The perioperative patient care team and professional credentialing

Chapter 4


The perioperative patient care team and professional credentialing



Chapter objectives


After studying this chapter, the learner will be able to:


• Define the concept of the sterile team.


• Define the concept of the nonsterile team.


• Describe the role of the circulating nurse.


• Describe the role of the scrub person.


• Describe the credentialing process for perioperative nurses.


• Describe the credentialing process for surgical technologists.



Key terms and definitions



Anesthesia provider 


Member of the nonsterile team who administers anesthetics during the surgical procedure; may be a physician (MD, DO), anesthesia assistant (AA), or a specially trained and certified registered nurse anesthetist (CRNA).


Certification 


A method of professional evaluation and recognition of an individual for meeting educational, practice, and national standard parameters that range above minimal competency.


Circulating nurse 


Perioperative Registered Nurse (RN) member of the nonsterile team who directs and coordinates the activities of the intraoperative environment during the surgical procedure. Role involves patient assessment, planning, and critical thinking skills.


Credentials 


Validation of professional recognition, such as licensure or certification.


Delegation 


A registered nurse or physician can assign and supervise tasks performed by an LPN/LVN, ST, or other UAP, provided the tasks are not intended for a licensed individual’s scope of practice and are within the capabilities of the person being assigned the tasks.


Licensure 


Governmental regulation of approval to practice in a specific profession to provide specific services. Practicing without a license is illegal and punishable by law. Some license renewals include attainment of continued education in the profession. Licensure is designed to ensure minimal competency of the licensee for the benefit of protecting the safety and welfare of the public. The laws that define the scope of practice governing a registered professional are called practice acts.


Nonsterile team 


Intraoperative caregivers who provide direct care from the periphery of the sterile field and environment; do not wear sterile attire (i.e., radiology technician, anesthesia technologist).


Perianesthesia nurse 


RN who renders care in the preoperative and postoperative environment. Member of the nonsterile team.


Registration 


Establishing a record of name, address, and qualifications of a professional with a state authority. This does not establish standards of practice, does not require a certain entry level, and does not provide for continued competency verification or continued education.


Scrub person 


Member of the sterile team who passes instruments and facilitates the surgical procedure. Is a surgical technologist (ST), registered nurse (RN), or licensed practical or vocational nurse (LPN/LVN).


Sterile team 


Intraoperative caregivers who provide direct care within the sterile field; wear sterile attire (i.e., surgeon, first assistant, scrub person).


Surgeon 


Physician (e.g., MD, DO, DDS, DPM) who performs the surgical procedure.


Surgical assistant 


Member of the sterile team who provides exposure and hemostasis during a surgical procedure. Is a physician, registered nurse first assistant (RNFA), surgical assistant (SA), physician assistant (PA), or certified surgical technologist specially trained and certified as a first assistant (CST/CFA).



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Dependence of the patient on the qualified team


The perioperative team works to promote the best interests of the patient every single minute. For the welfare and safety of the patient, the entire team must work efficiently as a functioning single unit. The members should be thoroughly familiar with procedures, setups, equipment, and policies and should be able to cope with the unpredictable. Their qualifications must be beyond reproach. They should have a high morale, mutual understanding, trust, cooperation, and consideration. Anyone who cannot function wholeheartedly as a qualified team member has no place in the OR.


All OR personnel should have the proven knowledge, skill, competency, and ability to perform at an optimal level at all times. The validation of clinical competence is an important aspect of providing safe patient care. Once each member of the team has passed the novice stage, other criteria demonstrate and document the knowledge and skills gained through experience and continuing education. Aligning professionally with local, state, and nationally recognized organizations that establish the standards of practice provides an opportunity for growth. Credentialing and certification may include completing a course of instruction or meeting certain criteria and passing an examination. Other measurements of competence include performance evaluations in a clinical setting.



Credentialing of qualified caregivers


Credentialing refers to the processes of accreditation, licensure, and certification of institutions, agencies, and individuals. These processes establish quality, identity, protection, and control for the competency-based education and performance of professional and allied technical health care personnel. Credentialing also protects the public from fraudulent practitioners.1,5



Accreditation of schools and facilities


An accrediting body of a voluntary organization evaluates and sanctions an educational program or an institution as meeting predetermined standards and/or essential criteria. The National League for Nursing (NLN) accredits schools of nursing. Surgical technology programs are accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) after a satisfactory review and recommendation by the Accreditation Review Council on Education in Surgical Technology and Surgical Assisting (ARC/STSA).


