oldguy55

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So... we've just endured the latest rectal exam sans lubricant, by the Joint Commission. This place has been in a tizzy all week while I just try to do my job, a good job I think, and not put on a show for the retired pediatrician or whatever he was.


While the final tally is not in, I am told our department was cited for two issues that will require immediate action:

Our preanesthetic evaluation did not show evidence of a physical examination. Airway examination is there, but nothing else is routinely documented. Now, I know there is some debate on how important it might be to listen to the heart and lungs of every patient (I do know how to use the search function, so I've read some pretty feisty debates on SDN!). I have always said I do the exam that is indicated. It is just rarely indicated, in my experience. I always examine the airway and document that.

Upon reflection, though, perhaps buying a good stethoscope wouldn't be such a bad idea. I read the H&P done by my own surgeon (mentioning normal heart, lungs and abdomen) and know with certainty that the very first time his hands touched my body was when he put the 'scope in my butt. Heck, I don't think I have ever taken my shirt off in my primary care doc's office. I suspect if I did pull out a stethoscope it would be the first time most of my patients had been examined. It takes a few seconds, it might, just might, pick up something important, and maybe just reinforces that I am the "anesthesia doctor".


The second "deficiency" is goofy. We were cited because there was no post-anesthetic evaluation for the patient who had a labor epidural. Not a note saying I saw her walking in the hall and she hugged my neck and said she loves me. I mean the form we have been using for postop evaluations, documenting that mental status has returned to baseline, that cardiac and respiratory functions are normal, that temperature is normal, etc. etc. No amount of arguing that there is a difference between an anesthetic and a labor analgesic would convince the geniuses. Nor would the fact that none of the surveys in the past 20+ years has mentioned this.


Tell me the truth: are we out of step with these things? Do you document a physical exam on every patient? Do you write a note documenting recovery from every labor epidural? Do you complete a full post-anesthetic evaluation on every labor epidural patient?
 

PainDrain

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Call me crazy but I actually do listen to heart and lungs on all my patients. Had 60 yo hip fx last week who, after going through a complete hx, told me she had no PMHx other than mild RA. When I went to listen to her she had a 4/6 systolic murmur. I asked if she knew she had a murmur and her response was "yah, they said it was aortic....aortic ...something or other." So what if I didn't listen and the surgeon says "it's a quick pinning, how about a spinal?" Needless to say the case was an uneventful GA , but it's good to do it and document it.

Same with labor epidural situation. What if a year from now a woman comes forward claiming a "nerve injury"? I know it's BS but simply documenting "patient w/ no complaints, neurologically intact by exam" may save you.

Don't get me wrong, I hate the joint commission more than anyone but this stuff may help you.
 

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I find that listening to the heart is way more relevant than to the lungs. Most patients will know if they have lung disease, but will be oblivious about valvular disease/arrhythmia. I still listen to everything in most patients.
 
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1st deficiency: It is not uncommon to hear wheezing patients in the pre-op area. Anesthetizing an elective case who is having an acute asthma attack is indefensible in court. It's just good practice to do a focused physical exam. Now, if this JCAHO moron wants you do do a full physical exam, that is something different.

2nd deficiency: Someone should document when the labor epidural is out that there are no residual neurologic deficits, etc. Having said that, there is a big push in the ACOG to have the nurses 100% manage labor epidurals (including adjusting the dosing) after we put them in. And the ASA agrees with that (Google "joint asa acog consensus statement"). I've worked in places where the epidural is placed by the MD/CRNA, and that's it. You periodically check on the patient but the next time you see them they've had the baby and you're only collecting the already-separated paperwork.

The problem with JCAHO is, that as much as they will disagree, it still operates as a decidedly human endeavor rife with the same errors that all other humans suffer as part of our collective condition: failures of observation, interpretation, and relevance. You can have two separate JCAHO auditors come into a place and perform an audit and come up with completely different findings. This, as another example, has been a major complaint in industry of OSHA for decades.
 

Monty Python

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,,,, there is a big push in the ACOG to have the nurses 100% manage labor epidurals (including adjusting the dosing) after we put them in..
In my state, that's forbidden by the state nurse practice act. RNs are not allowed to do any adjusting other than turning off the epidural pump for delivery per OB's order, nor can they do any top-up bolus. Nothing to stop ACOG, BON, or a nurse organization from trying to get that changed, but it will require legislative approval and governor's signature.

