QOTW – QUESTION OF THE WEEK: Protocols

Question:
Must an order be obtained prior to the initiation of a protocol?

Answer:
According to CMS, standing order policies and procedures must specify the process whereby the physician or other practitioner responsible for the care of the patient acknowledges and authenticates the initiation of all standing orders after the fact, with the exception of influenza and pneumococcal vaccines, which do not require such authentication in accordance with § 482.23(c)(2).

In the Interpretive Guidelines, CMS states, “There is no standard definition of a “standing order” in the hospital community at large but the terms “pre-printed standing orders,” “electronic standing orders,” “order sets,” and “protocols for patient orders” are various ways in which the term “standing orders” has been applied. For purposes of brevity, in our guidance we generally use the term “standing order(s)” to refer interchangeably to pre- printed and electronic standing orders, order sets, and protocols.”

Requirements for “Standing Orders”

  • Hospitals have the flexibility to use standing orders to expedite the delivery of patient care in well-defined clinical scenarios for which there is evidence supporting the application of standardized treatments or interventions.
  • In all cases, implementation of a standing order must be medically appropriate for the patient to whom the order is applied.
  • Standing orders may not be used in clinical situations where they are specifically prohibited under Federal or State law. For example, the hospital patient’s rights regulation at §482.13(e)(6) specifically prohibits the use of standing orders for restraint or seclusion of hospital patients.

Applicable regulations are as follows:

  • §482.23(c)(1) (ii)– Drugs and biologicals may be prepared and administered on the orders contained within pre-printed and electronic standing orders, order sets, and protocols for patient orders only if such orders meet the requirements of §482.24(c)(3).
  • §482.24(c) (3) Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital:
    • (i) Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital’s nursing and pharmacy leadership before it is used in the clinical setting
      • The regulation requires a multi-disciplinary collaborative effort in establishing the protocols associated with each standing order.
      • The hospital’s policies and procedures for standing orders must address the process by which a standing order is developed; approved; monitored; initiated by authorized staff; and subsequently authenticated by physicians or other practitioners responsible for the care of the patient.
      • For each approved standing order, there must be specific criteria clearly identified in the protocol for the order for a nurse or other authorized personnel to initiate the execution of a particular standing order, for example, the specific clinical situations, patient conditions, or diagnoses by which initiation of the order would be justified. Since residents are physicians, this regulation does not require specific criteria for a resident to initiate the execution of a particular standing order.
      • Policies and procedures should also address the instructions that the medical, nursing, and other applicable professional staff receive on the conditions and criteria for using standing orders as well as any individual staff responsibilities associated with the initiation and execution of standing orders. An order that has been initiated for a specific patient must be added to the patient’s medical record at the time of initiation, or as soon as possible thereafter.
      • Standing order policies and procedures must specify the process whereby the physician or other practitioner responsible for the care of the patient acknowledges and authenticates the initiation of all standing orders after the fact, with the exception of influenza and pneumococcal vaccines, which do not require such authentication in accordance with § 482.23(c)(2).
      • (ii) Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines;
      • (iii) Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols;
        • At a minimum, an annual review of each standing order would satisfy this requirement. However, the hospital’s policies and procedures must also address a process for the identification and timely completion of any requisite updates, corrections, modifications, or revisions based on changes in nationally recognized, evidence-based guidelines. The review may be prepared by the hospital’s QAPI program, so long as the medical staff and nursing and pharmacy leadership read, review, and, as applicable, act upon the final report.
      • (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.
        • An order that has been initiated for a specific patient must be added to the patient’s medical record at the time of initiation, or as soon as possible thereafter.

Related Products from MCN:
Medication Management Manual
http://www.mcnhealthcare.com/policy-library/medication-management-manual

Posted in CMS - Centers for Medicare and Medicaid Services, MCN Healthcare, QOTW - Question of The Week | Leave a comment

AHA Issues Antimicrobial Stewardship Toolkit for Hospitals

The American Hospital Association (AHA), along with six national partners, recently released a toolkit to help hospitals and health systems enhance their antimicrobial stewardship programs.

The AHA states that the toolkit includes resources for hospital leaders, clinicians and patients, starting with a tool developed by the Centers for Disease Control and Prevention to help hospitals assess their readiness for optimal antibiotic prescribing and use.

According to the Centers for Disease Control and Prevention (CDC),”Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible.  However, 20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate.”

“The misuse of antibiotics has also contributed to the growing problem of antibiotic resistance, which has become one of the most serious and growing threats to public health.  Unlike other medications, the potential for spread of resistant organisms means that the misuse of antibiotics can adversely impact the health of patients who are not even exposed to them.”

