Restraint remains one of the most challenging issues in hospital accreditation today. To that end, Bud Pate, REHS, vice president for content and development at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Lisa Eddy, RN, CPHQ, CSHA, one of The Greeley Company’s senior consultants, recently fielded a series of questions during the HCPro audio conference “New Joint Commission Standards: Anesthesia, Restraints, and More.”
Q. Can you please tell us what makes a restraints trainer competent?
BP: It is your judgment. They have to have sufficient experience. If you read the CMS requirements, there is more guidance in the interpretive guidelines than what you find in the Joint Commission standards. There is no certification that is needed; it is internal judgment. And the internal judgment can be based on experience and knowledge.
The Joint Commission talks about sufficient experience, and CMS talks about experience and knowledge in the restraint process. We talked earlier about the three levels of training program. Level one requires almost no competency, because level one is for medical staff members, and all they need to know is the policy and enough to be able to explain the policy to the medical staff.
Level two is the trainer who teaches the new nurse orientees, because there has to be training prior to their first episode of restraint. Now, who is going to do that? Usually there is a preceptor, and if that preceptor has been judged competent and has experience on restraint, then that preceptor can train the next person on restraint. If they are on an ICU, then that preceptor or the person doing the orientation will have enough experience in restraint and will have the background to train people.
However, if restraint is done less frequently in some units, then you may have to have a clinical nurse specialist who has experience in the application of restraint. And it is not just following the policy that you are interested in, it is the safe applications such as how to put the restraint on in such a way that it is not going to hurt the patient and be the least bit restrictive. The other part of the training that is going to be important are the interventions that can be put into place instead of restraint.
However, the folks that are talking about the management of the violent or self-destructive behavior that puts the patient or others at immediate jeopardy, at behavioral healthcare you really should be deferring to someone with a lot of experience and training in behavioral healthcare restraint. Because again, in the behavioral healthcare you will probably be surrounded by someone who is qualified to do that.
When you are training someone in the emergency department, remember that you are going to want to talk about alternatives to restraints. It is probably not going to be a buddy system, and you are probably going to have to bring someone in from the behavioral health unit or setting to help train staff members to meet that requirement.
LE: For the level two type of restraint, many organizations—for example, a nursing or clinical orientation, or a clinical update that they do yearly, orientation obviously on new hire, where they have clinical instructors that repeat this process, month after month, week after week—show people how to apply restraints such as your typical medical, surgical, or approved protected restraint. And then after repeat demonstrations, I certainly think that would be acceptable with someone who has experience, and of course, these people would have to be approved competent to their ability to: a) do the teaching and b) do the actual application. For the emergency department behavioral health type of restraint, many times we see something like a CPI training program where takedown and de-escalation and application of more stringent leather type of restraints are provided.
Q. Does a discharge assessment by a sedation-credentialed RN meet the requirements for postanesthesia evaluation?
BP: This really stems from the CMS requirements. CMS does not say those requirements are specifically for the postanesthesia evaluation in the Interpretive Guidelines, which do not apply to sedation settings.
You can say, “This whole standard does not apply to sedation settings, but even if it did, we are doing a criteria-based evaluation.” The standard is asking you to look for pain, cardiovascular status, medical symptoms, and, in this case, other evidence of complications postsedation, and those are all things in the typical discharge process of the RN. I think that would be fine.
LE: I agree. CMS does not really include sedation in their definition of anesthesia. But The Joint Commission uses the words anesthesia and sedation together. On the CMS side, the sedation component is not an issue for the post evaluation. But we are not sure, because of the Joint Commission language, how easily they are going to look at these. So what you are doing right now is truly postsedation assessment. I think what you are probably looking at is that both the pre-and postsedation have to be by Joint Commission standards, with an individual qualified to administer anesthesia.
Q. If we have anesthesia update the H&P, do they need to be credentialed to do so? If so, can a CRNA be credentialed to perform an H&P?
LE: Depending on state laws on the scope of practice for the CRNA, there might be issues relating to that.
BP: Absolutely, they can be credentialed to do that. Most people don’t want them to do that, so you have to be fairly careful about how you do that. It is perfectly acceptable to privilege a CRNA or a PA, or an advanced practice nurse, to perform an H&P. It is not a problem.
LE: As long as it is within the scope of their state regulations, and many states allow CRNAs full functionality.
BP: They can be dependent practitioners. I am not aware of any states that would prohibit that.
LE: One thing we want to make sure is if you are allowing your anesthesia providers to do the H&P, there is an FAQ that they do have to have for that privilege.
BP: You can privilege, if the state is notwithstanding, then you can certainly give them that privilege.
I have a question regarding the anesthesia changes, specifically the postanesthesia evaluation and when it can be performed. I am puzzled because we consider PACU to be perioperative and we do our postop visits the following day, and I am not sure how you can allow a postop visit being a PACU.
BP: For outpatient procedures, the anesthesiologist does not have the opportunity. The postop call is not what they are talking about in this evaluation. The postop call—let’s say they go home and you call them the next day and say, “This is a courtesy call”—that is not what they mean by the post-anesthesia evaluation. A postanesthesia evaluation has to be done by an anesthesiologist and what they did in the old version, they only required it for inpatients because, when they were originally written, there was no opportunity to do this for outpatients.
The changes that came two years ago is they started applying this to outpatients, and as they applied this to outpatients, they had to realize that the evaluation may have to be done before the patient leaves and so they wrote into the guidelines that they may do this during the recovery process.