ASPAN Standards and Practice Recommendations Update

1. ASPAN Standards and Practice Recommendations Update 3:45 – 5:00 PM

2. Objectives • Identify 4 elements needed to prove malpractice. • Identify the role ASPAN Standards have in your every day practice in caring for patients in the perianesthesia arena.

3. Standards of Care • All professions have standards of care • Minimal level of expertise that must be delivered to the patient • Starting point for acceptable nursing care

4. Standards of Care • Set internally or externally • Internal pertain to individual practitioner or institution • External pertain to nurses in all states and territories • Helps define scope of practice

5. Standards of Care • Found in • State nurse practice act • Published standards of professional organizations and specialty practice groups (ASPAN, AORN, ANA, ENA, AACN) • Federal agency guidelines and regulations • Hospital policy and procedure manuals • Individual nurse’s job description • Manufacturer’s published materials • Inservice films/materials

6. Standards of Care • Nurses are accountable for all standards of care as they pertain to their profession • To maintain competence and skill • Read professional journals • Attend pertinent continuing nursing education programs

7. Standards of Care • Determined for the judicial system by expert witnesses • ‘Court sees deviations from nursing standards’ • Experts testify to the prevailing standards in the community • These are standards that all nurses are accountable for matching or exceeding • Adherence to such standards ensures that patients receive quality, competent nursing care

8. Standards of Care • In specialty practice areas • Courts are almost universally holding health care providers to a national standard of care • Reasons • All have access to same information/educational opportunities • Most important: all patients have the right to quality health care regardless of where that care is delivered - small or large, rural or urban

9. Rule or standard of human conduct Established and enforced by authority, society or custom Tells us what we can and cannot do Statutory: Passed by federal or state legislature Public: constitutional, administrative and criminal law; private or civil; relationship with one another LAW

10. Tort Law • Concerns wrongful act, damage or injury done • Civil suit can be brought • Malpractice falls in this category

11. LEGAL ISSUE DEFINITIONS • TORT - “CIVIL WRONGDOING” • INTENTIONAL • Assault: Threat to do bodily harm • Battery: Committing bodily harm • Invasion of Privacy • False Imprisonment • Defamation • Inflicting Emotional Stress

12. LEGAL ISSUE DEFINITIONS • TORT - “CIVIL WRONGDOING” • NONINTENTIONAL • PROFESSIONAL NEGLIGENCE- Failure to do what reasonably prudent person under similar circumstances would do. • MALPRACTICE - Improper or negligent treatment resulting in damages/injury.

13. LEGAL ISSUE DEFINITIONS • RESPONDEAT SUPERIOR • “Let the Master speak” Hospital held liable for any damages that result from negligence of one of it’s employees. • RES IPSA LOQUITUR • “The thing speaks for itself” Negligence has been done

14. Legal Issue considerations • Time Out • Verification just before procedure starts • Right Patient • Right site • Right procedure • Correct positioning • Availability of implants or special equipment • Documentation “Time-out” taken • Risk Management

15. LIABILITY • 4 elements of negligence for liability suit • DUTY: Need to be professional relationship between health care provider and health care consumer. • BREACH of DUTY: Damages must be due to negligence • DAMAGE: There must be an injury (damages- physical, mental, financial) • CAUSES: Damages must be direct and proximate result of negligence

16. PACU LIABILITY • Failure to monitor • Failure to communicate • Errors in use of equipment • Errors in medication and treatment • Patient falls • Failure to follow orders/exercise independent judgment • Patient Safety

17. Current ASPAN Standards 2010-2012 Perianesthesia Nursing Standards and Practice Recommendations 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements

18. 2012-2014 Standards • This updated text contains • standards of perianesthesia nursing practice, • evidence-based clinical practice guidelines, • practice recommendations, position statements, • resources from partnering organizations • interpretive statements.

19. ASPAN Standards Include • Standards: generic statements which best describe the desirable and achievable level of performance • Guidelines: developed from systematic review of literature and research, a prime tool for evidence based practices, and require frequent updating as new information becomes available • Practice Recommendations: which best describe the desirable and achievable level of performance expected of perianesthesia registered nurses.

20. ASPAN Standards Include • Position Statements: represent an organization’s viewpoint on a particular issue • Resources: recommendations for practice based primarily on expert consensus, expertise and opinion from partnering organizations • NEW: INTERPRETIVE STATEMENTS provided in sidebar format offer clarification, definitions and examples

21. What are your needs? What would make your practice easier? What would make patient care safer?

22. 2012-2014 Standards • Effective December 2012 • Revised and expanded • Includes: • Scope of Practice • Principles of Perianesthesia Practice • Ethical Practice • Safety • 6 Standards • 3 Clinical Practice Guidelines (posted on web site) • 10 Practice Recommendations • 10 Position Statements • 3 Resources

23. 2012-2014 Changes Introduction expanded Introduced the sidebar concept for Interpretive Statements New*** Interpretive Statements: this format allows for the opportunity to provide clarification and add detail to the context of the standards

24. Scope of Perianesthesia Nursing Practice • Preanesthesia level of care • Preadmission • Day of surgery/procedure • Postanesthesia levels of care • Phase I • Phase II • Extended Care • Settings

25. Perianesthesia Standards for Ethical Practice • Competency, responsibility to patients, professional responsibility, collegiality, research, advocacy • Application to practice • Nurse refuses to attend unit inservices - always staffs so others can attend • Witness break in sterile technique while procedure performed, remains quiet

26. Principles of Safe Perianesthesia Practice • ASPAN’s core values for a culture of safety include • Communication • Advocacy • Competency • Efficiency • Timeliness • Teamwork

27. 2012 - 2014 Standards I. Patient Rights • Practice is based on concepts that recognize & maintain individual • Autonomy • Confidentiality • Privacy • Dignity • Worth

28. Standard I: Patient Rights Case Nurse loses position for breach of confidentiality through computer entry into patient files including diagnostics & other privileged information. Hospital/facility has policy regarding patient confidentiality

29. 2012 - 2014 Standards II. Environment of Care • Perianesthesia nursing practice promotes and maintains a safe, comfortable and therapeutic environment.

