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Private scrub nurse credentialing; role of the registered nurse first assistant; needle count omissions
JUNE 1992, VOL 55, NO 6
AORN JOURNAL
-
Clinical Issues Private scrub nurse credentialing; role of the registered nurse first assistant; needle count omissions
Q
uestion: A new group of cardiothoracic surgeons has joined the staff at the hospital where I am director of surgical services. This group has its own scrub nurses; no other surgeons in this facility use private scrubs. I am not opposed to this, but I am not sure what credentialing procedures are needed for these nurses. Does AORN have a recommendation for a credentialing process? Who should be on the credentialing committee? What should the committee’s policy include?
A
nswer: AORN does not have a recommendation for a credentialing policy; however, the AMHI92 Accreditation Manual f o r Hospitals, published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has a chapter on medical staff that addresses credentialing. Individuals applying for privileges usually are licensed physicians and may include other licensed individuals permitted by law and by the hospital to provide patient care services independently in the hospital.’ The JCAHO says there must be a mechanism to ensure that all individuals with clinical privileges provide services within the scope of the privileges granted.2 Each department is responsible for developing its own criteria for granting privileges. Because private scrub nurses are not employed by the hospital, credentialing through the medical staff policies is one method for ensuring the competence of these individuals. The credentialing process for private scrub nurses will vary from hospital to hospital. A
good place to start is writing a policy statement that identifies the targeted individuals. Then state the purpose of the credentialing policy. Try to identify specific information that is pertinent to the job the individuals will be doing. Use the employment application that your human resources department would use if this person was applying for employment for the same type of job. Information to obtain includes a copy of his or her nursing license, educational qualifications, professional work history, references, certification, professional liability (eg, carrier name, copy of policy, amount of coverage, liability history, other coverage), and Advanced Cardiac Life Support certification if appropriate. Applications submitted by private scrub nurses normally are reviewed by the hospital credentialing committee. When applications submitted by private scrub nurses are being reviewed, the director of surgical services should be present and should have a voice in the approval or denial of practice privileges. The nursing care chapter of the JCAHO accreditation manual states, The determination of a nursing staff member’s current clinical competence and the assignment of nursing care responsibilities are the responsibility of registered nurses who have the clinical and managerial knowledge and experi1575
AORN JOURNAL
JUNE 1992, VOL 5 5 , NO 6
An RN applying for first assistant priv leges in a hospital must meet that insti ution’s credentialing process requirements. ence to competently make these decision~.~ After the applicant is granted privileges, he or she should receive a copy of the policies and procedures of the operating room that are appropriate for the work that he or she will be doing. The director of surgical services then has the responsibility to make certain these individuals comply with the policies as any staff nurse would.
Q
uestion: As the director of an operating room, I have been asked by several surgeons to hire registered nurse first assistants (RNFAs). We are not affiliated with a surgical residency program, and surgeons have to use other physicians to assist on procedures in which a non-physician could have assisted. The role of the RNFA is new to me. Does AORN have information on the scope of RNFA practice, qualifications, and practice privileges?
A
nswer: AORN has an official statement on RN first assistants. This statement defines the role and scope of practice for the nurse acting as first assistant as part of his or her perioperative nursing practice. The RN first assistant assists the surgeon during surgery and practices perioperative nursing. He or she has acquired the knowledge, skills, and judgment necessary to practice under the direct supervision of the surgeon through organized instruction and supervised p r a ~ t i c e . ~ The scope of practice for the RN first assistant may include handling tissue, providing exposure, using instruments, suturing, and providing hemo~tasis.~ When the registered nurse is practicing as a first assistant, he or she does not concurrently 1576
function as a scrub nurse. The role and scope of practice for the RNFA will vary according to institutional policy and the nurse practice act in the state in which the nurse practices. Qualifications of the RN first assistant should include proficiency in the scrub and circulating roles; knowledge of the principles of aseptic technique; knowledge of anatomy, physiology, and operative technique on procedures in which the RN assists; ability to perform cardiopulmonary resuscitation; ability to perform effectively in stressful and emergency situations; and ability to meet the statutes, regulations, and institutional policy requirements that pertain to the RN first assistanL6 The registered nurse who pursues the first assistant specialty can receive additional preparation through structured education programs. This can include didactic and supervised clinical learning activities or independent study with didactic and supervised clinical components.’ An RN applying for first assistant privileges in a hospital must meet that institution’s credentialing process requirements. Some of the requirements may be the same as mentioned in the credentialing process for private scrub nurses. Additional requirements may include qualifications for practice, performance evaluation, and documentation of participation as a first assistant.x
Q
uestion: A cardiac surgeon has requested that we no longer count needles on his procedures. This surgeon uses very small nee-
AORN JOURNAL
dles (eg, 5-0, 6-0, 7-0). He says these needles are too small to be seen on x-ray, therefore, we would not be able to find one if it was lost. I disagree with this and have asked for verification that needles of this size would not show up on x-ray. He has not given me any verifiable information that would substantiate changing our count policy, which states that needles will be counted on all cardiac cases. Does AORN have any information to document that these needles are too small to be seen on x-ray?
