizations
• NEW: INTERPRETIVE STATEMENTS provided in sidebar
format offer clarification, definitions and examples
Clinical
Practice
What are
your needs?
Education
Research
Standards
YOU!
What would
make your
practice
easier?
What would
make
patient care
safer?
2012-2014 Standards
• Effective December 2012
• Revised and expanded
• Includes:
– Scope of Practice
– Principles of Perianesthesia Practice
• Ethical Practice
• Safety
– 6 Standards
– 3 Clinical Practice Guidelines (posted on web
site)
– 10 Practice Recommendations
– 10 Position Statements
– 3 Resources
2012-2014 Changes
• Introduction expanded
– Introduced the sidebar concept for Interpretive
Statements
• New***
– Interpretive Statements: this format allows for
the opportunity to provide clarification and
add detail to the context of the standards
Scope of Perianesthesia Nursing Practice
• Preanesthesia level of care
– Preadmission
– Day of surgery/procedure
• Postanesthesia levels of care
– Phase I
– Phase II
– Extended Care
• Settings
Perianesthesia Standards for Ethical
Practice
• Competency, responsibility to patients,
professional responsibility, collegiality, research,
advocacy
• Application to practice
– Nurse refuses to attend unit inservices - always
staffs so others can attend
– Witness break in sterile technique while procedure
performed, remains quiet
Principles of Safe Perianesthesia
Practice
• ASPAN’s core values for a culture of safety
include
– Communication
– Advocacy
– Competency
– Efficiency
– Timeliness
– Teamwork
2012 - 2014 Standards
I. Patient Rights
– Practice is based on concepts that recognize &
maintain individual
• Autonomy
• Confidentiality
• Privacy
• Dignity
• Worth
Standard I: Patient Rights Case
• Nurse loses position for breach of
confidentiality through computer entry into
patient files including diagnostics & other
privileged information.
• Hospital/facility has policy regarding patient
confidentiality
2012 - 2014 Standards
II. Environment of Care
– Perianesthesia nursing practice promotes and
maintains a safe, comfortable and therapeutic
environment.
Standard II Environment of Care Case
• QI shows increased PONV when preoperative
and postoperative patients are mixed in same
room.
• Mother transports infant home without second
person in auto. Child has obstructed airway.
2012 - 2014 Standards
III. Staffing and Personnel Management
– Appropriate number of RNs with demonstrated
competence in each level of care based on
• Patient acuity
• Census
• Patient flow process
• Physical facility
Staffing and Personnel Management
Application to Practice
• Usual daily patient population over age 18;
1 to 3 pediatric patients per week (under
age 7)
– All nurses ACLS provider status
– Do the nurses need PALS provider status?
Standard III Staffing & Personnel
Management Case
• Child has orthopedic surgery. Arrives in PACU
where only one nurse is available to care for
patient.
• 2nd nurse is changing clothes in the dressing room.
Anesthesiologist leaves patient with PACU nurse to
set up for next case.
• Patient is non-responsive and ultimately has
respiratory arrest after anesthesiologist leaves the
PACU.
2012 - 2014 Standards
IV. Quality Improvement
– RN monitors and evaluates care
– Areas for improvement are resolved through a
collaborative multidisciplinary approach
Standard IV QI Case
• Monitored pain levels in patients in
ambulatory setting.
• Same anesthesiologist for patients with
increased pain. Had no narcotics in the O.R. It
was his practice in anesthesia delivery.
• Department of Anesthesia reviewed cases
and looked at pain management within the
department.
2012 - 2014 Standards
V. Research and Clinical Inquiry
– Includes:
• Research
• Evidence-based practice
• QI initiatives
• Small tests of change that test innovation
Standard V Research & Clinical Inquiry
Case
• When ASPAN did one of the initial Delphi
studies, it was discovered that the Aldrete
scoring system had not been validated.
• Since that time the scoring system has been
changed.
2012 - 2014 Standards
VI. Nursing Process
– Applied to each patient
• Assessment
• Planning
• Implementation
• Evaluation
Standard VI
Nursing Process Case
• 9 month M&T brought to Phase I for recovery.
Given appropriate dose of Fentanyl but
immediately discharged to Phase II.
• In mother’s arms in Phase II the nurse could not
get adequate reading on pulse oximeter. Stated
“This equipment has not been working right.”
Standard VI
Nursing Process Case
• While child held by mother, became
obtunded. When the mother told the nurse
the child was having trouble breathing, it
was too late.
Standard VI
Nursing Process Case
• Pt develops compartment syndrome after
orthopedic procedure on leg.
• Upon review of charting, there is no evidence of
any capillary refill or pulse checks of lower
extremities.
• Assessment data not documented - so juries
concur: if not documented, not done.
Clinical Practice Guidelines
• Evidence-Based Clinical Practice Guideline for the
Promotion of Perioperative Normothermia
• Clinical Guideline for Pain and Comfort
• Evidence-Based Clinical Practice Guideline for the
Prevention and/or Management of PONV/PDNV
• All guidelines available on ASPAN Web Site.
(www.aspan.org)
Practice Recommendations
1.
Patient Classification/Staffing
Recommendations
1A. Staffing Recommendation and Management of
the Patient on Precautions
PR 1 - Patient Classification/ Staffing
Recommendations
• SIDEBAR:
– It is difficult to prescribe staffing ratios for the day of
surgery/procedure units based on wide variations
across the country in the role and function of the
nursing staff in these units.
