JC Source: Hospital Accreditation Standards 2007 Provision of Care, Treatment, and Services NOTE: Selected content from these standards are reflected below, for a complete review of the standards please see pages 155-218 of the JC Hospital Accreditation Standards 2007 Manual Standards for Additional Special Procedures
Standards for Operative or Other High-Risk Procedures and/or the Administration of Moderate or Deep Sedation or Anesthesia Operative or other procedures and the administration of sedation or anesthesia often occur simultaneously. However, procedures do occur without sedation, and sedation or anesthesia is administered for noninvasive procedures (hyperbaric treatment, CT scan, MRI). Therefore, the following standards address both operative or other procedures and/or the administration of moderate or deep sedation of anesthesia. Whenever an operative or other procedures is conducted, whether or not sedation or anesthesia is administered, appropriate patients must be involved in planning for and providing care to the patient. All procedures carry risk, but that risk is increased when sedation or anesthesia is administered. The standards for sedation and anesthesia care apply when patients in any setting receive, for any purpose by any route, the following: General, spinal, or other major regional sedation and anesthesia or Sedation (with or without analgesia) that, in the manner used, may be reasonable expected to result in the loss of protective reflexes Because sedation is a continuum, it is not always possible to predict how an individual patient receiving sedation will respond. Therefore, each hospital develops specific, appropriate protocols for the care of patients receiving sedation. These protocols are consistent with professional standards and address at least the following: Sufficient qualified individuals present to perform the procedures and to monitor the patient throughout administration and recovery Appropriate equipment for care and resuscitation Appropriate monitoring of vital signs heart and respiratory rates and oxygenation Documentation of care Monitoring of outcomes Definitions of four levels of sedation and anesthesia include the following: Minimal sedation (anxiolysis). A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and
coordination may be impaired, venilatory and cardiovascular functions are unaffected. Moderate sedation/analgesia (conscious sedation). A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanies by light tactile stimulation. No interventations are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep sedation/analgesia. A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation. The ability to independently maintain ventilatory functions may be impaired. Patients may require assistance in maintained a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Anesthesia. Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a druginduced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Standard PC.13.20 Operative or other procedure and/or the administration of moderate or deep sedation or anesthesia are planned. Rationale for PC.13.20 Because the response to procedures is not always predictable and sedation-to-anesthesia is a continuum, it not always possible to predict how an individual patient will respond. Therefore, qualified individuals are trained in professional standards and techniques to manage patients in a case of a potentially harmful event. Elements of Performance for PC.13.20 1. Sufficient numbers of qualified staff are available* to evaluate the patient, perform the procedures, monitor, and recover the patient. 2. Individuals administering moderate or deep sedation and anesthesia are qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. A registered nurse supervises perioperative nursing care. Appropriate equipment to monitor the patients physiologic status is available. Appropriate equipment to administer intravenous fluids and drugs, including blood and blood components, is available as needed.
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Resuscitation capabilities are available.
Before operative and other procedures or the administration of moderate or deep sedation or anesthesia: 7. 8. Patient acuity is assessed to plan for the appropriate level of postprocedure care. Preprocedural education, treatments, and services are provided according to the plan for care, treatment, and services. The site, procedure, and patient are accurately identified and clearly communicated, using active communication techniques, during a final verification process, such as time out, prior to the start of any surgical or invasive procedure. A presedation or preanesthesia assessment is conducted. Before sedating or anesthetizing a patient, an LIP with appropriate clinical privileges plans or concurs with the planned anesthesia. The patient is reevaluated immediately before moderate or deep sedation and before anesthesia induction.
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Standard PC.13.30 Patients are monitored during the procedure and/or administration of moderate or deep sedation or anesthesia. Elements of Performance for PC.13.30 1. Appropriate methods are used to continuously monitor oxygenation, ventilation, and circulation during procedures that may affect that patients physiological status. 2. The procedure and/or the administration of moderate or deep sedation or anesthesia for each patient are documented in the medical record. Standard PC.13.40 are Patients monitored immediately after the procedures and/or administration of moderate or deep sedation or anesthesia. Standard PC.13.50 Electroconvulsive therapy is used with adequate justification, documentation, and regard for patient safety. Elements of Performance for PC.13.50 1. Written policies regulate electroconvulsive therapy.
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Whenever electroconvulsive therapy is used, the procedure is adequately justified and documented in the patients medical record. Before initiating electroconvulsive therapy for a child or youth, two qualified, experienced child psychiatrists who are not directly involved in treating the child or youth do the following: Examine the child or youth Consult with the psychiatrist responsible for the child or youth Document their concurrence with the treatment in the childs or youths medical record Written consent for any electroconvulsive therapy is obtained from the patient and documented in the clinical/case record.
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Standard PC.13.60 Psychosurgery or other surgical treatments for emotional, mental, or behavioral disorders are performed with adequate justification, documentation, and regard for patient safety. Elements of Performance for PC.13.60 1. Written policies and procedures regulate psychosurgery or other surgical treatments for mental, emotional, or behavioral disorders. 2. Whenever these procedures are used, they are adequately justified and documented in the patients medical record.
Standard PC.13.70 Use of behavior management procedures conforms to the patients treatment plan and hospital policy. Rationale for PC.13.70 Behavior management and treatment interventations should be therapeutic interventions that foster adaptive behaviors and not used exclusively for behavior control. Policies and procedures should require that the selection of interventions consider both appropriateness and minimizing restrictiveness of interventions. Elements of Performance for PC.13.70 1. When behavior management procedures are used, they are included in the patients plan for care, treatment, and services. 2. Written policies describe the following: The conditions under which specific behavior management procedures can be used and when they should not be used That any behavior management and plan for care, treatment, and services that includes the use of aversive procedures is reviewed and approved by
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both appropriate clinical leaders and a person(s) external to the hospital, such as an outside expert, an advocate, or a human rights committee That no procedure that physically hurts or is a psychological risk to the patient is allowed Time-outs are limited to no more than 30 minutes Time-outs occur in an unlocked room Time-outs educate the patient about the condition under which time-outs are used Time-outs prohibit the use of intimidation, force, or threat
At a minimum, the following are prohibited: Procedures that deny any basic needs, such as nutritional diet, water, shelter, and essential, safe, and appropriate clothing Corporal punishment Fear-eliciting procedures Any behavior management and treatment intervention implemented by another patient Mechanical restraint and seclusion The hospital uses educational and positive reinforcement techniques (for example, alternative adaptive behaviors) wherever possible. When more restrictive techniques are clinically necessary, the least restrictive alternative is used to avoid harm to the patient. The hospital protects the patients physical safety. Patients and, as appropriate, their families participate in selecting behavior management and treatment interventions. Other individuals may assist in implementing a patients behavior management program only as follows: If it is conducted as part of a structured treatment plan If it is conducted under the sup...