REGULATORY REVIEW
Recording the Beyond Use Date Also under injection practices, CMS makes it clear that medications that are pre-drawn must be labeled with the date and time of draw, initials of the person drawing, medication name, strength (previous requirements) as well as the beyond-use date (BUD) and time. The newly added BUD will add another directive that was not neces- sary prior to the guidelines. Make sure that staff are aware of this requirement, and that any facility policies and pro- cedures that address pre-drawn med- ication
labeling requirements include BUD.
Use of Multi-Dose Vials CMS has added a question as to whether or not the ASC has “voluntarily adopted a policy that medications labeled for multi-dose use for multiple patients are
now
It would be advisable to have at least all clinical staff at your facility read the new IC worksheet.”
— Sandra A. Berreth, RN, CASC ASCA Board member, Accreditation Association for Ambulatory Health Care
nevertheless only used for one patient.” If facilities do not adopt this voluntary practice, surveyors will now be check- ing to make sure that “multi-dose med- ication vials used for more than one patient are stored appropriately and do not enter the immediate patient care area (e.g., operating room, anesthesia carts).” The new IC worksheet notes
that “once multi-dose vials enter the immediate patient care area, they must be dedicated for single patient use and discarded immediately after use.” This will be a change for many anesthesia practices, as multi-dose medications are often opened in an emergent situation and will now need to be wasted after the single use.
Immediate Use Steam Sterilization Perhaps one of the greatest changes involves the definition of immedi- ate use steam sterilization (IUSS) and its considerations. The incorpo- ration of this language comes almost nine months after a surveyor memo released in September 2014 clarify- ing the definition of IUSS, and when it may be used in ASCs. “Immediate use” is defined as the shortest possi- ble time between a sterilized item’s
ASC FOCUS NOVEMBER/DECEMBER 2015
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