ED Accreditation Update
CMS guidance, SIG response cast doubt about propriety of some standing orders
The world of emergency medicine was thrown into a state of turmoil on Feb. 10, 2008, when the Centers for Medicare & Medicaid Services (CMS), issued the following guidance: "If a hospital uses other written protocols or standing orders for drugs or biologicals that have been reviewed and approved by the medical staff, initiation of such protocols or standing orders requires an order from a practitioner responsible for the patient's care."
This guidance came on a the heels of a response from The Joint Commission Standards Interpretation Group (SIG) to a request for clarification from Texas Children's Hospital in Houston, which stated that administration of medications [by nurses] under protocol are not in compliance with Joint Commission standard MM.3.20 EP1, which governs the writing of medication orders. The SIG said, in part, that "medication orders are expected to be patient-specific/individualized."
However, standing orders and protocols allowing nurses to administer, for example, acetaminophen or ibuprofen, to patients under specified conditions without an individual order from the physician have been used in EDs for years. The leaders of the American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM) and the Emergency Nurses Association (ENA) wrote a joint letter of protest to Mark Chassin, MD, MPP, MPH, president of The Joint Commission, and requested that the opinions be retracted.
To date, this retraction has not occurred. "The Joint Commission is currently in discussion with CMS to understand the meaning and implications of the guidance. The concerns are being looked at," says Kenneth Powers, a spokesman for 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."
A threat to safety?
Meanwhile, ED managers are up in the air about whether their departments are in compliance and are concerned that a change in policy would, ironically, have a detrimental effect on quality of care and patient safety, as well as patient flow.
CMS has certain dimensions of care they want EDs to look at, and patient-centered care is one of them, notes Joe Luria, MD, medical director of the ED at Children's Hospital of Cincinnati. "When you walk through the door and you have pain or fever, it's very nice to give a patient [acetaminophen] or some other pain medication as soon as possible," he says.
This, treatment can happen right in the triage bay if there is a standing protocol that addresses who can give the medicines, what the medicines are, what the criteria are, and the dosing ranges, Luria says.
Advanced treatment protocols, or nurse-initiated treatment, have been long-standing practice in emergency medicine, says Denise King, RN, MSN, CEN, president of ENA. "With our crowding issues, [the elimination of such protocols] impedes our ability to expedite care and has a negative impact on patient safety and quality of care," King says. In addition, she notes, such protocols "are touted as best practices — and indeed they are."
Jedd Roe, MD, MBA, FACEP, the ED medical director at William Beaumont Hospital in Royal Oak, MI, says, "As I understand it, [the CMS guidance] holds that all orders for any drug or biologic agent — with the exception of a couple of vaccines — must be documented and signed by an individual physician or extender, and essentially any use of written protocol or guideline that involves administration involves an individual order by the practitioner responsible for that care. For emergency medicine, that flies in the face of 30 years of established practices."
Historically, what Children's Hospital had done was write those protocols in terms of a pain initiative. "If someone walked through the door and screened positive for pain, we offered them [acetaminophen] or ibuprofen if they met certain criteria," notes Luria.
When the SIG issued its statement, the hospital executives deemed the ED to not be in compliance and said the process had to stop. "We went from over 80% compliance in screening for pain and or fever and documenting if we gave the medicine down to zero," he reports. "In terms of a busy ED, you'd have to stop what you're doing in triage [to give individual approvals], which can slow down your ability to do triage, so people just stopped the process." Staff still screened for pain, he adds, but there was no intervention of acetaminophen or ibuprofen.
What's a manager to do?
The current state of affairs creates a conundrum for ED managers: Do they follow the latest guidance and, in their opinion, risk quality of care and safety, or disregard it and risk loss of reimbursement from CMS or being noncompliant with Joint Commission standards?
"I would advise nurse managers to clearly be in compliance with the nursing practice act in their state," says King, who notes that in some states nurses are allowed to initiate advanced treatment protocols if they follow specific guidelines on how to do this and meet education and competency requirements.
"Such issues are truly governed by the state board of nursing," she says. "To say a nurse cannot do certain things would have implications for our scope of practice — which is administered by the state board of nursing."
In fact, King adds, "Even with all that has been said, the Joint Commission seemed to understand this and has tentatively recommended that you need to comply with the regulations in your state." If your ED has any protocols governing administration of meds or ordering diagnostic tests, they must be properly approved by your hospital, she says.
Still, King warns, "ignoring what CMS says is certainly a risk, and I would never recommend anyone do that. It could have a huge impact on your financial stability as an organization." She recommends using "an extreme degree of caution and discussion with your risk management department."
On the other hand, says Roe, "People are going to have to think very carefully about making wholesale changes to practices based on this standard." Roe notes again that it is at odds with what emergency medicine is all about. "It isn't like we've created these protocols out of thin air," he says. "We've explored the literature carefully, so we have evidence-based practices and stringent protocols in which all the nursing and medical staff must get significant education."
However, he adds the following caveat: "Such protocols require a high level of quality improvement audits and a continuous examination to make sure all processes are properly in place."
People know the Joint Commission is discussing the issue, and they are waiting anxiously for a final interpretation, says Luria.
As for the organizations' latest thinking on advanced treatment protocols, King notes that while The Joint Commission appears flexible, CMS does not. "We get the impression that CMS really does not care," she says. "The Joint Commission is working with them and talking with them to try to get some agreement, but currently there is none."
The world of emergency medicine was thrown into a state of turmoil on Feb. 10, 2008, when the Centers for Medicare & Medicaid Services (CMS), issued the following guidance: "If a hospital uses other written protocols or standing orders for drugs or biologicals that have been reviewed and approved by the medical staff, initiation of such protocols or standing orders requires an order from a practitioner responsible for the patient's care."You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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