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ous complicating issues. Or what if the agent is administered by a person who can do so under your laws but that per- son gets pulled away and, at that split second, something happens. Then the question becomes ‘Would this hap- pen, or would the outcome have been improved, if that person had been monitoring the sedated patient?’” Twenty-five states have laws or


regulations addressing the importance of the role of the RN circulator in OR safety in the ASC setting, Stinch- comb says. “Know your state regula- tions and advocate for your nursing staff,” she says. “Per the Association of periOperative Registered Nurses (AORN), one perioperative RN cir- culator must be dedicated to every patient undergoing an operative or other invasive procedure.” The use of LPNs/LVNs poses another problem area, Stinchcomb says. “We find LPNs/LVNs not prac- ticing within their scope of licensure and not being directly supervised,” she says. “LPNs/LVNs can be scrub techs and handle delegated tasks from RNs, such as administering medications and maybe assisting with IVs, however, they require supervision by an RN. This supervision can be direct, indi- rect or available depending on the type of facility, but ASCs, typically, require direct supervision. You may not substi- tute an LVN/LPN for an RN.” Written physician orders play a key


role in keeping an ASC out of trouble, Stinchcomb says. “The importance of having an order that the physician authenticates with signature, date and time so the RN can implement that order is paramount,” she says. “What may happen instead is that the nurse feels he/she knows what the physician wants, so he/she checks off that order within a pre-printed order form. In effect, that person provided care prior to an order being authenticated. RNs cannot assume physician orders; oth- erwise, they are practicing medicine without a license.”


Twenty-five states have laws or regulations addressing the importance of the role of the RN circulator in OR safety in the ASC setting.”


— Debra Stinchcomb, RN, CASC Progressive Surgical Solutions


Another area of concern is allied health care providers, Miller says. “These days, scribes come into some ASCs to help with recording entries,” he says. “If that’s going to be a new way of the future, an ASC needs to understand what its state allows the scribes to do in an ASC.”


The Joint Commission describes a scribe as an unlicensed person hired to enter information into the medical record, normally in emergency depart- ments (ED), Stinchcomb says. “If an ASC uses a scribe, a physician must authenticate the scribe’s entry by sign- ing, dating and timing it before leav- ing the patient care area,” she says. “Scribes cannot take verbal orders, as only licensed personnel can take ver- bal orders. Scribes can write down the history and physical (H&P) of a patient. What we are seeing, however, is that physicians are using RNs or scribes to write down or augment their op reports.” Given that an ASC has a smaller setting than a hospital, the staff know each other closely, rely on each other and work as a tightly knit team, Miller says. “The problem is that compla- cency is not the same as team work,”


he says. “If you have over-stretched your staff where they have to deviate from how the law defines your staff’s scope of work, some people might think that is teamwork, but that then becomes complacency. When you see staff multi-tasking at the time of a crit- ical event, that then becomes a ques- tion whether they were doing someone else’s job and, in the process, ignoring their own job.” When you have a staff member


exceeding their scope of what they can do in that state per state laws, you increase the chances of getting sued, Miller says. “In some scenarios, the burden of proof could then shift from the patient to you, in that instead of the patient trying to prove that you caused injury, you have to disprove that you caused injury.”


Solutions Know your state regulations on scopes of practice as they apply to your ASC, Stinchcomb advises.


“Nursing management should edu- cate their staff on their scope,” she adds. “If I am the clinical director, I need to sit down with my RN circulator and let her know what she can or cannot do. She, in turn, can then help her staff understand when they go out of the scope of their licensure or practice.” Laws vary from state to state, Miller says. “Sometimes the licensing agen- cies have a hotline for questions,” he says. “You can call a licensing agency and ask a question generically, with- out specifically identifying the name of your ASC, and the agency may provide you with guidance. Good questions to ask a licensing agency are proactive questions, such as when you want to start a certain practice that you have not performed before and you want the guidelines. If, however, you have a con- cern that you are exceeding your scope, it might be time to call a health care lawyer. Educate yourself as to what you can appropriately do.”


ASC FOCUS AUGUST 2017|www.ascfocus.org 9


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