Chapter 2 After studying this chapter, the learner will be able to: • Discuss how standardization influences patient care. • Describe two professional sources of patient care standards. • List three main aspects of accountability. This chapter establishes the basis for perioperative patient care. The opening section gives a glimpse of historic patient care and progresses to modern perioperative practice. Florence Nightingale is credited with developing the environmental theory of patient care on which all perioperative patient care is based (Box 2-1). According to her theory, the caregiver is accountable for creating and maintaining the best possible environmental conditions to assist natural healing. She emphasized the need for prevention through education and teamwork. In her eyes, the team consisted of not only the caregivers, but also the patient and family. She often approached her legislators with suggestions for bills and laws designed to protect patients and caregivers. Her numerous letters and writings chronicle her work. 1. Establishes rapport with the patient, family, or significant others in a manner that conveys genuine concern and sincere caring 2. Encourages the patient and family or significant others to express feelings and ask questions 3. Helps relieve anxiety and apprehension by providing factual information regarding what to expect 4. Helps the patient make informed decisions throughout the perioperative experience 5. Acts as a patient representative by communicating pertinent information to other team members 6. Oversees all activities throughout the perioperative experience to ensure the safety and welfare of the patient 7. Keeps the family informed of significant events throughout the perioperative experience 8. Protects the patient’s rights by compliance with advance directives for care (living will, durable power of attorney, or both). Additional information about advance directives and durable power of attorney can be found in Chapter 3. • The main purpose is to ensure the safety and welfare of the patient and personnel. • It is easier for the perioperative educator and preceptors to teach learners consistent methods of patient care. • Learning is easier if everyone performs procedures in the same way. • Deviations show a need for evaluation of the procedures or the staff. Do the procedures need revision? • Consistent procedures provide an efficient check during preparation for any surgical procedure. • One person can take over for another at any time during the surgical procedure, if necessary, and know exactly where to find instruments and supplies. • Routine procedures establish habits that increase speed in thought and action. Doing work in a certain way promotes a high level of proficiency. • Knowing the standards allows intelligent decision making when a patient’s condition requires modification of a routine. 1. Standards of Perioperative Nursing. These standards, which originated as ANA standards of OR practice in 1975, were approved by ANA and AORN (Association of periOperative Registered Nurses) and originally published in 1981. Reviews and revisions are done yearly as needed. These five sets of standards for an optimal level of perioperative nursing practice are published annually in AORN Standards and Recommended Practices. The scaffold of the standards is premised in patient care quality and is primarily tri-fold—Structure, Process, and Outcome. These three components provide a means for the perioperative nurse to analyze and interpret care. Reviews and revisions are done yearly as needed. a. Standards of Perioperative Administrative Nursing Practice. These are structural standards that provide a framework for establishing administrative and organizational practices in a variety of settings. b. Standards of Perioperative Clinical Practice. These are process standards based on problem-solving techniques using principles and theories of biophysical and behavioral sciences. They describe how the nursing process is used in the perioperative setting. The Perioperative Nursing Data Elements (PNDS) provide a means to measure and collect performance improvement data. c. Standards of Perioperative Professional Practice. These are process standards that describe a competent level of behavior for the professional role of the perioperative nurse. The activities relate to quality practice evaluation, continuing education, collegial relations, collaboration, ethical conduct, and use of resources, evidence-based research, and leadership. d. Quality and Performance Improvement Standards for Perioperative Nursing. These are process standards to assist in the development of methods to measure, assess, and improve patient care. e. Perioperative Patient Outcomes: Standards of Perioperative Care. These are outcome standards that reflect desired observable patient outcomes during preoperative, intraoperative, and postoperative phases of patient care. They focus on patient and family responses to intervention during surgical, diagnostic, or therapeutic intervention. Each outcome has a unique identifier in the PNDS. 2. The Operating Room Nurses Association of Canada (ORNAC, www.ornac.ca) has published Recommended Standards for Operating Room Nursing Practice and Quality Assurance Audit. 