ASPAN Standards and Practice Recommendations Update

3:45 – 5:00 PM

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.

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

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

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

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

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

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

LAW

• 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

Tort Law

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

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

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.

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

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

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

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

Current ASPAN Standards2010-2012 Perianesthesia Nursing Standards and Practice Recommendations

2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements

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.

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.

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

What are your needs?

What would make your

practice easier?

What would make

patient care safer?

Clinical Practice

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

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

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

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

Principles of Safe Perianesthesia Practice

• ASPAN’s core values for a culture of safety include – Communication– Advocacy– Competency– Efficiency– Timeliness – Teamwork

2012 - 2014 StandardsI. Patient Rights

– Practice is based on concepts that recognize & maintain individual• Autonomy• Confidentiality• Privacy• Dignity• Worth

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

2012 - 2014 Standards

II. Environment of Care– Perianesthesia nursing practice promotes and

maintains a safe, comfortable and therapeutic environment.

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.

2012 - 2014 StandardsIII. 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

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?

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.

2012 - 2014 Standards

IV. Quality Improvement– RN monitors and evaluates care– Areas for improvement are resolved through a

collaborative multidisciplinary approach

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.

2012 - 2014 Standards

V. Research and Clinical Inquiry– Includes:

• Research• Evidence-based practice• QI initiatives• Small tests of change that test innovation

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.

2012 - 2014 Standards

VI. Nursing Process– Applied to each patient

• Assessment• Planning• Implementation• Evaluation

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.”

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.

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.

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)

Practice Recommendations

1. Patient Classification/Staffing Recommendations

1A. Staffing Recommendation and Management of the Patient on Precautions

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.

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.

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.

Practice Recommendations2. Components of Initial, Ongoing, and

Discharge Assessment and Management changed to Components of Assessment for the Perianesthesia Patient

3. Equipment for Preanesthesia/Day of Surgery Phase, PACU Phase I, Phase II, and Extended Care

4. Recommended Competencies for the Perianesthesia Nurse

Practice Recommendations5. Competencies of Perianesthesia Support

Staff

6. Safe Transfer of Care: Handoff and Transportation

7. The Role of the RN in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures

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Practice Recommendations

8. Fast Tracking the Ambulatory Surgery Patient

9. Visitation in the Perianesthesia Care Unit

10. NEW***Obstructive Sleep Apnea in the Adult Patient

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

Position Statements1. Perianesthesia Patient with a Do-Not-

Resuscitate Advance Directive2. Registered Nurse Utilization of

Unlicensed Assistive Personnel3. “On Call/Work Schedule”4. ICU Overflow

Position Statements5. Med-Surg Overflow6. Safe Medication Administration7. Older Adult8. Pediatric Patient9. Workplace Violence in the Perianesthesia

Settings

Position Statements10. NEW** Substance Abuse in Perianesthesia

Practice– Specialty practice areas have higher levels of

substance – These areas involve physical, emotional and/or

mental stress that may cause nurses to turn to substances

– Also have a rather wide range of access to and availability of controlled substances.

Resources1. Nine Provisions of the American Nurses Association

(ANA) Code of Ethics for Nurses with Interpretive Statements

2. American Society of Anesthesiologists (ASA) Standards: – Statement on Routine Preoperative Laboratory and

Diagnostic Screening– ASA Basic Standards for Preanesthesia Care – ASA Standards for Postanesthesia Care– NEW***ASA Standards for Basic Anesthetic

Monitoring

Resources

3. Association for Radiologic & Imaging Nursing (ARIN) Clinical Practice Guideline: Handoff Communication Concerning Patients Undergoing a Radiological Procedure with General Anesthesia

To Purchase Standards

ASPAN90 Frontage RoadCherry Hill, NJ 08034-1424Toll free 877.737.9696Fax 856.616.9601Email aspan@aspan.orgwww.aspan.org

Bibliography

• 2012-2014 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses, 2012

References• Atlee, John. Complications in Anesthesia. 2nd Edition.

Philadelphia: Saunders Elsevier. 20007• Cole, Daniel and Michelle Schlunt. Adult

Perioperative Anesthesia: The Requisites in Anesthesiology. Philadelphia: Mosby Elsevier. 2004

• Drain, Cecil and Jan Odom-Forren. Perianesthesia Nursing: A Critical Care Approach. 5th edition. St. Louis, MO: Saunders Elsevier. 2009

References

• Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care. Philadelphia: F.A. Davis Company. 2009

• Reed, Alan. Clinical Cases in Anesthesia. 2nd Edition. New York: Churchill Livingstone.1995

• Schick, Lois and Pamela Windle (Editors) PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd Edition. St. Louis, MO: Saunders Elsevier, 2010.

ONLINE References• His and hers heart disease accessed at

http://www.health.harvard.edu/fhg/updates/his-and-hers-heart-disease.shtml

• Obstructive Sleep Apnea. Accessed at www.CritCareMD.com• Pulmonary Disorders accessed at

http://dynamicnursingeducation.com/class.php?class_id=55&pid=18• Sutherland, Sara. “Pulmonary Embolism: Treatment and Medication”

at http://emedicine.medscape.com/article/759765-treatment• What is Obstructive Sleep Apnea (OSA)? Accessed at

http://www.medicalnewstoday.com/articles/178633.php

THANK YOULois Schick MN, MBA, RN, CPAN, CAPA12823 W. 3rd PlaceLakewood, CO 80228Home: 303-989-2281 Cell: 303-475-9854E-Mail: Schickles@aol.com