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Restraints Q and A

Hello, everyone. I was just doing some research on restraint and seclusion issues for an upcoming story and thought that you might be interested in the information below. The following are from the Q and A period from our Interpretive Guidelines audio conference just a few months ago, with Susan Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety for the Via Christi Wichita (KS) Health Network.

If you’re interested, the full audio conference is actually available for download (along with other recent accreditation programs) here. Susan is also joining AHAP’s own chairperson, Jodi Eisenberg, for a more indepth look at restraints from both the Joint Commission and CMS angle in March.

Q: If a patient is in restraints and it looks like he can do without them, and I take them off, can I then put them back on, if after 30-40 minutes it looks like he is going to need them after all?

Susan Hendrickson (SH): No, you may not. That is called a trial release. And trial release constitutes an as-needed (PRN) situation. Once a staff members ends an order to restraint intervention that the staff member has no authority to reinstate, without a new order. Using that example, if the patient is released because the staff assess that he or she didn’t need to be in restraint and later the patient exhibits that behavior…They have to go back and get an order, then you are using PRN, which is absolutely prohibited by both the CMS and The Joint Commission.

Q: What if the patient is removed from the restraints before the time limit for the physician to come in and assess them? Does the physician still have to come in and assess them?

SH: No, you can go ahead and remove the restraints. The physician is going to have to come in and assess that, in order to give the order. That’s the one thing about the time limit. The time limit is maximum time and it’s not minimum time. Actually, you are better off if you are able to get the patient out of restraints before the time limit ends. So no, that’s fine to take the patient out of the restraints ahead of time. The physician is going to have to document and agree with you that that short period of time where the patient was in restraints that he or she also agrees that was okay with the patient.

Q: If a patient has been assessed for needing a chemical restraint and you cannot order a chemical restraint as PRN, does the nurse have to call every four hours if they feel they need it or would the doctor write an order for a chemical restraint?

SH: The nurse would have to call. That is correct. The doctor doesn’t have to come in. The order can be removed for up to 24 hours so the physician wouldn’t have to come back in each and every time the nurse would have to call.

Q: With regards to education requirements, does the CMS want to see specialized training for the people who would provide restraint education to staff across the facility?

SH: Yes, you’re going to have to show that the staff member who is providing the training is competent.

You can develop training within your own hospital that’s not specific but you are going to have to show that staff maybe have education. Maybe you sent them for some specialized education, maybe they have completed some kind of course, something like that. It is not prescriptive as to what you have to do. But you need to be able to delineate that in your policy as to what makes a person confident. It may be that you do a train-the-trainer kind of thing.

Top medical device errors

Hi blog readers,

Although this posting isn’t specifically accreditation-related, I thought you might find the ECRI’s list of top 10 medical device hazards of 2008. The list is as follows:

  • Alarm hazards
  • Needlesticks and other sharps injuries
  • Air embolism from contrast media injectors
  • Retained devices and fragments left in patients
  • Surgical fires
  • Anesthesia hazards related to poor equipment inspection prior to use
  • Misleading displays on equipment
  • High radiation levels associated with CT scan
  • MRI burns
  • Fiberoptic light-source burns, usually from endoscopes, retractors, and head lamps

This year’s list differed from last years in that five new hazards were added. The ECRI institute does not want hospital staff members to think that those hazards left off the list this year are no longer problems–instead the institute felt that they should highlight some new concerns this year. Last year’s list also included burns during electrosurgery, caster failures, infusion pump programming errors, misconnection of blood pressure monitors to IV lines, and radiation therapy errors.

Do you see these hazards occurring in your facilities? How have you tried to make sure they don’t occur?

To read the ECRI Institute’s full report, click here.

IHI’s 20th annual National Forum on Quality Improvement

Hi blog readers,

I wanted to update you about the Institute for Healthcare Improvement’s latest campaign, launched last week at the 20th annual National Forum on Quality Improvement:

IHI launches newest quality improvement campaign

Piggybacking on its predecessors, the “100,000 Lives” and “5 Million Lives” campaigns, the Institute for Healthcare Improvement’s (IHI) latest quality improvement effort, the “Improvement Map,” adds new initiatives for hospitals to take part in to improve patient care. Introduced at the 20th annual National Forum on Quality Improvement in Healthcare last week in Nashville, TN, the Improvement Map hopes to incorporate and move beyond some of the earlier interventions, which mostly focused on preventing unnecessary death within hospitals.

Don Berwick, MD, MPP, FRCP, president of the IHI, introduced the Improvement Map to forum attendees, highlighting three new interventions that have been immediately added to the existing 12 from previous campaigns. These are:

  • Implementing the World Health Organization’s surgical safety checklist to prevent surgical errors

  • Improving patient safety by linking financial strategies to quality improvement projects

  • Preventing catheter-associated urinary tract infections

Berwick challenged attendees to “the sprint,” by asking them to implement the surgical safety checklist in one operating room in every hospital in the country within the next 90 days to have an immediate effect on patient safety. Other interventions will be added in the coming months to the new campaign.

To find out more about this campaign, click here.