The RNs will d/c the epidural for us if we're busy, and document blue tip intact. We still round on the pts after the RNs d/c the epidural and make a short close-out note. Unfortunately there's the occasional woman who gets the "drive through" vag delivery, who gets discharged before we can get back up there post-delivery to see them. We're not thrilled with that, but aren't in a position to fight it.
 
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Noyac

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Monty, do you bill for that visit? And more importantly do you actually collect anything?

We collect for intrathecal narc visits so it seems like this would be billable as well.

Another thought would be, could the nursing staff document recovery from the epidural in their labor notes?
 

IlDestriero

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I believe the post anesthetic eval has to be done by someone credentialed in anesthesia.
 

Colba55o

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Are you really that busy that you don't have time to put a stethoscope on a patient?

Doing a focused heart/ lung exam is always indicated when you are about to administer agents that are myocardial depressants. I hope you know that the lungs are at the other end of that airway you examine, so its not enough to just care about getting the tube in. You will never win an argument against doing a focused physical exam that includes basic ausculation; its too non invasive, quick and has the potential to catch serious comorbidities you didn't know about.

I think JHACOs assessment of your department was perfectly reasonable
 
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Monty Python

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Monty, do you bill for that visit? And more importantly do you actually collect anything?

We collect for intrathecal narc visits so it seems like this would be billable as well.

Another thought would be, could the nursing staff document recovery from the epidural in their labor notes?

Sorry Noyac, can't tell you if collection is successful ... I work at Club Fed and to my knowledge no one gets a bill for professional services. During the decade+ that I worked for the state university system as a state employee they may have sent bills to Medicaid, but who knows if they got anything as a labor epidural wasn't a medical necessity.

Most of the RNs will merely chart tip intact if they d/c the epidural, a few will add something to the effect of moves all extremities, denies headache, etc.
 

Monty Python

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So... we've just endured the latest rectal exam sans lubricant, by the Joint Commission. This place has been in a tizzy all week while I just try to do my job, a good job I think, and not put on a show for the retired pediatrician or whatever he was.
Did you get any unreasonable grief from TJC regarding your medication handling, storing, transporting, wasting, etc?
 

chocomorsel

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Gonna have to agree with Colba55o on this one.
I do focused exam on all my patients and we all do post epidural visits within 24-48hrs. To cover our asses.

Need to get a new smaller stethoscope though because the one I have is hurting my neck.
 

Monty Python

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OH, holy crap! Don't EVEN get me started...

We had some of those highly-paid Joint consultants/mock surveyors at my place a few months ago. We're in the window for a real JC inspection for the next 14 months. The mock surveyors dinged us for drawing up our benzo and narc in the OR, putting those syringes in shirt pocket, and immediately going to the holding room to administer them. You know, the concept of body heat going through the shirt material during the 30 second walk to the holding room as being sufficient to cause an SN2 reaction in the syringes, rendering the original drugs into something else. They wanted us to carry the unopened ampules from center core pyxis to the holding room in our hand, with the meds to be drawn up in the holding room at pt's bedside. When I pointed out that the glass ampules in the bare hand were exposed to more body heat than plastic syringes in the shirt pocket, and that glass has a much higher thermal conductivity factor than does plastic, I got a lecture about "transportation security." Apparently an ampule in my hand is more secure than a filled syringe in my shirt pocket. :nono:
 

pgg

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They wanted us to carry the unopened ampules from center core pyxis to the holding room in our hand, with the meds to be drawn up in the holding room at pt's bedside. When I pointed out that the glass ampules in the bare hand were exposed to more body heat than plastic syringes in the shirt pocket, and that glass has a much higher thermal conductivity factor than does plastic, I got a lecture about "transportation security." Apparently an ampule in my hand is more secure than a filled syringe in my shirt pocket. :nono:
What did they have to say about prefilled plastic syringes?

Can those be carried in a pocket, or should their contents be transferred to a glass container first?
 

