Posted November 24, 2008 2:52 PM
by Administrator
Related Categories:
CMS Conditions of Participation/EMTALA
The updated Interpretive Guidelines to the Conditions of Participation have been published by CMS and are available by accessing CMS_Interpretive Guidelines 2008-10-17 Complete IG for Hospitals. The Interpretive Guidelines (IG) is presented in a slightly different format and has been consolidated to allow for each of the elements to nest under the categories of the Conditions of Participation (meaning while there is a distinct standard for restraint and seclusion, for example, you’ll find this consolidated under the condition of Patient Rights.) While most of the requirements contained in the updated Interpretive Guidelines remain unchanged, there are some nuanced language changes and notably the changes with the Patient Rights component (restraint and seclusion changes, including restraint death reporting), changes to laboratory services and potentially infectious blood among others. Section II on the first page of the updated Interpretive Guidelines, outlines the specific changes to the CoPs. As this version of the IG was just released, we at Greeley are in the process of review and analysis for significant changes. More information on the impact of any changes will be posted to our blog as we work our way through this new IG update. Until we have an opportunity to notify you about the changes, we suggest you skim the document and focus on any language written in red lettering. Within the new IG, all updated language is annotated in red.
Posted November 24, 2008 9:37 AM
by Lisa Eddy, RN,CPHQ
Related Categories:
National Patient Safety Goals
If you haven't read the FAQs for the Universal Protocol published on November 5, 2008, please do so before reading the rest of this message. The FAQ can be accessed on this page: http://www.jointcommission.org/PatientSafety/UniversalProtocol/. A few nuances to the FAQ struck our attention.
The Universal Protocol's expansion of expectations, notably application in the wording of the UP requirements that the UP applies to all procedures involving percutaneous puncture has caused some confusion within the industry. The 2009 Universal Protocol FAQ, while answering some questions and raising others, does allow for some specification in what is and is not to be included in the UP.
Procedures:
The FAQ specifically states the protocol now applies to the insertion of PICC lines, other central lines and chest tubes. The FAQ also identified what protocol does NOT apply to:
- veinipuncture
- peripheral intavenous line placement (angiocath insertion)
- nasogastric tube insertion
- urinary catheter insertion
- electroconvulsive therapy
- closed reductions
- radiation oncology
- lithotripsy
- dialysis
The FAQ calls healthcare organizations to clearly define the scope of the protocol so all staff and physicians are clear as to when the protocol applies and when procedures are exempt. We recommend that the organization give a general definition and exclude those few procedures that have a risk profile similar to nasogastric tube insertion. For example, a hospital could say that "the universal protocol apples to all invasive procedures that place the patient at risk except: … " then list the Joint Commission exemptions and others you think are low risk, such as skin flap or eschar removal, suturing of the epidermis, joint injections or simple aspirations, etc. Your list should be reviewed and approved by your medical staff, and we suggest sending your approved list of exclusions to someone in the Standards Interpretation Group or to Dr. Angood (who is the individual responsible at TJC for the NPSGs) directly to avoid any surveyor second guessing during your accreditation visit.
Time Out:
You may have noted some contradictions about time-outs.
- On one hand the FAQ requires one and only one time-out for most surgeries: either before anesthesia or after anesthesia and prior to incision. On the other hand, the FAQ seems to require two time-outs when a spinal or regional block is involved: prior to the block and again prior to incision. (hmmmm … ?)
- On one hand the FAQ indicates that only one time-out is necessary when the same team will perform all portions of a multi-part procedure. On the other hand it requires a separate time-out when the various parts of the procedure require separate consent forms.
Because there is contradiction within the FAQ about time-outs, we suggest you do what makes good clinical sense. The FAQ is now allowing for more flexibility related to when the time-out should take place. Recent changes to the UP called for the time-out to be "ideally" called prior to anesthesia or sedation. Many organizations have voiced concern over this requirement, citing the safest method is to call the time-out closer to incision time. As the updated FAQ states that each organization must "define under which situations the time-out is required to be performed prior to anesthesia or when it is preferable to do so immediately prior to the procedure/incision" we suggest you determine, in collaboration with your medical staff, when the time-out should optimally be called and include this in your Universal Protocol policy.