– When considering staffing patterns, patient safety is
of highest priority with plans to accommodate
patients with high acuity needs.
PR 1 - Patient Classification/ Staffing
Recommendations
• SIDEBAR:
– The intent of this standard is that a nurse providing
care to a Phase I patient is not left alone with the
patient.
– The second nurse should be able to directly hear a
call for assistance and be immediately available to
assist.
PR 1 - Patient Classification/ Staffing
Recommendations
• SIDEBAR:
– Appropriate staffing requirements should be met
to prioritize the safe, competent nursing care for
the immediate postanesthesia patient, or the
patient with the highest level of care needs, in
addition to the care of the blended patient
population.
– Patient safety is of highest priority.
Practice Recommendations
2. Components of Initial, Ongoing, and
Discharge Assessment and Management
changed to Components of Assessment for
the Perianesthesia Patient
3. Equipment for Preanesthesia/Day of Surgery
Phase, PACU Phase I, Phase II, and Extended
Care
4. Recommended Competencies for the
Perianesthesia Nurse
Practice Recommendations
5.
Competencies of Perianesthesia Support
Staff
6.
Safe Transfer of Care: Handoff and
Transportation
7.
The Role of the RN in the Management of
Patients Undergoing Sedation for ShortTerm Therapeutic, Diagnostic, or Surgical
Procedures
Practice Recommendations
8.
Fast Tracking the Ambulatory Surgery
Patient
9.
Visitation in the Perianesthesia Care Unit
10. NEW***Obstructive Sleep Apnea in the
Adult Patient
49
2012-2014 Retirements
• Position Statements
– Minimum Staffing in Phase I PACU
• Has a PR
– The Nursing Shortage
– Visitation in Phase I
• Has a PR
– Perianesthesia Safety
• Elevated to Perianesthesia Principles
Position Statements
1.
2.
3.
4.
Perianesthesia Patient with a Do-NotResuscitate Advance Directive
Registered Nurse Utilization of
Unlicensed Assistive Personnel
“On Call/Work Schedule”
ICU Overflow
Position Statements
5.
6.
7.
8.
9.
Med-Surg Overflow
Safe Medication Administration
Older Adult
Pediatric Patient
Workplace Violence in the Perianesthesia
Settings
Position Statements
10. NEW** Substance Abuse in Perianesthesia
Practice
–
–
–
Specialty practice areas have higher levels of
substance
These areas involve physical, emotional and/or
mental stress that may cause nurses to turn to
substances
Also have a rather wide range of access to and
availability of controlled substances.
Resources
1. Nine Provisions of the American Nurses Association
(ANA) Code of Ethics for Nurses with Interpretive
Statements
2. American Society of Anesthesiologists (ASA) Standards:
– Statement on Routine Preoperative Laboratory and
Diagnostic Screening
– ASA Basic Standards for Preanesthesia Care
– ASA Standards for Postanesthesia Care
– NEW***ASA Standards for Basic Anesthetic
Monitoring
Resources
3. Association for Radiologic & Imaging Nursing (ARIN)
Clinical Practice Guideline: Handoff Communication
Concerning Patients Undergoing a Radiological
Procedure with General Anesthesia
To Purchase Standards
ASPAN
90 Frontage Road
Cherry Hill, NJ 08034-1424
Toll free 877.737.9696
Fax 856.616.9601
Email [email protected]
www.aspan.org
Bibliography
• 2012-2014 Perianesthesia Nursing Standards,
Practice Recommendations and Interpretive
Statements. Cherry Hill, NJ: American Society
of PeriAnesthesia Nurses, 2012
References
• Atlee, John. Complications in Anesthesia. 2nd Edition.
Philadelphia: Saunders Elsevier. 20007
• Cole, Daniel and Michelle Schlunt. Adult
Perioperative Anesthesia: The Requisites in
Anesthesiology. Philadelphia: Mosby Elsevier. 2004
• Drain, Cecil and Jan Odom-Forren. Perianesthesia
Nursing: A Critical Care Approach. 5th edition. St.
Louis, MO: Saunders Elsevier. 2009
References
• Litwack, Kim. Clinical Coach for Effective
Perioperative Nursing Care. Philadelphia: F.A. Davis
Company. 2009
• Reed, Alan. Clinical Cases in Anesthesia. 2nd Edition.
New York: Churchill Livingstone.1995
• Schick, Lois and Pamela Windle (Editors)
PeriAnesthesia Nursing Core Curriculum:
Preprocedure, Phase I and Phase II PACU Nursing. 2nd
Edition. St. Louis, MO: Saunders Elsevier, 2010.
ONLINE References
• His and hers heart disease accessed at
http://www.health.harvard.edu/fhg/updates/his-and-hers-heartdisease.shtml
• Obstructive Sleep Apnea. Accessed at www.CritCareMD.com
• Pulmonary Disorders accessed at
http://dynamicnursingeducation.com/class.php?class_id=55&pid=18
• Sutherland, Sara. “Pulmonary Embolism: Treatment and Medication”
at http://emedicine.medscape.com/article/759765-treatment
• What is Obstructive Sleep Apnea (OSA)? Accessed at
http://www.medicalnewstoday.com/articles/178633.php
THANK YOU
Lois Schick MN, MBA, RN, CPAN, CAPA
12823 W. 3rd Place
Lakewood, CO 80228
Home: 303-989-2281
Cell: 303-475-9854
E-Mail: [email protected]