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AFT2 Task 1
Christian Fisher
Western Governors University

AFT2 Task 1 A. Compliance Status
During the last Joint Commission survey two years ago, there were several areas of deficiency surrounding the use of moderate or deep sedation or anesthesia. These noted deficiencies gave Nightingale Community Hospital the opportunity to revamp and strengthen our procedures in all areas of peri-operative services. These include the Main OR, CVOR (Cardiovascular OR), Interventional Labs (Cardiac Catheterization and Interventional Radiology), and Endoscopy Suites. Significant process has been made especially in the area of the Time Out. A Time Out is the step by which all work in the particular surgical area halts and everyone in the suite actively participates in ensuring that for the current surgery we have: 1. Correct patient. 2. Correct side and site. 3. Correct procedure to be done. 4. Correct patient position. 5. Correct implants and equipment. All of the Peri-Op services procedural areas brought members of their teams to participate in brainstorming and development sessions in the area of the Time Out to ensure that it was robust and all encompassing.
As well, some of these components and other important details should actually be completed prior to the patient’s arrival in the surgical suite. While the Time Out is an effective last act before a surgery proceeds, many other details should and must be completed long before that. This ensures the safety of the patient and our staff.
This has led to significant improvements under the Joint Commission standards for Universal Protocol in the area of Communication. There is now a system wide Pre-Procedure Handoff for Peri-Op Services that ensures all of the key elements are covered and the communication of all pertinent information is documented from the hand-off nurse to the accepting Peri-Op nurse. The patient cannot be accepted into the Peri-Op area unless this checklist document is completely filled out. As well, internal audit has demonstrated that we are now consistently performing this communication and robust Time Out before all Peri-Op procedures 100% of the time.
A1. Plan for Compliance While all of these efforts are excellent and laudable, there still remains one area of key concern for the Peri-Op areas that was noted at our last survey. At that last survey it was discovered that patients had procedures without an evaluation of airway prior to moderate sedation. In our efforts to ensure that this area was addressed, a check item was placed on the Pre Procedure Checklist that ensures that a patient is seen by an Anesthesia provider and the subsequent form is completed and placed on the chart. This is effective for cases in which Anesthesia is involved (deep sedation and general anesthesia) but it does not address the issue of Moderate Sedation. Moderate or Conscious Sedation involves the use of simple analgesics and sympathomimetics to achieve a “twilight” state for the patient which reduces or eliminates pain and controls anxiety. The medications are administered by a Registered Nurse (RN) under the order and direction of a certified procedural physician. While the risk of complication as a result of the administration of these medications is much less than that of deeper sedation or general anesthesia, there is still significant risk of airway compromise as not all patients react the same to these agents. Therefore, another area that needs to be addressed on the Pre-Procedure Checklist is that of an airway assessment with Mallampati score (see Figure 1). This needs to be documented by the procedural physician on each patient that would receive moderate sedation (World Health Organization [WHO], 2008). This record is automatically included in the documentation completed by the Anesthesia providers, but it is not currently part of the usual documentation of the interventional proceduralists. Therefore we have created a Moderate Sedation documentation form that will be utilized for all Moderate Sedation cases. Completion of the form will be added to the Pre-Procedure Checklist to ensure that it is present and completed on all patients that Moderate Sedation applies. This will ensure our compliance with the Joint Commission standard. We will then track each case and watch for compliance and fall-out. This will take place over the next 3 months well ahead of our next Joint Commission review.
Figure 1.

A2. Justification While all of our current efforts in the area of the Time-Out are exemplary and necessary, this documentation of the airway prior to moderate sedation is essential for the safety of the patient and the success of the procedure. It will help secure the intended outcome of the procedure while reducing the risk of airway associated complications. Again drawing on the WHO (2008) there are several of the Ten Essential Objectives that pertain directly to our goal in this matter. They are: “2. The team will use methods known to prevent harm from administration of anesthetics, while protecting the patient from pain. And, 3. The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function.” By completing this form and ensuring effective hand-off communication, the various teams in the Peri-Op area will be able to plan for various contingencies long before the patient arrives in the theater. Thus, if the there is an area of significant concern, the team can raise those issues with the interventionalist and anesthesia long before we reach the final stage of the Time Out. This will ensure that patient safety is paramount and that we meet all Joint Commission standards in the area of Communication. It will also reduce complications, recovery time, and financial concerns over those complications and increased length of stay.

World Health Organization. (2008). WHO Guidelines for Safe Surgery (2008.08-1E). Retrieved from

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