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Action to take when a surgeon oversteps privileges
JCAH
Action to take when a surgeon oversteps privileges
Q
The other day a surgeon was performing surgery for which he had privileges. During surgery, he discovered a condition he did not know existed. It was not an emergency. Even though he did not have privileges to perform this procedure, he performed the additional surgery. His reasoning was that he did not want to subject the patient to the hazards of anesthesia again. Not only did he not have appropriate privileges, but the patient had not consented to the additional surgery. To make matters worse, the surgeon did a poor job. As OR supervisor, what should I have done? I know that JCAH does not permit a surgeon to perform a procedure for which he has no privileges.
A
Many conscientious OR supervisors find themselves in the position you described. Because the surgeryturned out poorly, it is tempting to say you should not have allowed the surgery to proceed. The operation could have gone perfectly, but the issue remains. If a surgeon attempts to schedule surgery for which he has no privileges,you deal with the situation before surgery by contacting the chief of surgery or chief of staff for assistance. If an emergency arises during the course of surgery, the issue is clear-the surgeon must do everything possibleto save a life or prevent serious harm no matter what his privileges are. In your situation though, you probably did the best you could. However, you should have
468
immediately notified the chief of surgery, administration, and the risk manager of the situation in progress.
Q
On evenings and weekends, the nursing supervisors have the OR nurse recover patients. The OR nurses do not feel qualified, but the supervisors will not listen. What do the JCAH standards say about situations like this?
A
The standards say that patients with the same diagnosis are entitled to the same safety and quality of care without regard to where care is given in the hospital and who gives the care. This includes patients in the recovery room. Recovery is a specialty. Some anesthetists send patients to the recovery room beforethey are extubated, and a remiss few expect the recovery room personnel to ventilate the patients. This requires current expertise. If your patients require such care, the hospital would be wise to keep the recovery room open 24 hours or call in recovery room personnel as necessary. If, on the other hand, the anesthetist does not leave until your patients are fully recovered, the hospital might offer the OR nurses or require them to take appropriate training in recovering patients. Anywhere patients are recovered, the personnel who recover them must have training in recovery.
Q
How can I make individual patient assignments to conform with JCAH standards?
A
JCAH says that a registered nurse must plan, supervise, and evaluate patient care, and
AORN Journal, September 1983, Vol38, No 3
that to the extent possible, a registered nursd make a patient assessment before assigning some parts of care to ancillary personnel. This means that a registerednurse should interview the patient before surgery and make a nursing assessment based on the patient’s needs and the surgery planned. This implies there is a care plan to ensure that the patient’sneeds are met while he/she is in the OR suite. Preoperative interviews by registerednurses need to be a part of the OR nursing program. Initial assessments are made during the preoperative interview, and assignments for each case are made matchingthe staff members’ qualifications to the patient‘s needs. A reassessment upon arrival in surgery is needed to ensure that the patient’s condition has not changed. Patient care assignments must take into consideration the risk of infection and accidental contamination. This aspect of the JCAH requirement is nearly second nature to most OR staff. Remember, though, the danger of infection is not from known problems but from unsuspected problems. When students and nurses who are not employees of the hospital perform nursing duties in the OR, the hospital and nursing service are responsible. This requirement is fairly easy to meet with students becausemost students are observers. Nursing personnel who are not hospital employees can be a real problem though. The principle is that all persons in the OR are bound by the hospital rules and must always comply with them. (See “JCAH,” AORN Journal, January 1983, for more information about JCAH standards on personnel who are not hospital employees.)
Q
What will the JCAH surveyor expect to see relating to staffingthe OR suite? What is a staffing pattern?
A The nurse surveyor will first look for a staffing pattern that includes the number of personnelassignedto the OR service by category, time frames, and designated areas. Designated areas would include specific places, such as recovery room and sterile processing. A staffing pattern differs from a schedule in that the schedule includes individual names
460
and details of coverage for each day of the week. It covers a definite period. A staffing pattern gives the number and categories of individuals needed to conduct OR service activities. It is similar to the informationneeded to develop a budget. Generally, the staffing pattern includes “budgeted bodies” rather than real bodies. In reality, there may be vacancies in certain positions. When this happens, a person may be assigned duties higher than those of hidher category. Show the surveyor the budgeted positions and how they are currently filled or not filled. According to JCAH, staffing must be based on “patient care requirements, staff expertise, unit geography, availability of support services, and methods of patient care delivery.” Patient care requirements include the number and complexity of cases performed as well as patient’s needs. Staff expertise relates to categories of personnel and the expertise of individualswithin those categories. The JCAH standards mandate that only registerednurses can circulate. Unit geography refers to the actual layout of the unit. Some OR suites are well planned, and others are like a maze and require extra personnel to run smoothly. Availability of support services affects how large the OR staff needs to be. If OR personnel do the cleaning, more personnel are needed than if housekeeping does it. If OR personnel clean and steam sterilize their equipment and supplies, more employees are needed. If OR personnel are responsible for taking specimens to the laboratory and picking up blood from the laboratory, extra help may be required. The method of patient care delivery depends upon the philosophy of how staff is assigned to patients. If your OR service uses primary care, staffing may be different than if one person is assigned to one room.