A
nswer: AORN does not have information that would verify that 5-0, 6-0, and 7-0 needle sizes are too small to be seen on x-ray. If your policy states that all needles are to be counted for cardiac cases, then your policy should be followed. You may want to work with your radiology department to determine if what this surgeon is saying is true. The radiologist will be able to take an x-ray of the needles in question and verify whether they would be seen on an x-ray should a needle loss occur. When a surgeon accepts privileges in an institution, he or she agrees to abide by the policies and procedures of the institution. If there are documented reasons to make an exception to a specific policy, then the policy should be modified to reflect the changes in practice. The AORN recommended practices state that Written and approved policy may be established within the practice setting allowing subsequent counts to be deleted i f significant risk for retention or harm from sharps does not exist.9 If the policy is not changed, then it should be strictly adhered to. MARYO’NEALE,FW,BS, CNOR PERIOPERATIVE NURSING SPECIALIST CENTERFOR PRACTICE Notes 1. Joint Commission on Accreditation of Healthcare Organizations, “Medical staff,” AMH/92 Accreditation Manual f o r Hospitals (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 1992) 55. 1578
JUNE 1992, VOL 5 5 , NO 6
2. Ibid, 56. 3. Joint Commission on Accreditation of Healthcare Organizations, “Nursing care,” AMH/92 Accreditation Manual f o r Hospitals (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organization, 1992) 81. 4. Association of Operating Room Nurses, Inc, “AORN official statement on RN first assistants,” AORNJournal51 (June 1990) 1599-1600. 5. Ibid, 1600. 6. Ibid. 7. Ibid. 8. Ibid. 9. “Recommended practices for sponge, sharp, and instrument counts,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1992) III:19-1.
0PTI-GARD
TM
Protect Patient Eyes Protect your patients’ eyes during general anesthesia against corneal abrasion, lacerations and scleral hemorrhage with OPTI-GARDTMeye covers. These rigid, clear plastic protective covers are supplied with a non-allergenic selfadhesive foam cushion for fast and accurate application. A vital consideration in ENT, head and neck surgery, OPTI-GARDTMprotects the eyes from blood, fluid and other foreign materials. A disposable safeguard, OPTI-GARDrM is sterile packaged. For protection of patient eyes, OPTI-GARD? u s PATENT NO 4 122 847 25 per box Part No. 2831 0 GREGORY JORDAN Operations Manager
DUPACO
(619 1 756-4550 F a x (619 1 941 -0843
2620 Temple Heights Drive Oceanside. CA 92056
AORN JOURNAL
-
Clinical Issues Private scrub nurse credentialing; role of the registered nurse first assistant; needle count omissions
Q
uestion: A new group of cardiothoracic surgeons has joined the staff at the hospital where I am director of surgical services. This group has its own scrub nurses; no other surgeons in this facility use private scrubs. I am not opposed to this, but I am not sure what credentialing procedures are needed for these nurses. Does AORN have a recommendation for a credentialing process? Who should be on the credentialing committee? What should the committee’s policy include?
A
nswer: AORN does not have a recommendation for a credentialing policy; however, the AMHI92 Accreditation Manual f o r Hospitals, published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has a chapter on medical staff that addresses credentialing. Individuals applying for privileges usually are licensed physicians and may include other licensed individuals permitted by law and by the hospital to provide patient care services independently in the hospital.’ The JCAHO says there must be a mechanism to ensure that all individuals with clinical privileges provide services within the scope of the privileges granted.2 Each department is responsible for developing its own criteria for granting privileges. Because private scrub nurses are not employed by the hospital, credentialing through the medical staff policies is one method for ensuring the competence of these individuals. The credentialing process for private scrub nurses will vary from hospital to hospital. A
good place to start is writing a policy statement that identifies the targeted individuals. Then state the purpose of the credentialing policy. Try to identify specific information that is pertinent to the job the individuals will be doing. Use the employment application that your human resources department would use if this person was applying for employment for the same type of job. Information to obtain includes a copy of his or her nursing license, educational qualifications, professional work history, references, certification, professional liability (eg, carrier name, copy of policy, amount of coverage, liability history, other coverage), and Advanced Cardiac Life Support certification if appropriate. Applications submitted by private scrub nurses normally are reviewed by the hospital credentialing committee. When applications submitted by private scrub nurses are being reviewed, the director of surgical services should be present and should have a voice in the approval or denial of practice privileges. The nursing care chapter of the JCAHO accreditation manual states, The determination of a nursing staff member’s current clinical competence and the assignment of nursing care responsibilities are the responsibility of registered nurses who have the clinical and managerial knowledge and experi1575
AORN JOURNAL
JUNE 1992, VOL 5 5 , NO 6
An RN applying for first assistant priv leges in a hospital must meet that insti ution’s credentialing process requirements. ence to competently make these decision~.~ After the applicant is granted privileges, he or she should receive a copy of the policies and procedures of the operating room that are appropriate for the work that he or she will be doing. The director of surgical services then has the responsibility to make certain these individuals comply with the policies as any staff nurse would.
