When preventable medical errors occur, one of the very first questions asked by patients, families, the legal system, the press, and the public is: “were appropriate care standards met?”. As a professional Registered Nurse, I look at this question from a quality and patient safety perspective to ask what could have been done differently? What are the best practice medical standards, and why are they not applied across the US health care systems? How applicable should the medical standard of care be? And how do we, as clinicians and patient advocates, define the best practice standard of care?
The reality is that the definition of best practice and standard of care differs between acute care hospital settings and outpatient surgery centers. And, even then, the standard of care being applied by the ambulatory surgical center, anesthesiologist and the gastroenterologist may not be the same.
I discussed this during a recent presentation to the Massachusetts chapter of the Association of periOperative Registered Nurses (AORN). The presentation – entitled “Reducing Risks and Malpractice Claims: Lessons learned from The Joan Rivers Lawsuit” – focused on the diﬀerences in standards between hospitals and ambulatory centers. I compared the standards set out by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and the American Society of Anesthesiologists (ASA). Perioperative nurses play a key role in patient advocacy and speaking up during pre-operative universal protocol (time out) prior to surgical or invasive procedures in both settings
One of the most clinically significant distinctions between the two standards is the difference in requirements for continuous electronic monitoring. The outpatient standards set out by the AAAASF require the monitoring of patient oxygenation levels, which is typically monitored by pulse oximetry as well as assessment of circulation by one or several of the following:
- Continuous electrocardiogram (EKG) during procedures
- Arterial blood pressure
- Heart rate every five minutes (minimum)
- Heart auscultation
Temperature should be monitored when clinically significant changes in body temperature are expected additionally should be continuously monitored during anesthesia if the patient is at risk for hyperthermia.
In comparison, the ASA standards applied to acute care hospital settings specify that all of the physiological parameters be specified, and not just “one or several” must be monitored. This means multiple avenues to assess patient’s health during sedated procedures, as well as more sensitive methods to detect the early signs of opioid-induced respiratory depression, such as capnography monitoring.
This distinction can mean the difference between detecting and preventing an adverse event and not, and is particularly important as more procedures under sedation are moved to outpatient clinics. So, why is there a difference in standards? And what can we do to ensure a higher standard of safety for everyone?
What Can We Do?
For nursing organizations, it starts with the establishment of a safety agenda/commitment: to achieve endorsement goals that support continuous respiratory monitoring with pulse oximetry for oxygenation and with capnography for adequacy of ventilation for any patient receiving sedation or opioids during surgery, regardless, if in a hospital or ASC setting. This position is already supported by the Association of periOperative Registered Nurses (AORN) and the Association for Radiologic & Imaging Nursing (ARIN); both organizations have released separate statements calling for the use of capnography to monitor patient end-tidal CO2 during moderate sedation procedures.
It will also require a group consensus between hospitals, ASC, pain centers, and healthcare facilities that have procedural/interventional suites on the highest standard of care to adhere to. This includes not only monitoring standards, but also the training and credentialing of staff to demonstrate competency in the management and minimization of respiratory compromise risks and, sedation/opioid related adverse events regardless of the practice setting.
This is a tall order; gaining organizational consensus is not an easy task. But it’s our ethical duty to uphold the best standard of practice for our patients, regardless of where they go for their care. If the efforts mean one less respiratory- or cardiac-induced patient harm, then it’s worth it.
Acknowledgements: AORN MA Chapter #2202