Jacqueline P Gary, RN Vice-president of professional services Dallas-Fort Worth Hospital Council Dallas
AORN Journal, September 1983, Vol38, No 3
Action to take when a surgeon oversteps privileges
Q
The other day a surgeon was performing surgery for which he had privileges. During surgery, he discovered a condition he did not know existed. It was not an emergency. Even though he did not have privileges to perform this procedure, he performed the additional surgery. His reasoning was that he did not want to subject the patient to the hazards of anesthesia again. Not only did he not have appropriate privileges, but the patient had not consented to the additional surgery. To make matters worse, the surgeon did a poor job. As OR supervisor, what should I have done? I know that JCAH does not permit a surgeon to perform a procedure for which he has no privileges.
A
Many conscientious OR supervisors find themselves in the position you described. Because the surgeryturned out poorly, it is tempting to say you should not have allowed the surgery to proceed. The operation could have gone perfectly, but the issue remains. If a surgeon attempts to schedule surgery for which he has no privileges,you deal with the situation before surgery by contacting the chief of surgery or chief of staff for assistance. If an emergency arises during the course of surgery, the issue is clear-the surgeon must do everything possibleto save a life or prevent serious harm no matter what his privileges are. In your situation though, you probably did the best you could. However, you should have
468
immediately notified the chief of surgery, administration, and the risk manager of the situation in progress.
Q
On evenings and weekends, the nursing supervisors have the OR nurse recover patients. The OR nurses do not feel qualified, but the supervisors will not listen. What do the JCAH standards say about situations like this?
A
The standards say that patients with the same diagnosis are entitled to the same safety and quality of care without regard to where care is given in the hospital and who gives the care. This includes patients in the recovery room. Recovery is a specialty. Some anesthetists send patients to the recovery room beforethey are extubated, and a remiss few expect the recovery room personnel to ventilate the patients. This requires current expertise. If your patients require such care, the hospital would be wise to keep the recovery room open 24 hours or call in recovery room personnel as necessary. If, on the other hand, the anesthetist does not leave until your patients are fully recovered, the hospital might offer the OR nurses or require them to take appropriate training in recovering patients. Anywhere patients are recovered, the personnel who recover them must have training in recovery.
Q
How can I make individual patient assignments to conform with JCAH standards?
A
JCAH says that a registered nurse must plan, supervise, and evaluate patient care, and
AORN Journal, September 1983, Vol38, No 3
that to the extent possible, a registered nursd make a patient assessment before assigning some parts of care to ancillary personnel. This means that a registerednurse should interview the patient before surgery and make a nursing assessment based on the patient’s needs and the surgery planned. This implies there is a care plan to ensure that the patient’sneeds are met while he/she is in the OR suite. Preoperative interviews by registerednurses need to be a part of the OR nursing program. Initial assessments are made during the preoperative interview, and assignments for each case are made matchingthe staff members’ qualifications to the patient‘s needs. A reassessment upon arrival in surgery is needed to ensure that the patient’s condition has not changed. Patient care assignments must take into consideration the risk of infection and accidental contamination. This aspect of the JCAH requirement is nearly second nature to most OR staff. Remember, though, the danger of infection is not from known problems but from unsuspected problems. When students and nurses who are not employees of the hospital perform nursing duties in the OR, the hospital and nursing service are responsible. This requirement is fairly easy to meet with students becausemost students are observers. Nursing personnel who are not hospital employees can be a real problem though. The principle is that all persons in the OR are bound by the hospital rules and must always comply with them. (See “JCAH,” AORN Journal, January 1983, for more information about JCAH standards on personnel who are not hospital employees.)
Q
What will the JCAH surveyor expect to see relating to staffingthe OR suite? What is a staffing pattern?
A The nurse surveyor will first look for a staffing pattern that includes the number of personnelassignedto the OR service by category, time frames, and designated areas. Designated areas would include specific places, such as recovery room and sterile processing. A staffing pattern differs from a schedule in that the schedule includes individual names
460
and details of coverage for each day of the week. It covers a definite period. A staffing pattern gives the number and categories of individuals needed to conduct OR service activities. It is similar to the informationneeded to develop a budget. Generally, the staffing pattern includes “budgeted bodies” rather than real bodies. In reality, there may be vacancies in certain positions. When this happens, a person may be assigned duties higher than those of hidher category. Show the surveyor the budgeted positions and how they are currently filled or not filled. According to JCAH, staffing must be based on “patient care requirements, staff expertise, unit geography, availability of support services, and methods of patient care delivery.” Patient care requirements include the number and complexity of cases performed as well as patient’s needs. Staff expertise relates to categories of personnel and the expertise of individualswithin those categories. The JCAH standards mandate that only registerednurses can circulate. Unit geography refers to the actual layout of the unit. Some OR suites are well planned, and others are like a maze and require extra personnel to run smoothly. Availability of support services affects how large the OR staff needs to be. If OR personnel do the cleaning, more personnel are needed than if housekeeping does it. If OR personnel clean and steam sterilize their equipment and supplies, more employees are needed. If OR personnel are responsible for taking specimens to the laboratory and picking up blood from the laboratory, extra help may be required. The method of patient care delivery depends upon the philosophy of how staff is assigned to patients. If your OR service uses primary care, staffing may be different than if one person is assigned to one room.
Jacqueline P Gary, RN Vice-president of professional services Dallas-Fort Worth Hospital Council Dallas
AORN Journal, September 1983, Vol38, No 3