ED nursing standing orders for meds in jeopardy?
Concern is growing among emergency nurses
Any ED protocols involving emergency nurses administering medications as standing orders are under scrutiny, as a result of interpretive guidelines issued Feb. 8, 2008, by the Centers for Medicare & Medicaid Services (CMS).
The guidelines interpret CMS' Hospital Conditions of Participation as requiring that all medication orders, with the exception of influenza and pneumococcal polysaccharide vaccines, must be documented and signed by a physician. (Editor's note: To access the guidelines, go to www.cms.hhs.gov. Click on "Medicare," and under "Provider Enrollment & Certification," click on "Survey & Certification General Information," "Policy & Memos to States and Regions," and scroll down to "Revised Interpretive Guidelines for Hospital Conditions of Participation" which is Memo 08-12.)
In addition, some EDs recently have had problems involving the use of standing orders by nurses during surveys by The Joint Commission, reports Denise King, RN, MSN, CEN, president of the Emergency Nurses Association (ENA).
The problem involves medication management standard 3.20, which is being interpreted as follows by The Joint Commission's standards interpretation group: "Protocols can be initiated by a registered nurse once the protocol is ordered by a licensed independent practitioner. Initiation of a protocol, which includes a medical intervention (i.e., decision to administer a medication) requires an order by an independent licensed practitioner." (Editor's note: To see the letter that ENA and other organizations sent to The Joint Commission, go to www.ena.org. Click on "Future of Emergency Care" and "Nursing Issues.")
"The initiation of advanced treatment protocols has been a longstanding practice in many EDs and is indeed a best practice. To forbid that practice would have significant negative implications for our patients," says King. In addition, the ability for a nurse to implement a treatment protocol is a scope of practice issue to be regulated by state boards of nursing, not The Joint Commission or other regulatory bodies, she says.
Several performance indicators for EDs can't realistically be met without the use of protocols involving administration of medications by nurses, including some established by The Joint Commission, King says. She gives the example of rapid response teams that don't always include physicians and might require a nurse to give a diabetic patient with low blood sugar an ampule of D50, and American Heart Association standards involving door-to-aspirin time. "Treatment protocols allow the nurse to go forward and do these interventions, to allow us to meet these time frames," says King.
After doing further investigation on The Joint Commission standards, ENA discovered that CMS recently had clarified their interpretive guidelines on this same issue. "At that point, it became muddy as to whether this was an issue driven by The Joint Commission, CMS, or both," says King. The Joint Commission has clarified that they are only concerned with protocols that involve administration of medication, so other nurse-driven protocols, such as giving electrocardiograms to chest pain patients, were not of concern to them, she says.
"Joint Commission told us that indeed, CMS is revisiting this issue. There is a high likelihood that CMS and the Joint Commission will not be in alignment in their interpretation of this," says King. "CMS may very well be more rigid and restrictive in their interpretation. It is always a challenge when there is conflict between Joint Commission and CMS standards."
At press time, The Joint Commission was still in discussion with CMS to understand the meaning and implications of the guidance. The concerns are being looked at, says Robert A. Wise, MD, vice president of the Division of Standards and Survey Methods at The Joint Commission. "Nothing has been settled yet, and The Joint Commission is working on getting a better understanding of which way CMS is headed," he says.
Meanwhile, there is growing concern among emergency nurses on this issue, says King, "and we expect it to become an increasingly big issue as the word gets out."
Any ED protocols involving emergency nurses administering medications as standing orders are under scrutiny, as a result of interpretive guidelines issued Feb. 8, 2008, by the Centers for Medicare & Medicaid Services (CMS).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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