Q
uestion: As the director of an operating room, I have been asked by several surgeons to hire registered nurse first assistants (RNFAs). We are not affiliated with a surgical residency program, and surgeons have to use other physicians to assist on procedures in which a non-physician could have assisted. The role of the RNFA is new to me. Does AORN have information on the scope of RNFA practice, qualifications, and practice privileges?
A
nswer: AORN has an official statement on RN first assistants. This statement defines the role and scope of practice for the nurse acting as first assistant as part of his or her perioperative nursing practice. The RN first assistant assists the surgeon during surgery and practices perioperative nursing. He or she has acquired the knowledge, skills, and judgment necessary to practice under the direct supervision of the surgeon through organized instruction and supervised p r a ~ t i c e . ~ The scope of practice for the RN first assistant may include handling tissue, providing exposure, using instruments, suturing, and providing hemo~tasis.~ When the registered nurse is practicing as a first assistant, he or she does not concurrently 1576
function as a scrub nurse. The role and scope of practice for the RNFA will vary according to institutional policy and the nurse practice act in the state in which the nurse practices. Qualifications of the RN first assistant should include proficiency in the scrub and circulating roles; knowledge of the principles of aseptic technique; knowledge of anatomy, physiology, and operative technique on procedures in which the RN assists; ability to perform cardiopulmonary resuscitation; ability to perform effectively in stressful and emergency situations; and ability to meet the statutes, regulations, and institutional policy requirements that pertain to the RN first assistanL6 The registered nurse who pursues the first assistant specialty can receive additional preparation through structured education programs. This can include didactic and supervised clinical learning activities or independent study with didactic and supervised clinical components.’ An RN applying for first assistant privileges in a hospital must meet that institution’s credentialing process requirements. Some of the requirements may be the same as mentioned in the credentialing process for private scrub nurses. Additional requirements may include qualifications for practice, performance evaluation, and documentation of participation as a first assistant.x
Q
uestion: A cardiac surgeon has requested that we no longer count needles on his procedures. This surgeon uses very small nee-
AORN JOURNAL
dles (eg, 5-0, 6-0, 7-0). He says these needles are too small to be seen on x-ray, therefore, we would not be able to find one if it was lost. I disagree with this and have asked for verification that needles of this size would not show up on x-ray. He has not given me any verifiable information that would substantiate changing our count policy, which states that needles will be counted on all cardiac cases. Does AORN have any information to document that these needles are too small to be seen on x-ray?
A
nswer: AORN does not have information that would verify that 5-0, 6-0, and 7-0 needle sizes are too small to be seen on x-ray. If your policy states that all needles are to be counted for cardiac cases, then your policy should be followed. You may want to work with your radiology department to determine if what this surgeon is saying is true. The radiologist will be able to take an x-ray of the needles in question and verify whether they would be seen on an x-ray should a needle loss occur. When a surgeon accepts privileges in an institution, he or she agrees to abide by the policies and procedures of the institution. If there are documented reasons to make an exception to a specific policy, then the policy should be modified to reflect the changes in practice. The AORN recommended practices state that Written and approved policy may be established within the practice setting allowing subsequent counts to be deleted i f significant risk for retention or harm from sharps does not exist.9 If the policy is not changed, then it should be strictly adhered to. MARYO’NEALE,FW,BS, CNOR PERIOPERATIVE NURSING SPECIALIST CENTERFOR PRACTICE Notes 1. Joint Commission on Accreditation of Healthcare Organizations, “Medical staff,” AMH/92 Accreditation Manual f o r Hospitals (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations, 1992) 55. 1578
JUNE 1992, VOL 5 5 , NO 6
2. Ibid, 56. 3. Joint Commission on Accreditation of Healthcare Organizations, “Nursing care,” AMH/92 Accreditation Manual f o r Hospitals (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organization, 1992) 81. 4. Association of Operating Room Nurses, Inc, “AORN official statement on RN first assistants,” AORNJournal51 (June 1990) 1599-1600. 5. Ibid, 1600. 6. Ibid. 7. Ibid. 8. Ibid. 9. “Recommended practices for sponge, sharp, and instrument counts,” AORN Standards and Recommended Practices for Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1992) III:19-1.
0PTI-GARD
TM
Protect Patient Eyes Protect your patients’ eyes during general anesthesia against corneal abrasion, lacerations and scleral hemorrhage with OPTI-GARDTMeye covers. These rigid, clear plastic protective covers are supplied with a non-allergenic selfadhesive foam cushion for fast and accurate application. A vital consideration in ENT, head and neck surgery, OPTI-GARDTMprotects the eyes from blood, fluid and other foreign materials. A disposable safeguard, OPTI-GARDrM is sterile packaged. For protection of patient eyes, OPTI-GARD? u s PATENT NO 4 122 847 25 per box Part No. 2831 0 GREGORY JORDAN Operations Manager
DUPACO
(619 1 756-4550 F a x (619 1 941 -0843
2620 Temple Heights Drive Oceanside. CA 92056