The United States Government Department of Education has been accepted by the National Board of Surgical Technology and Surgical Assisting (NBSTSA) as an accepted accrediting body. The Accrediting Bureau of Health Education Schools (ABHES) accredits many colleges and vocational settings in the United States. Certifying and licensing bodies require graduation from an accredited program before eligibility criteria are met to take professional certification or licensing exams.


The Joint Commission (TJC) accredits hospitals and ambulatory care centers. Other professional organizations offer accreditation for special-interest groups.



Licensure and registration


A license to practice is granted to professionals by a governmental agency, such as the state board of nursing or medicine. Licensure implies a certain amount of appropriate independence in actions. On completion of a formal academic education, nurses and physicians who successfully pass a state examination receive a license to practice in that state. To maintain this license, they must register with the state as required by law; hence the term registered nurse. Licensed practical/licensed vocational nurses (LPN/LVNs) also are licensed.


Most states grant a license by reciprocity or endorsement to applicants who wish to practice in their state but who took the examination in another state.3 Some states require licensure for some categories of allied health occupations, such as physical therapists.


Licensure is not offered on an indefinite basis. Applicants apply for renewal at specific time intervals determined by each state. Many states require proof of continuing education for nurses and physicians as a prerequisite for eligibility of relicensure.


Registration is a method of state regulation of practice parameters and designation for disciplinary action. Perioperative nurses are registered as well as licensed.



Certification


A nongovernmental private organization can award a credential that attests to level of knowledge above minimal competency of an individual who meets predetermined qualifications. Certification may be defined as documented validation of an individual’s professional achievement of knowledge and skill in identified standards. To be certified is to demonstrate the attainment of more than minimal competency; it is a statement of certification-level knowledge.


Certification is granted for a limited time. To retain this credential, an individual must complete the recertification process established by the certifying body. For recertification, some certifying organizations require a specified number of clinical hours, continuing education contact hours, a written examination, or a combination of these in a portfolio format. Maintaining certification by going through this process demonstrates a high level of motivation and commitment.2


Physicians, nurses, and allied health care personnel may be certified by their professional specialty association as being competent in knowledge and skills to practice. Applicants take an examination that tests knowledge in the area of specialization.



Perioperative patient care team


The perioperative patient care team is like a symphony orchestra, with each person an integral entity in unison and harmony with professional colleagues to accomplish the expected outcomes. Communication using a comprehensive surgical checklist can provide a seamless interface between patient care areas and minimize the risk of error (see Fig. 2-1). Preoperatively, the perianesthesia nurse initiates the use of the comprehensive surgical checklist and performs the preoperative assessment. The surgeon should mark the surgical site with indelible ink marker. The patient is transferred to the care of the surgical team and information concerning the patient’s condition is communicated verbally and in writing.


In the OR, the patient is surrounded by the surgeon, the surgical assistant, the scrub person, the anesthesia provider, and the circulating nurse. Before the procedure begins the OR team takes a “timeout” and reaffirms the correct patient is having the correct surgery on the correct body part. The circulating nurse documents this collaboration.


Postoperatively, the perianesthesia nurse receives information from the circulating nurse and the anesthesia provider concerning the surgical procedure and the patient’s condition. The patient remains in the postanesthesia care unit (PACU) until his or her physiologic status is deemed stable by the anesthesia provider.


These individuals, each with specific functions to perform, form the perioperative patient care team. (More information is available at www.aspan.org; the role of the perianesthesia nurse is described in more detail in the postoperative section in Chapter 30.)


U.S. Medicare and Medicaid regulations Title 42, Public Health, describe conditions for participation of individuals in surgical services departments. In Chapter IV, Part 482, Section 482.51, the regulation states that the OR must be supervised by an experienced registered nurse (RN) and that the circulator must be an RN. It further states that an LPN/LVN and surgical technologists may serve as scrub nurses or assist with circulating duties under the supervision of the qualified RN (a copy in of the Center for Medicare and Medicaid Services (CMS) regulation is available at www.aorn.org/publicpolicy/currentlaws/rncirculator).



