History and Physical:
In April TJC posted 4 new frequently asked questions or standards interpretations, at least 3 of which are very important and frequently asked. The first discusses an inpatient who has an H+P performed at the time of admission, who will later in the hospitalization undergo a surgical procedure and, if there must be any update to the H+P. This subject was addressed in an FAQ years ago that was later removed and its return is very welcomed. The answer is no, there is no need to update the H+P for the inpatient because there are daily assessments and progress notes since the time of admission.
A second FAQ also discusses the history and physical and this one is really important to understand. They discuss the outpatient who has an H+P performed as an outpatient less than 24 hours before they come to the hospital for a surgical procedure (e.g., H&P at 4 pm the day prior to surgery scheduled at 7 am the next day), if whether that H+P requires an update or not. The answer is YES, the H+P performed on an outpatient anytime up to 30 days prior to the day of their arrival and registration, does need an update. The only way you can omit the H+P is if the patient arrives and registers for their surgery, has an H+P performed and then several hours later will have the surgery. In this case, the H+P was performed after arrival, after registration and the patient has been monitored by your organization since the H+P was performed, thus no update is needed. This is very often a difficult issue for staff and physicians to understand.
By way of warning we would advise not trying to outsmart the system by registering the patient the day before their surgery and letting them go home, thinking you can avoid the H+P update. If the patient has gone home, has not been observed and monitored, then you are always going to need to update the H+P.
The third FAQ discusses the required elements of a complete titration order, a subject we have addressed multiple times in this newsletter. TJC states each titration order must include the name of the medication, the route, the initial or starting infusion rate, the incremental rate the infusion can be increased or decreased, the frequency at which you can adjust the rate, and the objective endpoint for the infusion such as a RASS or a blood pressure. Although not stated in the FAQ we would add that each time you adjust a rate there should be documentation that indicates why an adjustment was needed, and that the patient responded as expected. This means an assessment of need and a reassessment of effect should be documented.
So, for example if the RASS goal is -3 and you increase the rate, you want to make sure you document that the patient was not at a -3, and then re-evaluate the patient after the adjustment to see if they now reached the -3. We have seen the significant difficulty hospitals have documenting their sedation titrations completely. This problem is intensified if you are using 2 sedating agents and have indicated both are intended to achieve a RASS score. The problem is there is no guidance on adjusting drug 1 or drug 2. If one drug is really used for pain, and the second for sedation, make sure your orders state the correct indications. Also, be careful when patients have pre-existing conditions such as a head injury that results in an observed RASS that is already deeper than the prescribed goal.
The 4th FAQ is not what we would call a burning issue. It deals with linen management and keeping linens clean in storage. TJC does not have any specific linen standards, but they refer readers to the CDC and the National Association of Institutional Linen Management. As you might expect they advise carts stored in hallways must be protected from contamination by using covers. However small carts used to distribute linens, out and exposed for only a short period of time, need not have covers. Our recommendation is to select a national guideline to follow, update your policy and train staff. You may want to consider a risk assessment to validate your procedures for keeping linens clean until used.
Storage of Sterile Supplies outside of Central Sterile:
There is a fifth issue that has not yet resulted in a published FAQ, but we have seen responses on the issue provided to the TJC Consultant Forum and to two different hospitals. The issue is the multiple locations in a hospital where you might want to keep a small quantity of sterile items processed by your central sterile supply department. For example, a chest tube insertion tray in a surgical ICU or a trauma tray in the ED trauma room. We have seen many RFI’s on this issue for a failure to document daily temperature and humidity measurement to verify storage conditions compliant with AAMI. While this sort of monitoring is clearly required in the large centralized storage location maintained by central sterile, many organizations have struggled with these satellite locations. TJC has recognized that these satellite locations with small quantities of sterile items need some additional flexibility, but at this time we see nuances between the different responses that don’t yet make us comfortable on how to bullet proof the process from criticism.
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