Monty Python

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So Monty, did you make the switch? Or did you say screw y'all paper pushers without real world clinical experience.
I painfully bit my tongue, smiled at the surveyors, and taped the syringe plungers to my shirt where they emerged from my pocket. That, and I kid you not, satisfied them for "security" purposes. I never got a reply from them on the dreaded temperature issue.

How can a hand-carried glass ampule, susceptible to accidental dropping and breaking, be more secure than a plastic syringe carried in a shirt pocket a short distance for immediate usage? I ask that half in jest, and half in all seriousness eager to hear an objective rationale if one exists.
 

Monty Python

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What did they have to say about prefilled plastic syringes?

Can those be carried in a pocket, or should their contents be transferred to a glass container first?
For a short while last year we had prefilled sux, neo, and ephedrine plastic syringes. Then the bean counters complained about cost, and we haven't had them for months (including when the surveyors were with us). It would have been fun asking your question to the surveyor to watch their facial contortions.
 
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Just remember: they always have to find something.

That's the bullsh*t about this entire process.
 

epidural man

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We implemented a 24 hr "toe check" on all our epidural patients - both in L&D and main OR.

Colba55o - the OP's point is that your physical exam is really not sensitive - the history is much better. I think it is a valid point.

However, it is really quick to listen to the heart and the lungs. I have all my patients sit up to do the airway (most residents let them stay lying down in the bed) - then when they are up, it is easy to listen. It is just as fast to write "CTA, RRR".

JC is a horrible, evil, company.

There is an anesthesiologist at my workplace who years ago as a member of the CSA - (I think this is how it went....) fought so that JC policy became standard of care and JC would have to sign off on it. The effects of this would be absolutely tremendous. That would make JC have serious culpibility - and when their horrible decisions harm the patient because we were following "standard of care", they would be on the hook, not physicians. Because this would be the consequent, JC would think LONG AND HARD about what they are recommending - much more than they do now.
Currently, if you follow JC, but you kill someone because of their stupidity - then you get sued because it wasn't "standard of care." This happens all the time. Remember that neat article that showed that since the 5th vital sign by JC was enforced, mortality went WAY up - we were killing people treating a number. But they won't defend you - because that is way out of standard of care.


JC has NO ONE looking over their shoulder. They have NO culpibility in their decisions. In today's environment where NSA can listen to your phone and read your emails and you can't put sharps in the wrong sharp container for containing medications, it is astounding to me that this rogue company continues to get away with this lack of oversight.


rogue = a dishonest or unprincipled man
 

pgg

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I think CMS is worse than JC. The CMS wankers introduced one hospital I worked at to the concept of color-coded sharps containers. Sharps with meds in them went in blue ones, and sharps with no meds went in red ones.
 

jwk

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We had some of those highly-paid Joint consultants/mock surveyors at my place a few months ago. We're in the window for a real JC inspection for the next 14 months. The mock surveyors dinged us for drawing up our benzo and narc in the OR, putting those syringes in shirt pocket, and immediately going to the holding room to administer them. You know, the concept of body heat going through the shirt material during the 30 second walk to the holding room as being sufficient to cause an SN2 reaction in the syringes, rendering the original drugs into something else. They wanted us to carry the unopened ampules from center core pyxis to the holding room in our hand, with the meds to be drawn up in the holding room at pt's bedside. When I pointed out that the glass ampules in the bare hand were exposed to more body heat than plastic syringes in the shirt pocket, and that glass has a much higher thermal conductivity factor than does plastic, I got a lecture about "transportation security." Apparently an ampule in my hand is more secure than a filled syringe in my shirt pocket. :nono:
If I had to guess, I would wager there is no such TJC policy or standard.
 

pgg

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If I had to guess, I would wager there is no such TJC policy or standard.
That's half the problem right there.

These clowns visit for an inspection and just make stuff up because it sounds like a good idea to them. Next thing you know, every OR has color-coded sharp containers. It's madness.
 

epidural man

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That's half the problem right there.

These clowns visit for an inspection and just make stuff up because it sounds like a good idea to them. Next thing you know, every OR has color-coded sharp containers. It's madness.
That happened to us - every OR had a blue and a red. The cost to dispose each of one is very different. It was a complete mess.
 

IlDestriero

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What's the difference? One with meds still in them and one without?
 

sevoflurane

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We had a red, blue and black sharp container + trash can. Got rid of the black one... but still... Anesthesia real estate is precious to me, not to mention one more thing to get in the way or trip over.