3. Association of Surgical Technologists Standards of Practice (AST, www.ast.org). These are process standards that provide guidelines for safe and effective patient care in appropriate preoperative, intraoperative, and postoperative practice settings. They include interpersonal skills, environmental safety, and application of principles of surgical technology. 4. The Joint Commission (TJC) standards (www.jointcommission.org). These standards, published in the Accreditation Manual for Hospitals are functional, performance-based standards that focus on actual clinical care provided directly to patients and on management of the health care organization providing services. They relate to efficiency, effectiveness, safety, and timeliness; appropriateness, continuity, and availability of care; and patient satisfaction. TJC evaluates compliance with these standards and reviews clinical outcomes of care provided as fundamental criteria for accreditation. Selective clinical indicators serve as outcome measurements for the processes of patient care. Additional information about error reporting and monitoring of patient care standards is found in Chapter 3. • TJC established National Patient Safety Goals (can be found in their entirety at www.jointcommission.org/patientsafety). • Improve the accuracy of patient identification by using at least two forms of patient identification. • Improve the effectiveness between caregivers by using standardized patient “hand off” reporting (change from one caregiver to another), verbal reflection, avoiding abbreviations and symbols, and assuring timely communications. • Improve the safety of using medications by identifying potential “sound-alike” or “look-alike” drugs in the facility, labeling all drug containers and delivery devices on and off the field, decrease the risk of anticoagulation error. • Reduce the risk of health care–associated infections by meticulous hand hygiene and by recording and reporting as a sentinel event any unanticipated death or loss of function associated with sepsis or health care–acquired infection. • Accurately and completely reconcile medications across the continuum of care by comparing patient current medication regimen with medication orders during care in the facility. Patient and subsequent caregivers in and out of the facility are provided a complete list of current medications on discharge. • Reduce the patient’s risk for harm from falls by implementing a program of safe patient positioning and transport in the OR. Fall prevention programs should have an evaluation process. • Encourage the patient’s participation in the safe delivery of care by defining and communicating the steps of care and encouraging the patient and family to ask questions and voice concerns for safe care. • Identification of potential safety risks in the patient population relevant to patients with emotional or behavioral disorders by prevention of self-harm or suicide. • Improve recognition and response to changes in the patient’s condition by ongoing assessment and immediate access to specially trained individuals when a patient’s condition has changed. 5. National Fire Protection Association (NFPA) standards (http://safety.science.tamu.edu/nfpa.html). These standards apply to environmental safety to reduce, to the extent possible, hazards to patients and personnel. 6. Association for the Advancement of Medical Instrumentation (AAMI) device standards (www.aami.org). These standards provide industry with reference documents on accepted levels of device safety and performance and test methods to determine conformance. AAMI standards have also been established for sterilization, electrical safety, and patient monitoring for health care providers in relation to evaluation, maintenance, and use of medical devices and instrumentation. 7. Clinically based risk-control standards. These standards are written by medical specialty groups and professional liability underwriters. They establish appropriate benchmarks of acceptable practices and outcomes specifically for controlling liability losses. They may be incorporated into the health care facility’s risk management program. The standards set by these organizations are enforceable by law: 1. Federal Medicare Act and all subsequent amendments to this Social Security Act (http://www.cms.gov/). This legislation incorporates the provision that institutions participating in Medicare must maintain the level of patient care recognized as the norm. Specific requirements are included. a. Health Insurance Portability and Accountability Act (HIPAA, http://www.cms.gov/hipaageninfo/). The Department of Health and Human Services (HHS) set national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Many facilities require the employees to sign a confidentiality agreement upon hire. Schools of nursing and surgical technology, clinical sites and patient care training sites require students to sign confidentiality agreements. Some schools prohibit tape recording in class because of patient and facility confidentiality