Speaking to that second bullet point, Ken Rohde’s session at the 3rd annual AHAP conference, taking place May 14-15 2009 in Las Vegas, will focus on leadership strategies for improving quality within hospitals. To find out more about the conference, click here.

NPSG update


I just wanted to make sure everyone was aware that The Joint Commission updated its Facts about the National Patient Safety Goals page, summing up what changes and updates we can expect to see in 2009 surrounding the NPSGs.

On a related note, senior Greeley Company consultants Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, and WendySue Woods, RN, MHSA, CSHA, will be presenting on the NPSGs at the upcoming AHAP Conference:

Making the 2009 NPSGs Come to Life:  There have been many new additions to the 2009 NPSGs, including new goals about patient identification for blood transfusions, infection control and prevention, and medication reconciliation. Learn how proven strategies for compliance with these, as well as the existing goals.

If you haven’t had a chance yet, check out the full agenda for this year’s conference here.

Joint Commission changes standards as part of deeming authority application

The Joint Commission announced yesterday that, as part of its application to the Centers for Medicare & Medicaid Services (CMS), a number of changes will be made to the accreditation process.

Industry experts have noted that many of the changes are requirements hospitals already meet due to existing state or other regulatory requirements. According to The Joint Commission’s announcement, many of the requirements are already being met by accredited facilities.

“A lot of these [requirements] are current law or regulation,” says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.

Di Giacomo-Geffers suggests facilities compile a list of the changes to see which changes the hospital already complies with–a checklist of yes, no, or not applicable.

“If the answer is no, you’re not complying with the requirement, then ask, what do we need to make this happen?” she says.

Many of the changes have resulted in added specificity to existing standards, though others have required the creation of entirely new standards. All changes go into effect immediately. These requirements will not be scored, however, until July 2009. The Joint Commission has a policy that it will, when possible, give its accredited organizations six months notice for new requirements.

The Joint Commission’s official announcement can be found here. The new requirements can be downloaded here.

Stay tuned to the AHAP Blog for further analysis on this issue in the coming days.

AHAP Conference update

Hello, everyone. We’ve just completed this year’s full-color AHAP Conference brochure, and we wanted to share an advance copy with our members. We’re very proud of the conference we’re putting together for you this year and excited to have the chance to meet with everyone again in May.

Make sure to keep an eye out for the print brochure, which will be arriving in the next few weeks. But for now, please take a look at here if you’d like an early preview of what we’re offering at this year’s AHAP Conference.

New Sentinel Event posted

Hello, everyone. The Joint Commission has released its latest Sentinel Event Alert, this time on errors related to the use of technology in the healthcare setting.

The Alert states that there is very little data documenting the frequency with which technology-related errors occur, but notes that computers and automated medication dispensing devices are frequently involved when an error occurs. The Alert also advocates using Joint Commission Information Management standards to improve the use of technology in the healthcare environment.

The Joint Commission suggests 13 steps to prevent healthcare technology errors, including training for new users and refresher courses for those who continue to use technology in the hospital, and clearly defining who is authorized and responsible for the technology. Their complete press release and additional information can be found here.

Agenda for AHAP conference posted

Hello AHAP blog readers,

The Agenda for the 2009 AHAP annual conference has been posted (click here to see the full agenda). I thought you might like to know about a few highlights:

As listed below, we’ll be having an accreditation panel with speakers from the Joint Commission, HFAP, and DNV.

Additionally, both days of the conference will start out with a general session (after the keynote speaker on the first day). Day one’s session will be lead by Ken Rohde, a Senior Consultant for The Greeley Company. He’ll talk about the 2009 Joint Commission leadership standards and how your facility’s leaders can emphasize creating a culture of safety.

The second day’s general session will be lead by Kurt Patton, principal at Patton Healthcare Consulting. He’ll be discussing The Joint Commission’s scoring changes for 2009.

Hope to see you at the conference!

CMS proposes changes to wrong site, wrong patient, wrong surgery rules

Hello, everyone. The Centers for Medicare & Medicaid Services (CMS) issued several proposed decision memos yesterday indicating they will not pay for wrong site/patient/surgery cases. The proposed decision memos can be found on the CMS Web site at the following links:

Surgery on the Wrong Body Part

Surgery on the Wrong Patient

Wrong Surgery Performed on a Patient

Exclusive panel discussion on the options for healthcare accreditation

Our 2009 conference will include a special session featuring executives from The Joint Commission, DNV Healthcare Inc., and the Healthcare Facilities Accreditation Program.

Speakers will include Ann Scott Blouin, PhD, RN, Executive Vice President in the Division of Accreditation and Certification Operations at The Joint Commission, Patrick Horine, Executive Vice President of Accreditation Services at DNV Healthcare Inc., Rebecca Wise, Chief Operating Officer at DNV Healthcare Inc., and George A. Reuther, Chief Operation Officer at the Healthcare Facilities Accreditation Program.

Each organization will have 15 minutes to present, followed by 45 minutes of Q&A. Join us for what will undoubtedly be an interesting discussion on how all three organizations are changing accreditation in healthcare.