The CDC estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually.

Components of the toolkit include the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs and the Checklist for Core Elements of Hospital Antibiotic Stewardship Programs.

  • The CDC’s Core Elements of Hospital Antibiotic Stewardship Programs summarizes core elements of successful hospital Antibiotic Stewardship Programs.  It complements existing guidelines on ASPs from organizations including the Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America, American Society of Health System Pharmacists, and The Joint Commission.
  •  The Checklist for Core Elements of Hospital Antibiotic Stewardship Programs should be used to systematically assess key elements and actions to ensure optimal antibiotic prescribing and limit overuse and misuse of antibiotics in hospitals.

The CDC recommends that all hospitals implement an Antibiotic Stewardship Program.

The American Hospital Association’s Physician Leadership Forum’s  Antimicrobial Stewardship website page has many resources available including Pediatric Stewardship Resources

Posted in CDC - Center for Disease Control and Prevention, MCN Healthcare | Leave a comment

MCN Learning: Legal Drugs and Nursing Licensure

Sometimes an issue comes up that is so controversial most people don’t even want to think about it however changes are occurring nearly every day about medicinal marijuana. Currently 21 states and the District of Columbia have approved the use of marijuana for medicinal purposes. To make matters even more interesting, two states have approved the use of marijuana for recreational purposes and other states are close behind by decriminalizing the possession of marijuana to a misdemeanor.

Depending upon the attorney’s website that is viewed, the use of marijuana is primarily still considered a federal offense. This means that even though a person lives in a state in which the use of marijuana is either approved for recreational or medicinal purposes, that person can still be charged with a federal crime.

This is an interesting issue in health care and for nurses. A myriad of studies have been conducted that weigh the benefits against the detriments of using medicinal marijuana. As most nurses would agree, anything that would help bring comfort to a suffering patient should be considered as an option. However there isn’t much information available about the legal use of the substance by a nurse.

Every nurse knows that licensure is regulated by the individual state. But if the nurse resides in a state where marijuana is either legal for recreation or medicinal purposes, what are the legal ramifications for adhering to state board of nursing licensure expectations? From what I can comprehend from the different state boards of nursing websites, marijuana is an illegal substance with zero-tolerance within the profession.

This situation is being discussed more frequently on nursing social media sites. The most frequently raised question focuses on the use of medicinal marijuana versus legal but controlled substances for pain control. There has been discussion about some nurses who have prescriptions for controlled substances needed for chronic musculoskeletal disorders – which developed by virtue of the nurse’s work – and the use of these medications while working.

Several nurses have been particularly vocal about the issues surrounding the use of minimally legalized marijuana versus the use of legal but controlled substances. As one group of nurses argues marijuana is rarely used before “going to work.” But if the nurse lives in a state in which the use of marijuana is legal, and it is used legally, the substance remains in the urine for days or weeks. Should a random urine test be performed, the nurse can be terminated for the presence of this substance in the body.

In contrast, nurses who have prescriptions for legally controlled substances may take doses of the medication before or while attending work. A random urine drug test may also be performed on these nurses but because the medication is considered a “legal drug” termination would not occur if traces of the medication are in the urine.

Situations such as these are occurring in other professions around the country. Individuals have been terminated for positive urine drug testing for marijuana in the telecommunications and manufacturing industries. And these terminations are occurring in states in which the use of marijuana is approved for either recreational or medicinal purposes. These cases are being argued and thus far, the federal mandate stands – the use of marijuana is not federally approved and therefore the employee can be terminated if evidence exists that it has been used.

Right now this issue is just getting started. Many more states are considering legislation to legalize the use of medicinal marijuana. And other states are moving in the direction to legalize this substance for recreational purposes. Even though it appears that approval for use is controlled at the state level, prosecution occurs federally. This is a Catch-22 in which nurses are going to find occurring more frequently.

Unfortunately there is no easy answer to this dilemma. Nurses are trained to adhere to ethical and legal requirements of the profession. As one social media site nurse writer stated, the use of the substance pales in comparison to the long-term effects of losing licensure and forfeiting a potentially lucrative career in nursing.

Even though the country is moving, state by state, in the direction of legalizing this substance, the profession is standing firm on the opinion that it is an illegal substance. And until the federal government makes any decision regarding marijuana, it is difficult for the profession of nursing to agree otherwise.

Hopefully we will all continue to serve as positive role models for our patients and employers and adhere to legal and ethical role expectations. As always, embrace the day!

Posted in MCN Healthcare, MCN Learning | Leave a comment