30. Standard II Environment of Care Case • QI shows increased PONV when preoperative and postoperative patients are mixed in same room. • Mother transports infant home without second person in auto. Child has obstructed airway.

31. 2012 - 2014 Standards III. Staffing and Personnel Management • Appropriate number of RNs with demonstrated competence in each level of care based on • Patient acuity • Census • Patient flow process • Physical facility

32. Staffing and Personnel ManagementApplication to Practice • Usual daily patient population over age 18; 1 to 3 pediatric patients per week (under age 7) • All nurses ACLS provider status • Do the nurses need PALS provider status?

33. Standard III Staffing & Personnel Management Case Child has orthopedic surgery. Arrives in PACU where only one nurse is available to care for patient. 2nd nurse is changing clothes in the dressing room. Anesthesiologist leaves patient with PACU nurse to set up for next case. Patient is non-responsive and ultimately has respiratory arrest after anesthesiologist leaves the PACU.

34. 2012 - 2014 Standards IV. Quality Improvement • RN monitors and evaluates care • Areas for improvement are resolved through a collaborative multidisciplinary approach

35. Standard IV QI Case Monitored pain levels in patients in ambulatory setting. Same anesthesiologist for patients with increased pain. Had no narcotics in the O.R. It was his practice in anesthesia delivery. Department of Anesthesia reviewed cases and looked at pain management within the department.

36. 2012 - 2014 Standards V. Research and Clinical Inquiry • Includes: • Research • Evidence-based practice • QI initiatives • Small tests of change that test innovation

37. Standard V Research & Clinical Inquiry Case • When ASPAN did one of the initial Delphi studies, it was discovered that the Aldrete scoring system had not been validated. • Since that time the scoring system has been changed.

38. 2012 - 2014 Standards VI. Nursing Process • Applied to each patient • Assessment • Planning • Implementation • Evaluation

39. Standard VI Nursing Process Case 9 month M&T brought to Phase I for recovery. Given appropriate dose of Fentanyl but immediately discharged to Phase II. In mother’s arms in Phase II the nurse could not get adequate reading on pulse oximeter. Stated “This equipment has not been working right.”

40. Standard VI Nursing Process Case • While child held by mother, became obtunded. When the mother told the nurse the child was having trouble breathing, it was too late.

41. Standard VI Nursing Process Case Pt develops compartment syndrome after orthopedic procedure on leg. Upon review of charting, there is no evidence of any capillary refill or pulse checks of lower extremities. Assessment data not documented - so juries concur: if not documented, not done.

42. Clinical Practice Guidelines • Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia • Clinical Guideline for Pain and Comfort • Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV • All guidelines available on ASPAN Web Site. (www.aspan.org)

43. Practice Recommendations • Patient Classification/Staffing Recommendations 1A. Staffing Recommendation and Management of the Patient on Precautions

44. PR 1 - Patient Classification/ Staffing Recommendations • SIDEBAR: • It is difficult to prescribe staffing ratios for the day of surgery/procedure units based on wide variations across the country in the role and function of the nursing staff in these units. • When considering staffing patterns, patient safety is of highest priority with plans to accommodate patients with high acuity needs.

45. PR 1 - Patient Classification/ Staffing Recommendations • SIDEBAR: • The intent of this standard is that a nurse providing care to a Phase I patient is not left alone with the patient. • The second nurse should be able to directly hear a call for assistance and be immediately available to assist.

46. PR 1 - Patient Classification/ Staffing Recommendations • SIDEBAR: • Appropriate staffing requirements should be met to prioritize the safe, competent nursing care for the immediate postanesthesia patient, or the patient with the highest level of care needs, in addition to the care of the blended patient population. • Patient safety is of highest priority.

47. Practice Recommendations • Components of Initial, Ongoing, and Discharge Assessment and Management changed to Components of Assessment for the Perianesthesia Patient • Equipment for Preanesthesia/Day of Surgery Phase, PACU Phase I, Phase II, and Extended Care • Recommended Competencies for the Perianesthesia Nurse

48. Practice Recommendations • Competencies of Perianesthesia Support Staff • Safe Transfer of Care: Handoff and Transportation • The Role of the RN in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures

49. Practice Recommendations 49 Fast Tracking the Ambulatory Surgery Patient Visitation in the Perianesthesia Care Unit NEW***Obstructive Sleep Apnea in the Adult Patient

50. 2012-2014 Retirements • Position Statements • Minimum Staffing in Phase I PACU • Has a PR • The Nursing Shortage • Visitation in Phase I • Has a PR • Perianesthesia Safety • Elevated to Perianesthesia Principles