I agree. It can get a little ridiculous and frustrating.
 

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That's half the problem right there.

These clowns visit for an inspection and just make stuff up because it sounds like a good idea to them. Next thing you know, every OR has color-coded sharp containers. It's madness.
Yep, it's happening in my neighborhood, although not to me. Different types of meds, not just sharps but meds, go in different containers.

Next thing we know we'll be recycling the plastic and metallic parts separately. :p
 

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We got some sort of stupid electronic "cactus" "smart sink" to squirt the liquids into. No body knows how it is supposed to work, or even where it came from. I think you guys may have just answered that.

But speaking of THE JOINT COMMISSION (call them JCAHO and they get their knickers in a twist), two weeks ago there was a rumor they were around. I boldly proclaimed to the room that if they went into our room, I would ask if they met the patient and had a signed consent acknowledging their presence. When, not if, they said no, I would request, then demand they leave and call security to remove them. I got a standing ovation from the staff that heard me. And you bet your ass I meant it. Is there ANY other person or group that you'd let wander aimlessly around the OR during a case? What makes them different?

I have nothing to say to them other than get out of my way.
 
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Wiseguy
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We gOt some sort of stupid electronic "cactus" "smart sink" to squirt the liquids into. No body knows how it is supposed to work, or even where it came from. I think you guys may have just answered that.

But speaking of THE JOINT COMMISSION (call them JCAHO and they get their knickers in a twist), two weeks ago there was a rumor they were around. I boldly proclaimed to the room that if they went into our room, I would ask if they met the patient and had a signed consent acknowledging their presence. When, not if, they said no, I would request, then demand they leave and call security to remove them. I got a standing ovation from the staff that heard me. And you bet your ass I meant it. Is there ANY other person or group that you'd let wander aimlessly around the OR during a case? What makes them different?

I have nothing to say to them other than get out of my way.
Ouch! You seem to really want to meet your medical chief of staff. Good luck with that.
 
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jwk

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Ouch! You seem to really want to meet your medical chief of staff. Good luck with that.
Sounds perfectly reasonable. There is nothing in any of our consents that allows "surveyors" to be in the room. Absent that consent, why is that problematic?
 

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And I'll say to the chief of staff the same thing I told you guys.

We have a policy that any observers (including students), are to meet the patient and consent to the observers presence. The Joint Commission would have a fit if I wantonly disregarded policy. Ergo, they can find their own way out.

How can I be faulted for following policy?
 

Monty Python

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And I'll say to the chief of staff the same thing I told you guys.

We have a policy that any observers (including students), are to meet the patient and consent to the observers presence. The Joint Commission would have a fit if I wantonly disregarded policy. Ergo, they can find their own way out.

How can I be faulted for following policy?
To anyone with an in-depth knowledge of Joint Commission standard operating procedure when they inspect (which excludes me): does a condition of their being on-site to conduct the inspection include a blanket allowance for them to go wherever they want, whenever they want? Does the facility have to agree to such freedom, including them wandering into a randomly-chosen OR without the patient's knowledge or consent? I completely agree with the personal feelings on this subject posted above by Ipassgas, JWK, et al.
 

Mman

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To anyone with an in-depth knowledge of Joint Commission standard operating procedure when they inspect (which excludes me): does a condition of their being on-site to conduct the inspection include a blanket allowance for them to go wherever they want, whenever they want? Does the facility have to agree to such freedom, including them wandering into a randomly-chosen OR without the patient's knowledge or consent? I completely agree with the personal feelings on this subject posted above by Ipassgas, JWK, et al.
Yes. They can go anywhere they want. Trying to stop them from going somewhere would be a big red flag.
 

Mman

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And I'll say to the chief of staff the same thing I told you guys.

We have a policy that any observers (including students), are to meet the patient and consent to the observers presence. The Joint Commission would have a fit if I wantonly disregarded policy. Ergo, they can find their own way out.

How can I be faulted for following policy?
Your own hospital consents for them to go anywhere including into the OR. I doubt you have an option. You can call security, but I'm betting your hospital survey won't go so well and I'm not sure your hospital would even give permission to their own police to remove them. Furthermore, I'd be willing to wager that your group or department has a contract or agreement with the hospital that requires you to abide by all rules and regulations relating to hospital accreditation.
 