issues. b. Medicare’s “No Pay List”: Accuracy of documentation of conditions present on admission as differentiated from conditions acquired during hospitalization determines facility reimbursement for patient care. Claims for payment that have no documentation about conditions “present on admission” are immediately rejected without reimbursement. More information can be found at http://www.cms.gov/. As of October, 2008, CMS will not reimburse the facility for the following: 3) Vascular catheter–associated infection 4) Retained foreign objects from surgery 5) Certain surgical site infections (mediastinitis after cardiac surgery, bariatric gastrointestinal procedure, and orthopedic procedures of spine, neck, shoulder, or elbow) 9) Deep vein thrombosis (DVT) and pulmonary embolus (PE) after knee or hip joint arthroplasty 10) Urinary catheter–associated infection c. National Quality Forum (NQF): Serious reportable events mirror the CMS “No Pay List” and the 45-page 2010 serious reportable events document can be viewed using Acrobat Reader at www.premierinc.com/safety/topics/guidelines/nqf.jsp The NFQ document details include, but are not limited to, the following: 1) Surgical events such as wrong site or wrong patient surgery 2) Device or biologic material–associated deaths (equipment and medication contamination) 3) Patient protection event such as patient suicide 4) Care management event such as wrong drug or blood administration 5) Environmental event such as electrocution or falls 2. American National Standards Institute (ANSI) standards (www.ansi.org). These standards concern exposures to toxic materials and safe use of equipment such as lasers. 3. U.S. Food and Drug Administration (FDA) performance standards (www.fda.gov). Federal Medical Device Amendments regulate the manufacture, labeling, sale, and use of implantable medical devices and many products used in or on patients. The FDA also controls treatment protocols for use of drugs. The manufacturer’s lot number and product description of implanted devices should be attached to or included in the patient’s chart. 4. Agency for Health care Research and Quality (AHRQ) clinical practice guidelines (www.ahcpr.gov). These standards include indicators for performance measurement. They are based on research and professional judgment regarding effectiveness and appropriateness of medical care, including safety, efficacy, and effectiveness of technology. This agency was created in provisions of the Consolidated Omnibus Budget Reconciliation Act of 1989. AORN has included perioperative interpretations of the AHRQ guidelines in the AORN Standards and Recommended Practices publication. 5. Occupational Safety and Health Administration (OSHA) standards (www.osha.gov). These legally enforceable standards include permissible levels of toxic substances in the environment. Although explicitly developed to protect employees, patients receive secondary benefits from control of hazards in the environment. 1. Facility-specific patient care standards. The patient care services department establishes standards for appropriate patient care based on the standards developed by the American Nurses Association (ANA). Optimal standards of nursing practice guide the provision of patient care throughout the institution. Written policies and procedures reflect these standards. Institutional standards are based on standards established at national levels by TJC, AORN, ANA, and other nursing organizations and governmental agencies. Nurses should practice within the limitations of the nurse practice act of the state in which they are licensed and practice. Licensure is a legal requirement to practice nursing. Copies of facility-specific documents are available for review from the nursing or hospital administration. 2. Hospital policy and procedure manual. This manual contains basic and general administrative and patient care policies that apply to all hospital personnel. A copy is retained on each patient care unit and in all departments of the hospital. 3. Safety plan manual. The potential hazards and identifiable situations that may cause injury to a caregiver or patient are described in the manual provided by the hospital safety committee. Plans for fire or disaster drills and evacuation routes are outlined. 4. Material safety data sheets (MSDS). These detailed sheets describe chemicals used in the workplace and actions to take if they are spilled into the environment. Specific cleanup and disposal methods are outlined. Most facilities require a yearly review of the MSDS process. Individual MSDS sheets for specific chemicals are online at www.msds.com. 5. Disaster plan manual. This manual outlines the plans for both internal and external disasters. Both internal and external disasters require rapid activation of all services within the hospital. Personnel who are off duty will be called to the facility and assigned as needed. Command centers and communications will be critical stations for the entire facility to follow and respond. Triage protocol will be followed carefully as defined by the facility. a. An internal disaster is an event that happens within the facility (e.g., an