Nonsterile and sterile team members


The perioperative team is subdivided according to the functions of its members:



The team also may include biomedical technicians, specialty technicians, and others who may be needed to set up and operate specialized equipment or monitoring devices during the surgical procedure. Specialty technicians are usually considered separately from the main sterile and nonsterile team members. They may not enter the sterile field.


Sterile team members perform a surgical scrub on their hands and arms, don a sterile gown and gloves, and enter the sterile field. The sterile field is the area of the OR that immediately surrounds and is specially prepared for each individual patient. To establish and maintain a sterile field, all items needed for the surgical procedure are sterile and handled in a sterile manner. Only sterile items and personnel dressed in sterile attire may enter the sterile field.


Nonsterile team members do not enter the sterile field; they function outside and around it. They assume responsibility for maintaining sterile and aseptic techniques during the surgical procedure. They handle supplies and equipment that are not considered sterile. Following the principles of aseptic technique, they keep the sterile team supplied, provide direct patient care, and handle situations that may arise during the perioperative care period.



Nonsterile team members




Anesthesia provider.

Anesthesia and surgery are two distinct but inseparable disciplines; they are two parts of one medical entity. Adequate communication between the surgeon and the anesthesia provider is the patient’s greatest safeguard. The anesthesia provider is an indispensable member of the perioperative team. Functioning as a guardian of the patient’s physiology throughout the entire care period, the anesthesia provider manages the patient’s medication, vital signs, and generalized well-being. Throughout this text the term anesthesia provider is used to refer to the person responsible for inducing and maintaining anesthesia at the required levels and managing untoward physiologic reactions throughout the surgical procedure. Medically delegated functions of an anesthetic nature are performed under the overall supervision of a responsible physician or in accordance with state regulations and individual written guidelines approved within the health care facility.


An anesthesiologist is an MD or DO, preferably certified by the American Board of Anesthesiology, who specializes in administering anesthetics to produce various states of anesthesia. To become eligible for certification, physicians complete a 2-year anesthesia residency program after successful completion of medical school. The term anesthetist refers to a qualified RN, anesthesiologist assistant (AA), dentist, or physician who administers anesthetics.


An RN is required to have a minimum of a bachelor’s degree in nursing or science for entrance into a school of nurse anesthesia. To become a certified registered nurse anesthetist (CRNA), a graduate of an accredited nurse anesthesia program (a minimum of 2 years) is required to have a master’s degree in nursing and pass the certification examination of the Council on Certification of Nurse Anesthetists. Nurse anesthetists are recertified every 2 years.


An anesthesia assistant (AA) is a master’s prepared nonphysician, non-nurse anesthetist who administers anesthesia under the direction of an anesthesiologist. The AA’s education consists of a baccalaureate in biologic science and 2 additional years of specialty training in biophysical science. More information on the AA degree is available online at www.anesthetist.org.


Some anesthesia providers prefer to specialize in one area, such as cardiothoracic or obstetric anesthesia. The latter involves the simultaneous care of two patients—the mother and the neonate. In some settings, anesthesia providers participate in teaching and research as well as in clinical practice.


Anesthesia providers are not confined to the perioperative environment, but this is their primary arena. In addition to providing anesthesia during surgical procedures, anesthesia providers oversee the PACU until each patient has regained control of his or her vital reflexes. They also participate in the hospital’s program of cardiopulmonary resuscitation as teachers and team members. They are consultants or managers for problems of acute and chronic respiratory insufficiency that require respiratory therapy, as well as for a variety of other fluid, electrolyte, and metabolic disturbances that require intravenous (IV) therapy through a central venous catheter. In the intensive care unit or emergency department, their advice may be sought regarding the total care of unconscious, critically ill, or injured patients with acute circulatory disorders or neurologic deficits. Anesthesia providers also are integral staff members of pain therapy clinics.

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Apr 6, 2017 | Posted by in GENERAL SURGERY | Comments Off on The perioperative patient care team and professional credentialing

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