IlDestriero

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The only thing being a douche to the inspectors will bring is big problems. And if you cause enough problems, you might be looking for a job, or maybe the AMC contract looks that much better. Tread very carefully there chief.
I doubt they need permission to do anything, see anything, etc. they require access to do their jobs to evaluate the hospital and everyone from the CEO to the guy pushing the mop is onboard.
 
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Ipassgas

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I appreciate the feedback, you guys are smart and I respect (most of) the people here. Federal law is my trump card I figure. If I mention HIPPA violations enough while politely asking them to leave, and follow up with a call to the feds, I'll get whistleblower status. There is no carve out for privately contracted non- governmental entities to have access to protected health information.

I will be firm, but polite.

I like my job, a lot. But I will take a principled stand against a heard of jabberwockies interrupting a case and potentially interfering with patient care. Someone trusted me with their life. I will be their advocate (someone it looks like Joan Rivers didn't have). This is a sword I will fall on.

Fortunately for me, the odds of them walking into a room I'm in, while a procedure is happening, is almost none. When I've seen them wandering before, I've always found somewhere else to be, and I figure I can continue that trend.

Eta: "everone . . . is on board". Not quite. The patient, the most vulnerable person involved, is not on board. Unless they produce a signed consent, or I witness them introduce themselves and ask permission to be there. My oath is to the patient, or have we fallen so far as to have forgotten that?
 
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I appreciate the feedback, you guys are smart and I respect (most of) the people here. Federal law is my trump card I figure. If I mention HIPPA violations enough while politely asking them to leave, and follow up with a call to the feds, I'll get whistleblower status. There is no carve out for privately contracted non- governmental entities to have access to protected health information.

I will be firm, but polite.

I like my job, a lot. But I will take a principled stand against a heard of jabberwockies interrupting a case and potentially interfering with patient care. Someone trusted me with their life. I will be their advocate (someone it looks like Joan Rivers didn't have). This is a sword I will fall on.

Fortunately for me, the odds of them walking into a room I'm in, while a procedure is happening, is almost none. When I've seen them wandering before, I've always found somewhere else to be, and I figure I can continue that trend.

Eta: "everone . . . is on board". Not quite. The patient, the most vulnerable person involved, is not on board. Unless they produce a signed consent, or I witness them introduce themselves and ask permission to be there. My oath is to the patient, or have we fallen so far as to have forgotten that?
Dude, one has to be able to recognize the very few moments of life when it's worth pissing against the wind, and the very many when it's not. This is one of the latter. Defending a patient against a JC inspector is laughable; those people are there exactly to make the place better for patients (or at least that's the general intent). Nobody will interfere with your care.

Do you really think that a hospital would intentionally and repeatedly break federal law during a JC inspection? Do you really think that there is a HIPAA restriction about who can enter an OR, as long as it's a hospital-authorized person with relevant business? And if that's the case, do you really think the hospital consent does not include language authorizing them to do that?

I admire people who have strong principles, except when everything has to be either black or white. Life is all about shades of grey.
 
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IlDestriero

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HIPPA wouldn't apply in this scenario as the inspectors do have a need for access to specific patient information to complete their survey of the facility. They would be bound to privacy themselves, of course. Nice try though.
I am sure the patient's consent/hippa legalese sheet has some vague wording about access to records/pt information for "necessary administrative use", "compliance", "mandatory reporting", etc. That would cover mock inspections, actual inspections, JC followup, etc.
I suspect you're just trolling now. If not, good luck.
 
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Mman

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There is no carve out for privately contracted non- governmental entities to have access to protected health information.
It isn't a HIPAA issue. It's a CMS/accreditation issue. You can do whatever you personally want, but your hospital has already consented to them being there. Your boss (department chair) has already consented to them being there. Consent from the patient is implied if not given directly. They are allowed to be there just like the scrub tech is allowed to be there even though the scrub tech never met the patient out in preop holding and didn't get specific permission to be there. Just like the anesthesia tech is allowed to be there. And on and on and on. Lots of people are allowed in an OR without the patient specifically meeting them and granting them permission to be there.