explosion, a fire) and requires employee assistance for control of the situation and evacuation of personnel and patients. An evacuation plan should be part of this planning structure because in-process surgeries cannot be abruptly halted and simply carried out of the building. b. An external disaster is an event that happens outside the confines of the facility (e.g., the World Trade Center terrorist actions of September 11, 2001). An external disaster could also be a natural phenomenon such as an earthquake or an accident (e.g., a train wreck). c. A combined internal-external disaster such as Hurricane Katrina is complex and may have multiple stages of resolution. Extremes of patient casualties may be brought in only to find the facility is to capacity in census. In some circumstances the facility may be out of communication with surrounding communities because of power failure or flooding and cannot easily reroute patients to a safe receiving hospital. 6. Infection control manual. This manual contains the policies and procedures designed to minimize the risk of infection and control the spread of disease within the health care facility. It includes state, local, federal, and professional standards for the protection of the patient and the caregiver. 7. Perioperative policy and procedure manual. This manual, usually a hardcover ringed binder, contains the policies pertaining solely to the administration and operation of the perioperative environment. A copy is available for reference in the manager’s office, at the control desk, or in both places. The primary purpose of the perioperative policy and procedure manual is to detail why and how procedures should be specifically performed within the perioperative environment. It includes both supportive activities and practices that involve direct perioperative patient care. 8. Orientation manual. This manual is designed to acquaint personnel with the environment, policies, and procedures specific to performance and the position descriptions of all personnel in the department. 9. Instrument book. The individual instruments and trays required for each surgical procedure are listed in a central processing computer or in a separate book that is kept in the instrument processing area. Photographs or catalog illustrations help instrumentation personnel identify the vast number of instruments and how they are compiled into sets. Flash cards and educational instrument textbooks are commercially available. 10. Surgeon’s preference cards/case cart sheet. A preference card is maintained in a computerized database or written note card for each surgical procedure that each surgeon performs. The surgeon’s specific preferences and any variance from the procedures in the procedure book are listed on these cards. The cards are revised as procedures and personal preferences for new technology change. A set of these cards is kept readily available in a central file or in a computer under the surgeon’s name, and they are pulled for each day’s surgical procedures. In preparing for each surgical procedure, nurses and surgical technologists consult both these cards and the procedure book. A surgical central supply department may use these cards to pack a case cart for each individual procedure. Box 2-2 shows sample case cart sheet components incorporating the surgeon’s preference card. 11. Directories. Alphabetic listings of the location of supplies and equipment are maintained for the instrument room, general workroom, sterile supply room, and general perioperative storage areas. Regardless of where the storage areas are located, personnel should know the location of supplies and equipment. Directories save time in trying to locate items. The initial 19 items require oral confirmation at three critical points during perioperative patient care that include: (1) the “sign in” before induction of anesthesia, (2) “time out” before skin incision, and (3) “sign out” before the patient leaves the OR. The universal checklist provides a means for documentation of each step of care for patients undergoing invasive and noninvasive surgical procedures. AORN has incorporated the Joint Commission’s 2010 Patient Safety Goals and Universal Protocol into the WHO Surgical Safety Checklist to create a Comprehensive Surgical Checklist (Fig. 2-1). Before making the incision the entire team pauses for a time out as the surgical site listed on the consent form is read aloud. The entire team confirms that this is correct information and that any scans or x-rays reflecting the same body part are displayed in the correct orientation. During this process the availability of the correct implants or special equipment is confirmed (Box 2-3).
Foundations of perioperative patient care standards
Surgical conscience
Patient rights
Patient advocacy
Standardization of patient care
Importance of standardization
Professional sources of standards
Standards from regulatory bodies
Sources of standardization data within the health care facility
Recommended practices
Universal protocol
Identifying the surgical site
Foundations of perioperative patient care standards
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